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“In one sentence, and my statement is not original, our age has replaced a religious point of view with a pseudoscientific point of view,” responded Szasz. “Now everything is explained in terms of molecules and atoms and brain scans. It is a reduction of the human being to a biological machine. We don't have existential or religious or mental suffering anymore. Instead, we have brain disorders. But the brain has nothing to do with it, except that it is an organ necessary for thinking.”

“So by reducing everything to the physical,” I clarified, “have we distorted our understanding of the meaning and potential purpose of emotional discontent? We have turned it into a malady from which we need to be cured?”

“You put it perfectly. And that's why people keep looking to novels, to writers, to the cinema, and to the theater to see emotional stories acted out and lived out. They don't consult psychiatric textbooks.”

Sadly, a month after I interviewed Szasz he died at his home in Syracuse. He was aged ninety-two. I was probably the last person to have interviewed him. But among what must have been some of his closing words on psychiatry, he leaves us with the following statements, which I summarize: It was hubris for medicine to try and manage realms of life for which it was never designed to treat. It had become deluded in its belief that its physical technologies, its electroshock machines, and laboratory-manufactured molecules could solve the deeper dilemmas of the soul, society, and self. Professional grandiosity had blinded both the industry and a growing public to psychiatry's serious philosophical and technical limitations, and this had been compounded by the demise of traditional systems of meaning that once provided alternative solutions to the riddles of human despair.

If Szasz was correct that psychiatry is misguided about what it could hope to achieve, I now wondered how our culture would alternatively respond to the millions of suffering people who each year seek out psychiatric drugs and explanations for their pain. I decided to put this difficult question to consultant psychiatrist Pat Bracken, who had also written extensively on the limitations of the dominant biomedical approach.

“There are no easy answers,” said Bracken with a sigh. “This widespread suffering may actually be a social phenomenon. Go back a few decades and you would have seen a much more central role for the church. The Sri Lankan anthropologist Gananath Obeyesekere has talked about this a lot, about the crucial role of culture in handling people's distress, giving people words, giving people paths, giving people rituals through which they can find some peace in this world. Religion has often played that role. But in a post-religious secular society, what happens when we don't have religion to do those kinds of things? What do we do then?

“While turning to medicine or therapy may be appropriate in some cases, this is a far bigger problem than can be answered by medicine or psychotherapy alone. What complicates things more is that we also live in a capitalist society, where there is always going to be someone trying to sell you something—whether a drug or a psychotherapeutic session. In fact, some people would argue that capitalism can only continue by constantly making us dissatisfied with our lives so that there is always something new to sell us. It is constantly in the business of churning up our desires. You know, if everybody said I am very happy with my television, my car, and everything else I've got, and I am perfectly content with my lifestyle, the whole economy would come shattering down around us.

“And that's one of the ironies of our current recession—we are constantly saying we must get the economy going, we must consume more, we must buy more, but this all relies on our dissatisfaction. So I don't have an easy answer for the question of what we can do with the huge numbers of the ‘worried well' who now rely on psychiatric drugs. But what I am saying is that it is a vast sociological, anthropological, and almost spiritual problem for human beings. So the idea that medicine is going to come up with a neat answer is far from the truth. In fact, the belief that it can is also behind the rise of antidepressants and other drugs. But the only people who have benefited from that are those working in the drug companies.”

Bracken felt that his many years working as a consultant psychiatrist had taught him that what we customarily call mental illness is not illness in the medical sense. It is often a natural outcome of struggling to make our way in a world where the traditional guides, props, and understandings are rapidly disappearing and where negative experiences often blight our lives. Instead, our dominant worldview is now driven by barely perceptible capitalist imperatives: to work, to earn, to attain profit, to succeed, to consume. Not all mental strife is therefore due to an internal malfunction, but often to the outcome of living in a malfunctioning world.

The solution is therefore not yet more medicalization, but an overhaul of our cultural beliefs, a re-infusing of life with spiritual, religious, or humanistic meaning, with emphasis on the essential involvement of community, and with whatever helps bring us greater direction, understanding, courage, and purpose. This is something way beyond what the medical model can offer, with its technological outlook and its financial entanglements with key industries in the capitalist machine.

“What may also be needed,” said Ethan Watters, “is for people to become de-enthused.” So long as people continue to defer to psychiatric myths of biological breakdown and chemical salvation, the status quo in psychiatry will remain, including its many worrying excesses. “So if psychiatry itself starts to lose some of its status,” continued Watters, “by having to start proving its legitimacy in terms of outcome studies, then that's all for the better, because consumers will know a little more about what they are getting and the enthusiasms will weaken.” Watters's view is that as people become more aware of psychiatry's excesses, yes, it will lose some legitimacy; but insofar as this will bring public expectations back into line with what psychiatry can actually deliver, the change should be welcomed.

While it was interesting for me to hear these various pleas for greater professional modesty, it also struck me how at variance they were with what was actually happening on the ground. We now know, for example, that consecutive editions of the
DSM
and
ICD
keep expanding the number of diagnoses believed to exist. We know that psychotropic prescriptions are rising year on year. We know that public dependence on psychiatry is at an all-time high, and we know that alternative systems of meaning through which we once managed and understood their discontent (religious, philosophical, spiritual, etc.) no longer have their appeal for increasing numbers. So if a greater professional modesty does not seem to be on the horizon, where do we go from here?

