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Your keynote address at the ‘Anxiety: how can therapy help?’ conference incorporated interview data from your book, Cracked: why psychiatry is doing more harm than good, about the scientific research, or lack of it, behind the Diagnostic and Statistical Manual of Mental Disorders (DSM). Could you briefly outline your argument in the book? 

In a nutshell, I argue that psychiatry over the past 40 years, under the dominance of the medical model, has started to become bad for our mental health. Not intentionally, but as an outcome of taking the medical model too far. There are a number of reasons I argue this: it has wrongly medicalised more and more natural, albeit painful, responses to the difficulties of living; it has become wedded to medications of questionable value (for many people) and whose long-term effects are still uncertain; it has allowed itself to be compromised by pharmaceutical ties; it has stigmatised people through labels and has sold itself as closer to the rest of medicine than it is. All this has led to a situation in which the integrity and efficacy of the profession is now under serious scrutiny.

What inspired you to write Cracked?

A key factor was working as a psychotherapist in the NHS, encountering person after person who had been adversely affected by psychiatric diagnoses and drugs. As therapists we know it takes many months to really understand a person and the social and psychological reasons why they suffer. Yet most psychiatrists were assigning diagnoses after only one session. And I began wondering whether this hasty labelling was why I was so often encountering understandable human experience being wrongly medicalised and medicated. I felt that in many cases the diagnoses were leading to little other than the illusion of understanding for doctors, and stigma and self-stigma for patients; while the medications themselves, although sometimes helpful for the more severely distressed when taken short term, were in the long term harming or holding people back. So I often found myself working at cross-purposes with key psychiatrists and I was baffled why they didn’t seem to share my concerns.

It was then I started reading the sanctioned psychiatric literature to try and understand what I was missing. I began with the conventional textbooks but soon moved to more critical academic research. What I found in the latter really opened my eyes and launched me on a journey that was both fascinating and disturbing. Over a period of about two years I started interviewing psychiatrists both here and in the US, including many leading lights of the profession. The disconcerting story that emerged from these interviews – about psychiatry doing more harm than good – became the story I told in Cracked.

Why do you think we’re currently seeing a mental health pandemic and the shocking statistic that a supposed one in four of us suffers from some form of mental illness?

I think saying one in four people is suffering is a fair estimate. The problem is rather that we misunderstand and mismanage most of that suffering. We reconfigure it in medical terms, as an illness to be swiftly removed, usually with medication. This view is simplistic, dangerous and I might add scientifically and clinically unjustified. The fact is most people now being classed as ‘mentally ill’ are not suffering from mental illness per se but from natural and normal, albeit painful, human responses to the difficult social and environmental conditions in which they have been caught up – conditions that a pill was never designed to remedy. This is not to say sufferers don’t need care, but rather care of a different kind – psychological, social, relational, humanistic, spiritual, depending on your beliefs and needs. So it’s not that the statistic ‘one in four’ is wrong but that we as a society have made some pretty bad choices about how to respond to such widespread distress.

What are the implications of your research for counsellors and psychotherapists?

Well, one is that it may shift the balance of power. My own concern is that there is still too much deference to the medical model in counselling and psychotherapy. This deference is to do with many things: psychiatry’s aura of scientificity; its high status relative to therapy; our fear of professional marginalisation if we stray too far from the medical model; our unfamiliarity with the critical research (which is a shame since it is empowering – instilling confidence in the need for non-medical alternatives). But also, as I pointed out at the conference, I think our deference is to do with our anxieties about what it means to stand before any person in need, ourselves in need of the assurance that we know what is going on. Diagnosis can provide this sense of assurance and this can in turn stem our anxiety – because we are anxious about not knowing and because we think that by ‘knowing’ we can better deal with the problem at hand. When in fact, as the psychotherapist Alan Pope recently put to me, ‘The key to conquering anxiety is to be able to tolerate not knowing and remain in possibility or to be able to make that leap of faith.’

What has been the reaction to Cracked from the psychiatric profession and the pharmacological industry and were you anxious about how it would be received?

Very anxious indeed! Two weeks before Cracked was released my publisher called to tell me that The Times Magazine wanted to do a big feature on the book. They took photos of me and sent the journalist Robert Crampton over to my house to interview me. He was a decent man and made me feel at ease. But on the morning the article was published, I remember sitting with my wife completely unable to open the paper. Right then I started trembling. I was suddenly really, really afraid. I was afraid of the exposure the article would bring, and what that might mean. All I could think was: ‘Well, you did bring this upon yourself.’

Since then I have calmed down a bit, which is important, as I have received all sorts of reactions. There are psychiatrists who agree with me and psychiatrists who don’t, and some who partially agree. But, in all, whenever I have met professional opposition it has mostly been levelled in a spirit of congeniality. There have been some clear exceptions though – and these are usually industry related. Things get hidden, buried and manipulated and that’s what Cracked set out to expose and confront, so I shouldn’t be surprised if those interests sometimes bite back.

