This is a question frequently asked, and unsatisfactorily answered. I don’t know the answers, and I won’t pretend to, but I find it quite a difficult dichotomy – along with many others in the field of mental illness. I once worked for a psychiatrist, years ago, who took the trouble to reassure me that he thought that my illness was biological. The very fact that this reassurance was required reflects badly on us both, I think. But I was inexperienced and vulnerable, and just glad that someone seemed to think that I had a “genuine” illness.
The sciences of biology, psychology and their interface are complex, and continually evolving; but what interests me more is what these terms actually mean to people. There is little doubt that they can be laden with preconceptions and long-held beliefs, and often with emotional and moral overtones.
There can be an assumption that psychiatrists go for biology, and psychologists for psychology, and this is probably driven by the artificial divide in the tools at our disposal – we have drugs, psychologists have therapies. It would be quite hard to continue in our jobs without the belief that these actually work; and without a major reshuffle of roles this will continue. I like to think that my assessments involve psychological and social constructs as well as those of biology and “disease”, but ultimately I am usually offering drugs. There may well be a wide range of therapeutic input from other practitioners, but they, too, will come to me when they want a review of medication for the patient.
The problem is that our biological responses – drugs – remain less than perfect, and even when they seem effective, side effects can be problematic. Analogies may also be drawn to the psychological approach, but this is often seen, rightly or wrongly, as somehow better, or cleaner, than drugs. With psychiatric illness there may be a need to get to the bottom of things, and medication can be seen as an ineffective plaster, or even as something which is unhelpfully blocking feelings, and preventing understanding.
I don’t know what I think about any of this. When I was first ill, both I, and those close to me, thought that there was something underlying – that if we could only identify it, this would solve all my problems. We never did, although at times I occasionally still wonder. Was it my relationship with my parents, my lack of confidence, my uncomfortable stagger through medical school and beyond? Or was it my genes? Was this an illness, like any other, that would have struck me unawares, whatever? For me, it always comes back then to responsibility and guilt – which in themselves are seen as symptoms of a biological illness. I can’t win – or even lose, I suppose.
Moving away from my own experiences, it can be even harder looking at other people, and more so as a professional. I think, as a psychiatrist, that there are some people, often with schizophrenia or bipolar disorder, who are clearly seen to have biological illnesses. In fact, there are many others – OCD, anorexia nervosa, addiction, to name but a few. But for everyone, there will be psychological aspects, as there are for anyone who interacts in any way with the world and others. Yet sometimes symptoms and signs are put down more to behaviour, or personality. Some of these people will have a diagnosis of personality disorder, but not all, and not exclusively. There is a definite tendency for professionals to make an often quite subjective decision as to the patient’s ability to control their behaviour, or if it should be put down to a biological illness. We may even decide which of an individual patient’s behaviours are illness, and which are not, which seems actually quite remarkable (or unlikely). And who knows what an illness does to someone, and how they can be affected, both directly and indirectly? Medication and hospital environments don’t help, I have found to my cost.
Forgetting professionals, what do patients believe? A lot of people are comfortable with a clear biological model, that they have a shortfall of serotonin, and that pills will help. While that is too simplistic, I don’t blame them at all, and, in any case, that is what has been fed down by doctors. The success rate of treatment may not totally back this, and biology rarely operates in isolation, but at least it lifts the burden of responsibility and promotes compliance. I would personally like to believe this, I just find it difficult in relation to myself.
Others prefer a much more psychological model, one engrained in personality and past experiences. This can seem entirely reasonable, particularly for those who have experienced trauma, and a psychological approach to treatment may be preferable. But what if your biology is out of kilter, either as a result of trauma, or simply coincidentally? Many would agree that pills may help. But some, both patients and practitioners, are very anti-medication. Interestingly, this implies perfection in biology, that brains cannot go wrong. I don’t think many would deny that all of the rest of the body can go very badly wrong, and that medication can be necessary, so why not the brain? Of course, it is less visible, and acceptance of this does require a leap of faith.
I would quite like to be a psychologist, or even a psychotherapist, as I think that the work they do is both interesting and valuable for patients. I’m less convinced by attempts (often driven by resources) to shorten therapy or deliver it online, as, at a very basic level, it is so often about understanding oneself and others, and that is not quickly achieved. My psychiatrist would probably say, quite rightly that I’m not a fan of psychiatric medication, but that doesn’t mean that I don’t also have a strong belief in biological psychiatry. I’m just rather less convinced by the treatments, and repelled by their adverse effects.
Ultimately I remain unsure what I believe – I could probably be described as a psychological patient trapped in the body of a biological psychiatrist. Uncomfortable, but united.