‘The medical model has presided over four decades of flat-lining outcomes’

Author, anthropologist and psychotherapist Dr James Davies tells Fauzia Khan about his journey into the field of mental health and his work as co-founder of the Council for Evidence-based Psychiatry.

What brought you into the field of mental health?

My journey into the field, psychologically speaking, I could probably trace to my ninth year, when there was a lot of upheaval in my family. I would often spend long stretches of time away from them. Outside the safety of their care for the first time, I felt very exposed, afraid and unprotected. Who were these new people now taking care of me? Who could I trust, who could I not? As a result, I awoke rapidly from that warm haze of childhood to become hypervigilant about my new surroundings, mostly due to instinctual self-preservation. 

Later on, I learnt that such experiences are very common in children whose primary environment has been disrupted or precipitously removed. Childhood ends early for them. On the upside they may become resourceful, 'streetwise' and very perceptive for their age; on the down, they are more exposed to various dangers and harms, psychological, situational, relational etc. There are many literary representations of this childhood predicament – they are the Gavroches, the Dodgers and the Saroo Brierleys. 

And that early vigilance developed into a fascination with Psychology?

Only much later. In my early 20s I was experiencing a lot of emotional turmoil, some of it related to those earlier years. I began reading vociferously to work things out. One influential book I encountered was Peter Kramer's Listening to Prozac. As everything felt so painfully complicated at the time, I was seduced by its simple message that a pill could remedy my suffering. 

Putting my hopes in Prozac, I went to my GP and asked for a prescription. He sent me away, stating that I 'didn't look depressed' to him! So, my reading and searching continued, which ultimately led me into therapy. And so my entrée in our field was through my own lived experience, just as for so many others. 

You're the co-founder of the Council for Evidence-based Psychiatry (CEP). Can you tell me about that?

Yes, I co-founded the Council nearly a decade ago with the campaigner, Luke Montagu, who had suffered a truly harrowing experience when trying to withdraw from benzodiazepines and antidepressants (which he'd been originally prescribed for a failed sinus operation). The psychiatric profession, at that time, mostly denied the protracted harms that could be caused by psychiatric drug withdrawal and dependency. There were hundreds of thousands of people supporting each other online, often in the absence of their doctors recognising their problems as real. We started CEP to lobby with those disenfranchised people, sometimes referred to as the 'prescribed-harm community'. 

I went to my GP and asked for a prescription. He sent me away, stating that I 'didn't look depressed' to him!

Our joint work with that community led to some significant changes over the years, especially after CEP became secretariat to the All-Party Parliamentary Group for Prescribed Drug Dependence, which we helped to co-found in 2017. Our joint work with campaigners like James Moore, Marion Brown, Beverley Thomson, Fiona French, Stevie Lewis, and so many important others, led to the first major government review of prescribed drug dependence (PHE), which helped vindicate the claims of harmed patients and raise the profile of the withdrawal issue. It also led NICE to change its withdrawal guidelines to recognise, for the first time, protracted antidepressant withdrawal… a change also later ratified by the Royal College of Psychiatrists, under the crucial guidance of Dr Mark Horowitz. Right now, CEP's central work is getting dedicated provision established for those adversely affected.  

Much of your work is focused around challenging psychiatry and the medical model, then?

Yes. And this work has emerged out of a diversity of factors: personal, clinical, the experiences of others close to me, and what I think an honest appraisal of the research obliges us to accept. The medical model has presided over four decades of flat-lining outcomes, at best, while in contrast outcomes in general medicine have significantly improved. For instance, the effectiveness of psychiatric drugs has not increased since the 1980s, despite billions spent on research, marketing and promotion. Mental health disability rates have also trebled, while the prevalence of mental health problems has risen considerably (despite stable levels of general well-being in the community). Furthermore, for people diagnosed & treated for the most serious mental health issues, the gap between their life expectancy and everyone else's has widened (from 10 years to 20). 