How does it feel to be a critic swimming against the tide?

Really, am I swimming against the tide? I think I’m merely giving voice to things that people already know. When you articulate clearly what people already know, there is power in that. As more people begin to trust their heretical thoughts, they cease to be heretical. They become the new status quo. Obviously that new order is not with us yet but times are certainly changing. There is now an ever-expanding critical psychiatry community, which is increasingly confident and mainstream. In fact, the other day I met with a seasoned critic, the psychologist Lucy Johnstone, who mentioned how, when she began tackling psychiatry some 20 years ago, she was in a tiny and besieged minority. Since then, she said, there are more clinical professionals, academics, journalists and an ever-growing service user movement speaking out and lobbying for change. Of course, we still face a mountainous task ahead, but, as I put it in the book, all these voices have started to make a difference – and if more can be added to the crescendo, there is no telling what can be achieved.

You write that after nearly 50 years of investigation into the chemical imbalance theory of anxiety and depression, there is no convincing evidence that the theory is actually correct. How would you advise someone who, having read Cracked, is considering stopping taking antidepressant, anxiolytic or antipsychotic medication as a result of what they’ve read?

In Cracked I do not tell people what to do. I merely provide them with the information I believe they need to make an informed choice about whether to accept psychiatric intervention. Having said that, I do give one piece of advice, which I’ll share: any precipitous or sudden withdrawal from psychiatric drugs is always dangerous. Withdrawal should therefore be conducted under the supervision of an experienced physician who is, of course, well informed and so able to respect fully any person’s desire to explore non-medication alternatives. This last point is crucial because there are still too many physicians who don’t support such desires.

Psychiatry and the talking cure in the form of psychoanalysis were closely aligned until the middle of the last century. What caused the divergence in ways between them and do you foresee a future in which they might work more effectively together again?

Firstly, as you say, the alignment used to be stronger. This was particularly true in the United States until the 1980s. In fact, the DSM used until 1980 was actually compiled and written by psychoanalysts. Psychoanalysis ruled the roost. So what happened? Well, there were many influential factors but by far the most important in my view was the pharmacological revolution of the 1970s and 80s. You must understand before this revolution psychiatry was in crisis – psychoanalysis had momentarily lost its legitimacy, other physical treatments, like lobotomies, were now a source of shame, and bad press around the state of asylums and ECT treatments had deeply wounded public confidence and practitioner morale. It was at this time that industry-backed pharmacological psychiatry really took off. Companies funded research, paid individual psychiatrists and helped fund the development of new departments. As the power of biological psychiatry grew, so did psychotherapy almost disappear from British psychiatry and rapidly decrease in American psychiatry. (For example, in the US by 2004 the percentage of visits to psychiatrists that included psychotherapy had dropped to 29 per cent from 44 per cent in 1996–97.) In short, the influence of the pharmaceutical industry pushed psychotherapy out of medicine. And therapy has been struggling to return ever since.

In my view the only way we’ll see a reversal is if industry influence abates. And this will only happen if people really begin to open their eyes to how corrosive this influence has been, based as it was on the burying of negative clinical trials, the funding of the regulatory agencies and the financial co-opting of large sections of the psychiatric community who publicly endorsed and promoted pharmacological treatments. If you want to know how corrosive this influence was, then read the critical research. So there is a future for more psychotherapy in psychiatry but some critical changes must ensue first; changes that I’m not convinced will be embraced any time soon.

What is your hope for the future of psychiatry?

Well, in my view we clearly need a more humanistic psychiatry – more informed by anthropology, sociology, psychotherapy and philosophy than by industry-conducted drug trials and manuals like the DSM. In addition, we require greater transparency and accountability with respect to the profession’s financial ties with industry, more critical scrutiny of the disadvantageous effects drugs have for many, especially when taken long term, and finally, more time spent in psychiatric training on learning non-medical alternatives. There are many highly thoughtful, critical psychiatrists who have been requesting these things for years, so I am certainly not alone.

You studied medical and social anthropology at Oxford and lecture in social anthropology and psychology at the University of Roehampton. What motivated you to train as a psychotherapist?

My experience of going through my own psychotherapy. I expect many of your readers will get what I mean.

Dr James Davies graduated from the University of Oxford with a DPhil in social and medical anthropology. He is a Reader in Social Anthropology and Psychotherapy at the University of Roehampton and a practising psychotherapist. He has written widely academically and delivered lectures at the universities of Harvard, Yale, Oxford, Brown, UCL, Columbia and The New School (New York). He has also written for The Times, The New Scientist, The Guardian and Salon and is author of the recent book, Cracked: why psychiatry is doing more harm than good (Icon Books, 2013).

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