The idea that a psychiatrist could feel disempowered by mental illness may well seem ridiculous. Even when that psychiatrist is also a psychiatric patient, the notion may raise an eyebrow or two, although I am well aware that my professional position can put me in a position of power. Perhaps this knowledge is what also makes me feel so disempowered when I am a patient.
As a psychiatrist, I see people at times when they are low and crushed by life, perhaps seeking a diagnosis, perhaps not. Given that I work in addictions, many of my patients may also want a particular prescription, and they may seek support for their accommodation and their finances. They may seek psychological therapy, which is hard to come by and has long waiting lists. I know what is available, what I can and cannot offer. I may not always agree with them about what is best. I know what the diagnostic criteria are for different illness, and also when symptoms are less likely to point to a particular diagnosis.
But I can rarely fully appreciate each person’s beliefs, their background, and what may be right for them. I work with what I have, and I do my best, but I am well aware of the limitations of psychiatric services. They are understaffed, and of necessity deal with crises and emergencies, and with managing risk. Patients are often confused by what is offered, and by the need that services have to shed rather than nurture them.
Stigma is widely spoken of, and there is far more acceptance of mental illness than there was even twenty years ago – or at least of some mental illness. But there is still a reluctance to make diagnoses, at least some of the time. This can be very reasonable – it may not be helpful to make a diagnosis of schizophrenia after one psychotic episode, especially if other factors, such as drugs, were involved. But perhaps it’s important to mention it. Nothing is more frightening than that which isn’t talked of, and people jump to their own conclusions, which are often worse.
Being disempowered can be worse than feeling stigmatised, as you can rail against the latter. The former, by definition, tends to derail you. For me, like many others, diagnosis has been an area where I have felt unincluded and paralysed over the years. As a psychiatrist, making the right diagnosis may feel like an intellectual challenge, sometimes even a competition with previous diagnosticians, but it’s very different for the recipient.
I was given a diagnosis of depression then bipolar disorder, then back to depression, then a return to bipolar disorder. As a health professional, I was perhaps more worried than most that I might have a personality disorder, and I was well aware of the emotions, and even criticism, that such a diagnosis could engender. These shifts between diagnoses were not reassuring. But perhaps more importantly, I never felt that I was really a participant in any diagnostic process – it was more something that happened to me. In fact I suspected relatively early on that I might have bipolar disorder, but feared that if I suggested it, it would probably be refuted. So I became a very passive recipient of others’ opinions, unable to debate or even ask questions. And I think it’s important to say that this was not about my specific clinicians, but more my impression and experience of the whole system of psychiatry.
This has not only affected my experience of diagnosis, but also of treatment and support. My psychiatrist has been very good to me, but suggestions come from him, and on the few occasions when I have raised something myself, I have felt that I have come across as combative, or that I am asking for something inappropriate. I’m not sure whether I appear confident or not, but I certainly don’t feel it.
If this is how I feel, I can only imagine that it is worse for others. Many people have an impression of psychiatry from the media, from films and literature, and from other people. As psychiatrists, we should try to understand their ideas, not dismiss them as misconceptions. Even if done kindly, patients may be left bewildered or angry, and unable to participate. And I think that health professionals, especially those who work in mental health, may sometimes be at a particular disadvantage, because they know too much, including what is likely to be accepted or dismissed. But for those in the know, or out of it, the system can be a minefield to navigate. Symptoms and experiences don’t fit into neat little categories, or always warrant easy interventions, and those who don’t fit the bill can often feel rejected.
Mental illness is a reality, but psychiatrists have to use constructs to make sense of what they see, and to understand and attempt to treat people. This is fine, but patients don’t have the same constructs, and even different clinicians will have different ones. As a psychiatrist, I try to work with this, but as a patient I really struggle. One can fight, or argue, but even having to do so is a sign of disempowerment, of knowing that you are not on the winning side. Ultimately, for some, there is fear of compulsion, and once you’ve been on the other side of that – ever – it changes your view, in a way from which it is difficult to recover. Fortunately my experiences of this are minimal, but it is one of the reasons why I work in a specialty where it is rarely used. When people are very unwell, they may also require more paternalistic care, but this should always be balanced and considered, and it may be that their friends or families can be more empowered in such circumstances.
I would argue that disempowerment may be a subtle form of stigmatisation that we need to notice before we can address it. It may make life a little harder, but it’s the right thing to do.