Some might put those statistics down to a lack of mental health funding and/or ailing social environments.

Yes, and there is some truth to this of course. But if this becomes the only truth, we by default exonerate the medical paradigm from any responsibility. This would be wrong given outcomes have remained uniformly poor over differing historical and social contexts, and that we've also invested over a quarter of a trillion pounds in UK mental health services and research since the 1980s. 

I believe our significant failure in outcomes cannot therefore be primarily attributed to events and deficits in spending, but to our spending on the wrong kind of ideas and practices; on ones that have privileged the depoliticisation and commodification of our emotional pain, that have increased social and self-stigma, that have worsened long-term outcomes, that have neglected non-medical (yet effective) psycho-social alternatives, that have misdirected countless billions into bio-psychiatric research that has yielded very little of clinical value, and ones that have facilitated the over-medicalisation and unnecessary medicating of large swathes of the population, with approaching 25 per cent of UK adults now receiving a psych-drug prescription each year.

It is important to remember that mental health is a volatile field where every position is contested.

And then, of course, there are the harms caused by the epistemic confusions this model has sown in the general population about the nature of emotional pain and distress; its causes, meaning and implications. The medical model broadly sees suffering as an index of internal 'dysfunction' (as defined by the DSM), rather than, as say, the organism's legitimate protest against psycho, social or relational predicaments that hold us back – predicaments that our medicalised interventions were never designed to treat. In other words, the medical model is structurally and linguistically configured to dismiss the often deeply purposeful nature of emotional pain; pain whose functional meaning is revealed when you care to look deeply enough. At the very least such pain is a legitimate call to change harmful circumstances, seek accommodations, or to address unmet human needs and/or traumas yet worked through. It therefore demands care, understanding, relational and social support – not simplistic pathologisation. And yet, our services, as they are currently configured, make the medicalisation of our suffering or divergence the core precondition for receiving any care or support at all. That is wrong and must change.

Would you say you are 'anti-psychiatry'?

No, contrary to the impression my criticisms may convey! I accept that psychiatric drugs have a place when judiciously prescribed. I accept that there's a role for psychiatry in mental health care. It may be a very different role from the one we witness today, a more modest and tightly regulated role, but it's a role nonetheless… as I discuss in my latest book, Sedated. 

And so this leads me onto one of the concerns I have with the label 'anti-psychiatry' more generally. 

It not only often misrepresents many different critical perspectives, but it threatens to denigrate those perspectives given the multiple negative associations the phrase has come to accrue. What concerns me most is when I see the phrase being weaponised to try and silence, misrepresent or delegitimise critical debate and dissent. This happens a lot on social media, where the rules governing scholarly engagement do not hold. On the other hand, if someone wishes to self-identify as anti-psychiatry that's fine with me if that's their choice. What I object to, in essence, is the strategic imposition of the phrase against a person's will with the aim of dismissing that person as ideologically rather than evidence driven. 

Other pejorative phrases are also used to dismiss the critical voice. In all of this rancour, however, it's important to remember that mental health is a volatile field where every position is contested, and if you are a 'loud voice' often the louder the cry against you. You may feel or actually be poorly treated. But the important thing is not to wallow in that. Instead, speak your insights, keep an open mind, and learn to learn rather than be offended.

So, say you encounter a Psychiatrist, or Psychologist come to that, who says 'James, I agree with you. Every day, I come across that pain, I recognise it as a legitimate call to change harmful circumstances or to address unmet human needs. But I am just one person – one person who thinks, like you, that psychiatric drugs can have a place in judicious care. I'll do my bit, and hope other professionals, policy makers and politicians do theirs.' What do you say? 

Well, before I say anything, I'd like to learn more about this particular professional to test whether what they say is a veiled justification for complicity in a broken system. That sounds harsh, I know, and I am sorry, but I've seen this dynamic so often before. I've met well-meaning professionals who, for example, equate believing in a bio-psycho-social perspective with 'doing their bit' while they continue to practice in only bio-medically informed ways. I've heard professionals equate 'doing their bit' with working in multi-disciplinary teams, despite such teams being structurally determined to operate within (as so by default privilege) the dominant biomedical frame. 