This moves us to proposition number two: reforming the relationship between the pharmaceutical and psychiatric industries. We have seen how the medical model would never have attained such power and influence without the financial backing of the pharmaceutical industry. But we have also seen how the full extent of this patronage has not been made fully transparent to the public. Again and again I heard from critics a demand for this culture of concealment to end.

In this area, at least, there may be a sliver of good news. I have already spoken about the Sunshine Act in the United States, soon to be implemented by the Obama administration, where doctors will be increasingly forced to declare their pharmaceutical ties. This may discourage some of the excesses we have seen by shaming the unscrupulous into more ethical behavior. In Britain the situation is less clear. Sue Bailey, for example, assured me that the EU has now formed an “Ethical Life Science Group,” which will keep better track of industry payments to institutions and doctors, and that the Royal College is now “conducting its own internal survey asking members to report whether the organization they work for receives industry money.” These changes are to be welcomed. But do they go far enough?

My belief is that until we have a national online register where you can freely check what a given psychiatrist, researcher, psychiatric department, or mental health organization is getting paid, and by whom, internal surveys count for very little because the figures will continue to remain a professional secret. After all, you have a right to know whether the psychiatrist who has just prescribed you or your child a powerful drug is being paid by the company who makes that drug. You also have a right to know whether a mental health organization that speaks favorably about antidepressants receives yearly donations from antidepressant manufacturers. Until there are public websites where such payments are made fully transparent and which therefore enable the full extent of the problem to become clear, the real debates about how to reform industry ties won't even begin.

Should there be limits placed on what doctors receive yearly? To what extent should industry payments be donated to charity? To what extent should unpaid voluntary industry service be obligatory (for which companies then reimburse the NHS)? These are no doubt thorny issues, which warrant long and hard debate. But right now these debates are not only avoided, they aren't even being proposed in the places that count.

This brings us to the third proposition: the changes needed in the training of our future psychiatrists. At present, much psychiatric training in the UK and United States provides only cursory lip service to academic critiques of the bio-psychiatric world view. Serious anthropological, sociological, or philosophical critiques of the medical model are seen at best as interesting sidelines to what psychiatrists actually do. What is generally not imparted is a thorough and lasting social, critical, or historical awareness of what trainees are participating in, how they are participating in it, and in what ways this participation ultimately sustains practices disadvantageous to the patient community. Trainees are not educated to doubt or even question the system in any constructive way, but only to be certain in its application. As one trainee recently put it to me, “The critiques are all very well, but I did not come into medicine to
critique
medicine but to
do
medicine.” The assumption here is that what one thinks has little bearing on what one does.

Until a new, critically reflective generation of psychiatrists emerges, nothing will change. But right now such robust critical thinking is far from being instilled in the new generation. As Pat Bracken said frankly regarding training in the UK, “What I hear from the trainees working with me is that the exams are very much heavily skewed toward learning facts, diagnostic categories, and causal models all framed in the medical model, as though you can teach psychiatry in the same way as you teach respiratory medicine or endocrinology.”

This point was also echoed by the consultant psychiatrist Duncan Double, who has studied psychiatric training in Britain. As he writes, in Britain today there is still “an orthodox medical approach to the problems of interpreting and treating mental disorders” and that “any challenge to this orthodoxy is suppressed by mainstream psychiatry.”

Double provided a couple of examples of how this orthodoxy plays itself out. He recalled a consultant psychiatrist who had a critical approach, but who confessed that he nevertheless trained his psychiatrists conventionally to enable them to prepare for the examination of the Membership of the Royal College of Psychiatrists. What troubled this psychiatrist most was not just that he was acting against his convictions, but that by the time these trainees had passed their professional tests their critical sensitivities had been eroded. Double also recalled a consultant in psychiatry who had once ruefully remarked that she had become “irretrievably biological” in her approach to psychiatry. Although this was regarded as an acceptable outcome of her training, she felt she was not able to deal with any criticism of psychiatry. In short, her training had closed her off not only to the limits of what she was doing, but also to any seriously considered non-biomedical alternatives
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When I interviewed Duncan Double I asked him for more specifics, beyond the anecdotal, about how training looks today. I asked whether today's trainees are obliged to read, for example, works by Dr. Paula J. Caplan, Professor Irving Kirsch, Professor Joanna Moncrieff, Professor David Healy, and others. “No, those sorts of books would be largely ignored,” responded Double, as though I had said something very naïve.

“But how about other critical perspectives?” I pressed. “Would there be any critical scrutiny of, say, the construction of the
DSM
, psychiatry's relationship to the pharmaceutical industry, of the biomedical philosophy of suffering, of psychiatry's wider socio-cultural history?”

“There would be very little of this, really,” said Double, who then explained that a serious problem with introducing these perspectives is that outside criticism of the profession is often too readily dismissed by many as a kind of anti-psychiatry. “The problem with this dismissive view,” continued Double, “is that young psychiatrists are often fearful of being identified with critical positions because they think it may actually affect their progression in their careers.”

If we accept that propositions one, two, and three are far from being realized, we could be forgiven for thinking that psychiatry's future, and therefore the entire mental health system, will continue along the same lines as at present. And this is why the fourth and final proposition seems to many the most important proposition of all: the public needs to become better informed about the current state psychiatry is in, and if the mental health industry does not reform, be prepared to vote with their feet.

Time and again, commentators on both sides of the Atlantic, who despaired about the likelihood of internal reform, raised this crucial point with me. As Breggin put it, “The only thing that is going to change things is if people literally stop going. My own belief is that this is because psychiatry is a money-making self-contained machine, which is by definition resistant to change from the inside.”