says Frances…

Posted on Sunday 25 September 2011

Why Psychiatry Is Wonderful
Even If DSM 5 Isn’t
Psychology Today
by Allen J. Frances, M.D.
September 23, 2011

I recently experienced the odd coincidence of receiving two separate emails on the same morning each asking almost the very same question- how can I remain so high on psychiatry while at the same time being so critical of some of its recent trends and so fearful of the likely future harmful impact of DSM 5. My answer came easy- the first thought was straight out of Hippocrates. As psychiatrists, we heal whenever we can, we provide empathy and consolation whenever we can’t. Our field is blessed with powerful and varied treatment tools- both psychotherapeutic and medication- allowing us to achieve treatment results better than those in most of rest of medicine. A majority of our patients receive substantial benefit, a substantial minority recover completely. We are good at listening, caring, and using our experiences and personalities in the privileged journey of helping others to heal, adapt, and solve their problems.

The recent explosion in neuroscience knowledge is forming a rich and solid basic science foundation for the clinical practice of psychiatry. Admittedly, the truly remarkable findings still have very limited application to clinical work, but the future is bright and we are embarked on perhaps the most exciting of mankind’s intellectual explorations. The brain is by far the most complicated thing in the known universe and our field is central in accumulating an understanding of the ineluctably complex processes by which it creates mind, consciousness, and behavior. Psychiatric practice requires you to be a combination of doctor, scientist, shaman, philosopher, and healer. It is a good life and a high calling…

Psychiatry goes wrong when it over promises and under delivers. Not all of life’s myriad problems are psychiatric illnesses. Not all psychiatric disorders are ‘chemical imbalance’ or amenable to simply taking a pill. There is no shame in admitting that we still don’t understand the causes of mental illness – the rest of medicine deals with much simpler organs, but the causes of most illnesses remain obscure. Although we have general outlines that are valuable in guiding treatment, each person is unique and each treatment regimen must be something of a trial an error experiment to custom fit the needs of the patient. If patient and psychiatrist work and think hard and put their hearts into it, something good usually happens.

Psychiatry does best when it sticks to doing what it does well. Let’s treat the disorders we know how to treat in people who really need help. The greatest problem in the past fifteen years of psychiatry has been diagnostic inflation and the over treatment of people who really don’t need it. This misallocates scarce resources away from those who do most desperately need and can most use our help. I fear DSM 5 because it threatens to further medicalize normality and spread psychiatry too thin. Psychiatry is wonderful when done well and within its appropriate limits.
Last night, I was driving the 60+ miles to Atlanta to go to a gathering of colleagues before I read this. I was thinking that I’ve really enjoyed being a psychiatrist. It was a great way to spend my life. No regrets. But I really haven’t loved being in Psychiatry. So long as it’s one patient at a time, it has been an honor. But when it expands to big things, I find myself getting lost – particularly in these confusing times. I think the real thing that has me leaning into the Australian Better Access is that it’s about access to trained clinicians. I believe that trained clinicians help people. I’m not sure that programs necessarily can.

But back to Dr. Frances’ piece. I think he’s enjoying looking back over his time in grade as much as I seem to be. It has been something of a crazy ride – the general disillusionment with depth psychology, the rise and fall of deinstitutionalization and the community mental health movement, the coming and perhaps going of quaisi-biological reductioninsm. Viewed from the current vista, each of those things looks pretty tarnished, but in truth each has added something to the general understanding of mental illness. We seem to be at our best when looking at single cases or small cohorts, and at our worst when looking at the big picture.

That may be the lesson. I joke about the criticism about being an n=1 psychiatrist, but back when I was an internist, I guess I was an n=1 internist too. At any rate, Allen Frances’ "If patient and psychiatrist work and think hard and put their hearts into it, something good usually happens" has been my experience too…

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