What if psychiatry is wrong? I ask myself this question quite often. As a patient, because I find it hard to believe my diagnosis and I hate taking medication; as a doctor because I need conviction to treat my patients well.
This is all fine and good, but psychiatry is not a single entity. I don’t have any doubt that things go wrong with brains – if, for example, hearts can sicken, then why not the most complex organ in our bodies? But psychiatry is a construct, brought together from history, science, sociology, philosophy and more. It incorporates morals, and sometimes opposes itself. Critical psychiatry rightly asks questions of more traditional psychiatry, but even within this movement there are many changing views. Psychiatry also arouses emotion, perhaps more than other branches of medicine, for example as regards labels and treatments.
For me, I think it’s about the supremacy of the brain or mind within the body. Inside my head is what I am, and I can’t observe it from the outside, like my hand, or even my heart. I reach down into my body, but I’m not in it. My experiences are the only ones that I have for reference. When I was a child, I believed implicitly that they were true, and I suppose I still believe this, but it leaves a few questions about what came before my birth, or even when I sleep. And is memory reliable? We are only ever at that moment of present, so cannot rely on anything that came before, or that we are told by others.
Psychiatry is constructed by psychiatrists, and there is nothing wrong with this. Buildings should be built by builders. But we have to acknowledge that there will be different interpretations, and we have to be open to these. Listening and questioning are vital.
Diagnoses are usually made from linking groups of symptoms; the more you have of any category, the more likely that you have that particular diagnosis. This may work well in a very unwell patient with an apparent psychotic disorder, in that the doctor will rely less on the patient’s history and more on what they see. But it’s not so good if patients conceal their symptoms, or lie about them, or even just get them wrong. Psychiatrists get things wrong too – they hear one symptom, and look for another that fits with their thoughts, ignoring another that doesn’t.
We make diagnoses, however, so we must believe there is some benefit from them. One is that you have a label – you can say to your family, or your boss – I have depression. It’s been diagnosed, and it’s clinical depression. There are potential advantages around benefits, validation, and hope that you can get better. The other is – that you have a label. This may be stigmatising, it may be incorrect, it may get changed. You may be advised to take treatment with which you don’t agree, and in some cases forced to.
Personally I accept rather than fully believe my diagnosis. I actually want to believe it, because life would be far easier if it was black and white. But every time I nearly relax into it, that voice pipes up – I don’t think so! You weren’t depressed enough, you could talk to people, the timing was all wrong… And I think how could I have a real illness when I have no idea how it should feel? I am a trained psychiatrist, I can and do make diagnoses, but I am the only person whose head I will ever get into. I have no real reference points.
The other big issue is treatment. We have quite a lot of drugs, but there’s a certain sameness about them all. Many have unpleasant side effects, and we must discuss these with patients. Often a particular drug can be picked for its side effect acceptability for an individual patient. One question I’ve heard asked is whether these drugs cure people, and the answer is probably not. They control symptoms, and make illnesses more manageable, but they’re not like antibiotics. However this is the same as many drugs used for other chronic physical conditions – we can’t cure diabetes or hypertension with drugs (yet), but we can manage them. We can also sometimes help people to improve them with lifestyle changes, and we need to do more of this in mental illness, too. Unfortunately it requires considerable resource to do properly.
I take medication because I am advised to. I take it because my partner believes it works, and because I worry that I would lose my job if I don’t comply. When I am less well, I take it for the same reasons, and also because I hope it might work, without ever being completely convinced. And of the three drugs I mostly take, I stop them in order of side effects, as I suspect most other doubters do.
There is a power imbalance in psychiatry, which is acute as a patient. Unlike any other condition, you face unbelief, and you face being awarded a range of diagnoses, some of which are more acceptable than others. If there is a disagreement in views, the psychiatrist will likely be believed before the patient. You also face treatments where the risk must clearly be discussed with you, and balanced against the benefit. You may also receive great support from mental health professionals, many of whom are very kind, but this must include support to ask questions.
Most psychiatrists do their best, and we definitely need a framework, guidelines, agreement as to what is acceptable and has an evidence base, and what is not. Without this things would be far worse. But sometimes it’s the most junior trainees who ask the best questions, before they’ve learnt what it is to be a psychiatrist, and we must listen to them. And sometimes it’s the patients, the ones who know nothing of psychiatry, or what they ought (in our words) to say. We need to listen to them before they are changed by psychiatry.