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The perils of moderation: Why claims to occupy the centre ground in psychiatry impede radical change


I am a vocal critic of biological psychiatry and, like all of us on this side of the debate, receive regular criticism (and sometimes personal attacks) from those wedded to the ‘illness like any other’ approach to human suffering. One response I regularly hear from mental health professionals is something akin to, ‘We provide an eclectic service, offering a range of bio-psycho-social approaches’. Although this sounds, on first hearing, like a perfectly honourable and worthy position to adopt, further reflection reveals it to typically be a misleading and evasive mantra.

The eclectic argument is a seductive one. After all, a moderate middle-of-the-road view of a process is always preferable to an extreme one, isn’t it? The idea of adopting a centre-ground position oozes reasonableness and understanding, a willingness to listen, retain an open mind, and implement interventions of all kinds, in contrast to those fanatics screaming for a radically different approach. And surely it is optimal to offer service users a choice so they can select from a menu of options the kind of approach most suited to their needs? No right-minded people can criticise this egalitarian position, can they? Well, yes, they can and I’m going to give it a go.

Further examination reveals these claims and assumptions, if proffered by professionals embedded in Western psychiatry’s core services, to be deeply flawed and obstructive of progress to an eminently better way of responding to human distress and overwhelm. I will highlight three points to support my position.

1. Existing psychiatric provision is enduringly skewed towards biomedical approaches
The status quo does not provide an even playing field. Indeed, the current provision is so grotesquely skewed towards a biological, ‘illness like any other’ approach that any claim to be offering a balanced model of response must be illusionary or insincere.

A person presenting to psychiatric services describing emotional distress and overwhelm will undergo an assessment process principally aimed at identifying the presence of an assumed ‘mental illness’. Subsequently, a diagnostic label – provisional or otherwise – will be attached to the person. Once categorised in this way, psychotropic drugs will almost always be offered as a crucial component of the ‘treatment’, an essential requirement to rectify the assumed biological abnormality. This traditional approach to human suffering continues to dominate; eavesdropping on the communications within a weekly clinical meeting of mental health professionals would provide convincing support for this assertion.

The existence of a multi-disciplinary team (comprising social workers, psychologists and occupational therapists, as well as doctors and nurses) rarely translates into the delivery of a balanced, bio-psycho-social approach to the management of service users in their care. Power imbalances (with the psychiatrist omnipotent), together with a pervasive biomedical culture endemic within managers and most mental health professionals, ensures that the token presence of a couple of people offering talking therapies or help with social needs does not dent the dominant biological orientation of core provision.


2. Dubious claims to provide a balanced approach collude with the status quo
The misguided – or insincere – claim that an existing core psychiatric service is already providing a balanced approach effectively deflects criticism and avoids the need to consider radical change. During my many years of working within community mental health teams, and subsequently from my interactions on social media, I have heard professionals defend the existing system with a range of assurances of their reasonableness:
‘I am a social psychiatrist’
‘I refer a lot of people for talking therapies’
‘I’m an eclectic practitioner’
‘We have a truly multidisciplinary team where we respect each other’s viewpoint’
‘Our psychiatrist always listens to his colleagues in the team’
‘We adhere to a bio-psycho-social approach and reject the “one size fits all” view of mental health’
‘As a psychiatrist, I’ve always supported vocational projects within the service’

Even when expressed with sincerity, these type of statements give the impression that the existing psychiatric system is generally fit for purpose, requiring only a little tweaking around the edges in order to provide an optimal response to human suffering. It fails to recognise that, in contributing to the inertia around the need to change, such pleas of existing balance collude with an overarching model of mental health that routinely damages and stigmatises its service users. (In some ways it’s akin to pleading political moderation while embedded in the apartheid system of 20th-century South Africa).

3. A moderate, middle-of-the-road approach will not achieve radical change
It is unrealistic to expect that the biomedical dominance within Western psychiatry will be sustainably dismantled in incremental steps (See earlier post).  Vested interests, and entrenched culture,  will stubbornly resist any in-house evolution towards a radically different approach to human suffering. Consequently, even when some practitioners in the psychiatric system are offering genuine alternatives to the ‘illness like any other’ doctrine, these worthy efforts will be insufficient to trigger an organic transformation of core practices. On the contrary, enduring, radical change will require a hefty dose of revolutionary energy (See earlier post).

And meanwhile, the lifespan of biomedical psychiatry will be prolonged resulting in many more service users being let down, damaged and stigmatised.


In summary, there are three reasons why claims by mental health professionals (at least from those embedded in core psychiatric provision) to be offering a middle-of-the-road approach are misleading and unhelpful:
– Such claims are often inaccurate;
– Such claims collude with the status quo by implying that radical change is unnecessary;
– Such claims unrealistically suggest that the urgently-needed transformation can be realised organically by innovation from within the system.

So be wary of those in the psychiatric system who claim to be offering a balanced approach; wittingly or not, they may represent one of the major obstacles to the development of a more appropriate and enabling response to human suffering.


Photo courtesy of Stuart Miles at

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