Broken Brains and Broken Promises: Advice to an Aspirant Psychiatrist

On the first day of my training as a psychiatrist in the long hot summer of 1976 my consultant thrust Laing’s The Divided Self into my hands and told me to read itI did as I was told and fell under the spell of a psychiatrist who used existential philosophy and psychoanalysis to understand his patients. But the world was changing. Margaret Thatcher entered Downing Street in 1979, and a year later DSM-3 was published. Not that the two were related, but looking back it is possible to discern links between the two.

Throughout the 1980s Thatcher’s governments introduced economic and welfare policies that led to increasing income inequality and worsening health and mental health for the poor. This continues today[1]. At the same time DSM-3 was sowing the seeds of neo-Kraepelinism in psychiatry – the idea that mental disorders are primarily brain disorders. In this view psychiatrists like Laing were wrong. Attempts to understand madness through psychoanalysis or existentialism were doomed to failure. Mind and its contents were mere epiphenomena, of no more consequence than the cloud of steam that hangs over a factory at dawn, as Thomas Huxley is reputed to have said. The secrets of psychosis would yield to the new discipline of clinical neuroscience. We were promised new drugs and physical treatments that would cure madness. Forty years on we are still waiting.

Instead we have a neuroscientific psychiatry that sees no value in exploring people’s experiences in psychosis, experiences that epidemiological research has shown are rooted in childhood adversity, oppression, racism and poverty. Neuroscientific psychiatry ignores the consequences of structural inequalities, the contextual factors that drive people into madness [2].

There are three powerful, interlinked sets of interest that are served by such a psychiatry. First, the small number of academic psychiatrists whose careers have been carved out in broken promises to fix broken brains. Second, the pharmaceutical industry, which after the arms industry, is one of the most lucrative sectors of transnational capitalism. Third, the governments of the global north who are terrified that if the truth about inequalities and illness were told they would have to end their love affair with neoliberalism and institute fiscal and welfare policies to end income inequality [3].

So, if you really do believe the ideology and pseudoscience of neuroscientific psychiatry, and don’t consider the social and political contexts in which we live and work important, then by all means become a psychiatrist. If on the other hand you are concerned about social justice and consider it to be central to the practice of good medicine, then stay well away. Maybe try Public Health instead, a speciality that still appears to be concerned with social justice.


[1]For more detail see my recent chapter Neoliberalism: What is it and why does it matter? Chapter 1 in (eds. R. Rizq and C. Jackson) The Industrialisation of Care: Counselling and Psychotherapy in a Neoliberal Age.PCCS Books 2019.

[2]For a detailed consideration of the evidence here see my last book, Psychiatry in Context: Experience, Meaning and Communities (2014) Hay on Wye, PCCS, especially chapters 4, 5 and 6.

[3]See my recent paper with Tamasin Knight, Knight, T. & Thomas, P. (2019) Anxiety and depression in the age of austerity Perspectives in Public Health 139, 3, 128 – 130


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