We need to repoliticise our understanding of emotional pain, and cease relying on drugs to fill the vast gaps in relational, social and community-based interventions. 

On the other hand, 'if doing your bit' means, let's say, publicly challenging the problems as you see and experience them – taking a stand, being brave and political (rather than complicit), then I would say carry on doing your bit, and look for some collective support in doing so. 

What else still needs to change?

We need to significantly de-medicalise our services, interventions and narratives (starting by removing making being medicalised a precondition for receiving any care). We need to repoliticise our understanding of emotional pain, and cease relying on drugs to fill the vast gaps in relational, social and community-based interventions. We need to learn far more from service users and survivors in terms of service design. We need to remove coercion, decentre the biomedical approach, and with increased funding implement more widely effective community and relationally-based interventions. Finally, we need to reconceptualise our understanding of emotional pain so we can see more clearly what suffering or divergence may be trying to teach the individual or collective. For these things to happen we require wider structural change in our political economy. This is a vast area, which I partly explore in Sedated. 

Tell me about your books.

The four books I have written analyse different aspects of our mental health arena through a sociological or anthropological lens. My first book, The Making of Psychotherapists, constituted an anthropological analysis of the institutional dynamics that have fuelled hostility between the different psychotherapeutic traditions. I tried to expose ethnographically the tacit institutional devices used in training to transform persons into professional defenders of the tradition, often at the expense of patients, integration and progress. Much that I found occurring within analytic institutes I have subsequently learnt also exists within psychiatric training.

My second book, The Importance of Suffering, is a philosophical enquiry into the nature of emotional pain, exploring the idea that suffering can be highly psychologically facilitative, if understood and managed properly. It's very humanistic in orientation and provides the intellectual basis for the next two books that directly challenge the over-medicalisation of everyday life – its causes and consequences. 

The first, Cracked, was mostly for the general reader, in part based on interviews with leading figures from the world of mental health. The book emerged from the frustration I'd experienced while I worked as a psychotherapist in the NHS, which enabled me to dive deep into the many conflicts and excesses of psychiatry. I wanted to write a book that could benefit service users as they struggled through systems they often experienced as harmful. It explored the ways in which psychiatry may do more harm than good, even in the face of good intentions, so it was a controversial book as you can imagine. 

My most recent book, Sedated, explores the mechanisms that have enabled our medicalised system to remain dominant despite its poor outcomes. 

I argue it has secured its position by becoming, since the 1980s, a handmaiden to 'neoliberalism' (i.e. late capitalism). The mechanisms by which it has served neoliberalism include: conceptualising human suffering in ways that protect the current economic order from criticism; redefining 'wellbeing' in terms that are consistent with the aims of our economy; turning behaviours and emotions that perturb or disrupt the established economic order (e.g. low worker satisfaction) into a call for more psych-interventions; and turning suffering into a market opportunity, for the purpose of increasing taxation, profits and share-value. 

I don't argue that these and other mechanisms were engineered in a calculated way, but that they arose spontaneously as our mental health sector struggled to endure and adapt under a new set of socio-economic arrangements from the 1980s onwards. I locate on-going poor outcomes, systemic failure, growing harms and public disillusionment, in our mental health sector's servitude to neoliberalism.

What projects are you working on?

My academic life is structured around two primary occupations: writing books for the academic and general reader, and undertaking academic research that is relevant to social policy. In the latter area, most of my recent work has been around psychiatric drug dependency and withdrawal (its human and economic costs), while in the book department, I am currently exploring a number of themes. One I return to again and again is the issue of post-traumatic-depressive-etc growth. How does that actually happen? What do we really know about it? And why is it such a threatening idea to the status quo? I'm looking forward to digging deeper and reporting on what I find.