Why is psychiatry more value-laden than many other specialties, or at least perceived as such? I’ve been reading the views of the anti-psychiatry folk recently, and they trouble me; however, strangely I also find those who hold the opposite views quite troubling. And I think that this is because as soon as there are opposing views, the views held stop being about the facts and become more about both what we believe and what we want to believe. It is actually impossible to be right, if indeed that has a meaning.
This is, of course, more likely when the facts are hard to come by, or perhaps not clear. We might, for example, accept that there is statistical evidence that antidepressants can lift mood; but look askance at someone who tells us that this is because they fix a chemical imbalance in the brain. How can this be true? Where is the proof? And, when we start doubting that, it becomes harder to believe that they can work at all. This can create an unfortunate situation, from which doubt grows, and the original evidence is discarded.
I take lots of medication, and I can’t imagine what it does to my brain chemistry. I have side effects, but not too many, and perhaps this is just good luck. I think it’s easier for me not to ask too many questions, though, that way it doesn’t create incongruity between potential, vastly different views. I’m also a psychiatrist, so I may be interested in them; but not when it’s me.
It’s even worse with ECT. I’ve been accused on social media of wanting to fry my brain and suchlike. It is barbarous or lifesaving. Maybe both. Sometimes I just think – nonsense! But at other times I think – why do they think I would want to fry my mind? And it ties into my equally value-laden fear that one would only choose such drastic treatments if one had a disordered personality and was seeking the attention that would go with this. I don’t believe this. But why am I having to believe anything?! I have a severe mood disorder that responds to treatment.
There are difficulties, though, which I have written about before, one being the change of my diagnosis between bipolar and depression. One can literally have two psychiatrists saying, ‘Well, he said you have bipolar, but I believe you have depression,’ and then later changing his mind. I don’t actually resent time to diagnosis, I know it’s hard; it’s that old ‘believe’ word again. I used to query the old personality disorder label quite often, and I still do internally. But that, in itself, is a weird value-laden concept – if I say I have a personality disorder, then I don’t, and vice versa. I don’t know many people who would like such a diagnosis, but that’s much more about its associations than its true meaning.
I do also wonder whether these dichotomous beliefs are held more by people who have experienced some sort of mental disorder themselves, and possibly experienced treatment. Or it may be that they have family members who have had the same. And I think in many ways that this is much more understandable – there is emotion, and perhaps a desire to protect others from something they think is harmful. On the other hand, someone who holds and spreads such beliefs without any personal experience, and perhaps more for career advancement, is harder to understand.
Maybe all this is why I chose to work in a specialty that seems more black and white – dependence on alcohol or opioids has much clearer signs and symptoms than many other psychiatric diagnoses. But I am probably wrong. I can treat their dependence, but what about the many comorbidities – including mood disorders, psychotic illnesses, trauma and all sorts of anxiety disorders – that nearly all my patients have? These can be hidden by their substance use, and very often untreated for similar, belief-related reasons. I have heard many discussions about whether someone has depression or an alcohol disorder – sometimes I wonder if it even matters, if it has become just another academic discussion beloved of psychiatrists? Is it that we want to be right? Or do we think that this can, firstly, be proven, or, secondly, will make any difference to the way we manage the patient.
So, what is the solution? Is it to just stop trying, to acknowledge that we cannot ever really know anything for certain? I don’t think so, I think we should always continue our search, because it makes us human, and is something we need to do. And it is right to try to seek the best for ourselves and our fellow people. But, we must recognise that we are often wrong, and we must stop assigning so much value when we don’t have any proof.