The RCPsych Article of the Month for June is ‘Breaking out of the citadel: social theory and psychiatry‘ and the blog is written by authors Rob Poole and Catherine A. Robinson and the article is published in BJPsych Bulletin.

Artwork © Catherine Robinson

We are surprised and delighted that our paper has been chosen as RCPsych Article of the Month, especially as social theory is not a subject that usually makes psychiatrists’ eyes light up.

Sometimes you do not know what you really think until you are asked to explain yourself. Just before the world was changed forever by a coronavirus, we were invited by George Ikkos and Nick Bouras to contribute a chapter on social theory to their book “Mind, State and Society: Social History of Psychiatry and Mental Health in Britain, 1960–2010”. Normal life stopped and we were locked down in separate places, so our previous pattern of writing together in front of a computer was impossible. However, there was plenty of time to read, think and make Zoom calls. As we wrote, a number of ideas about the broken relationship between psychiatry and social science started to crystalise. The published chapter bore little resemblance to our initial outline. We finished writing it quite quickly, but our thinking continued to develop after we submitted it, helped by discussions with George Ikkos, Kevin Gournay, Peter Huxley and others. Our chapter was about the past, but this paper is based on what we thought about next, which was what British psychiatry can do to get out of its current unhappy embattled hole.

Some of the things that we believe would make a difference are set out in the article. Beyond those suggestions, if psychiatrists are to regain a degree of control over the future of their profession, they need to become better read and more broad minded. They need to come to terms with the fact that some criticisms of psychiatry are well-founded, without collapsing into self-loathing. For too long, psychiatry has adopted a position of defensive denial in the face of its critics, and that is the citadel that it needs to escape. Apart from anything else, the stance has failed.  Essential elements of good psychiatric practice, especially those relating to therapeutic relationships, are being destroyed in the absence of a coherent replacement.

Despite its faults, psychiatry still has a great deal to offer people with mental illnesses, but it must change to survive. We need to win over hearts and minds to a broader perspective, both within the profession and outside of it. Promotion of the genuine achievements of neuroscience will not do this on its own. We need to properly re-engage with the social aspects of mental illness, and that demands a better understanding of social theories of both left and right.

This article reminds us of the importance of social theory to psychiatry, difficulties that can arise when we attempt to narrowly assert the predominance of biological psychiatry, and the need to consider wider social factors including adverse circumstances in child- and adulthood. That is not the same as saying we should jettison biological psychiatry, with its many findings and accomplishments over recent decades. Rather, it is a call to rebalance the way in which we think about mental illness, and consider afresh what that might mean for psychiatry and the role of social theory. While the authors assert that “progress needs to be consolidated and extended”, they also acknowledge that “organised psychiatry has become substantially more reflective over the past decade or so”. This, surely, is a good thing.

Andrew Forrester

Editor-in Chief, BJPsych Bulletin