It’s the worst thing we could have done: years back psychiatry “rebranded” itself as “Mental Health Services” – a pernicious and meaningless phrase. Now I’m beginning to think that in order to save psychiatry as a profession, as a medical specialty, we need a divorce.
It’s not you, it’s me
… Well actually, it’s some of both of us. For our part, the American Psychiatric Association and the DSM 5 task force seem hell-bent on dragging our profession into idiocy and ridicule, proposing “diagnostic” categories like “temper dysregulation with dysphoria” for children, and “non-suicidal self-injury disorder”. Pleh, I say to that. And meh also.
Even the major disorders have become pretty wet. Major depressive disorder simply requires 2 weeks or more of pervasive low mood and/or impaired enjoyment, with a bunch of other very non-specific symptoms. Many of us would scrape into those criteria when in an ongoing stressful situation. Do we then have an illness? The recent national mental health survey in Australia trumpeted – almost proudly – that 47% of the population would suffer major depression during their lifetime.
…
If half the population get it (and it’s not part of ageing) how on earth can we call it a disease?! And yet this is what we do in “mental health services”.
So why do we do this? I think there are a number of reasons. One is that we don’t have pathophysiological definitions of psychiatric illness; we can’t do a blood test or a clever brain scan and tell what disease you have. We can’t even be crystal clear on history, as there is such overlap between different diagnostic categories (as currently defined), and so much variation within those categories. Some people (Thomas Szasz, I’m looking at you) take the simplistic and concrete view that therefore there is no such thing as psychiatric illness, but that’s foolish. It simply means we haven’t been able to pin it down – yet.
What society wants
… what it really really wants …
The other major factor, I think, is the pressure that (Western) society places on “mental health services”. What is that pressure? At the risk of sounding cynical and jaded, western society wants us to take all the weird, non-conforming, disturbing, or dangerous people … away. Honestly, society would be happy with that. Helping desperately ill people is what psychiatrists want to do, but that’s not what drives mental health policy and legislation.
As a consequence, we are required to see anyone with “mental health” problems. So what does that mean? … What doesn’t it mean? Who on earth has perfect mental health?? Perhaps the Dalai Lama, but the rest of us? Nah.
Anyone dangerous who seems a bit weird gets dragged in to see us. Anyone who harms themselves deliberately (or where someone thinks they might have done, or even thinks they might be thinking about it) gets dragged to see us. At first blush you might think that’s ok, but let me illustrate what it means, in an acute team like mine, and all I have worked in or with previously.
Someone gets swindled out of a bunch of money, has a huge argument with someone over it, and ends up dragged by the police to see us. Someone commits fraud, faces prosecution and possible incarceration, is stressed and says they’ll suicide if they go to prison … they become our problem. Someone is intoxicated and causing a disturbance and someone thinks they’re “at risk” or behaving oddly (remember: intoxicated…) – or if they’ve seen us before … They get dragged in to see us.
Meanwhile, what happens to those with real serious psychiatric illness? Those whose brains, and the rest of their bodies, just work wrongly, in such a way that their thinking, emotion, and function are markedly disrupted. What about them, when we’re so busy seeing drunks and cuckolds and the variously stressed that we have less time and resource available than is needed to provide care of proper quality?
They get sub-standard care. They get care based on factors other than their illness, such as how dangerous they are.
It’s all real
Now I’m not saying that all those other people don’t experience significant distress. I’m not saying they don’t need help of various kinds. I am saying they don’t need to see a psychiatrist. They’re not crazy. They’re not diseased. Why have them see a doctor? Somehow psychiatry has allowed itself to become a tool almost of social control.
Again.
If I can dream for a moment, I’d like psychiatry to return to medicine. To join the other medical specialties in the hospital and outpatient clinic. To perhaps consult to “mental health services” on some of their “clients” and “consumers”, while we get on with treating people with serious illnesses (you know: patients, like other, “real” doctors have…), and helping them regain as much of a normal life as possible.
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excellent summing up Raf, and I found it very thought provoking and interesting. Particularly when i look at it from the viewpoint both of an historian and as a teacher.
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I read this before, and agree fully. I have also read your next one, about compulsion, and the effects of that on what we actually do in psychiatry. Or at least what we are called upon to do.
It does seem that there is a complete reversal of what pertains in other branches of medicine, especially surgery. There, socially determined wants or needs are satisfied on a voluntary basis in the private sector primarily. Public surgery happens when the person is very ill and needs intervention, often urgently.
"Mental health" a name designed to emphasise that really these people are NOT ill is increasingly designed around the control of people who are unsafe to themselves or others, rather than the diagnosis and treatment of illness.
I have recently seen a person whose psychologist has diagnosed "burnout", and has further advised that what is in fact a severe depression most likely in the context of bipolar II, will require complete cessation of work, and a lot of time to recover. The end result is a patient who declines medication as she just needs to rest. Purely social explanations of illness have been devalued in other specialties, as logic emphasises that there is an interplay between genes and environment. Without ignoring environmental issues, we need to rescue psychiatry from the anti-biology camp.
Good writing
Allen
Quote: Meanwhile, what happens to those with real serious psychiatric illness?
Who are they? How would you know if you ever met one? Your studies are conflated by cases of more or less conscious trouble makers. And the trouble makers aren’t necessarily the people you end up seeing as patients. If they appear confused it’s very often that they are dazed and thinking, “What the hell happened?”