a long and lonely wait…

Posted on Monday 24 June 2013

by Pat Bracken, Philip Thomas, Sami Timimi, Eia Asen, Graham Behr, Carl Beuster, Seth Bhunnoo, Ivor Browne, Navjyoat Chhina, Duncan Double, Simon Downer, Chris Evans, Suman Fernando, Malcolm R. Garland, William Hopkins, Rhodri Huws, Bob Johnson, Brian Martindale, Hugh Middleton, Daniel Moldavsky, Joanna Moncrieff, Simon Mullins, Julia Nelki, Matteo Pizzo, James Rodger, Marcellino Smyth, Derek Summerfield, Jeremy Wallace and David Yeomans
The British Journal of Psychiatry. 2012 201:430–434.
[full text @ Mad in America]

Conclusion: Psychiatry is not neurology; it is not a medicine of the brain. Although mental health problems undoubtedly have a biological dimension, in their very nature they reach beyond the brain to involve social, cultural and psychological dimensions. These cannot always be grasped through the epistemology of biomedicine. The mental life of humans is discursive in nature. As Harre` & Gillet put it ‘We must learn to see the mind as the meeting point of a range of structuring influences whose nature can only be painted on a broader canvas than that provided by the study of individual organisms’. Reductionist models fail to grasp what is most important in terms of recovery. The evidence base is telling us that we need a radical shift in our understanding of what is at the heart [and perhaps soul] of mental health practice. If we are to operate in an evidence-based manner, and work collaboratively with all sections of the service user movement, we need a psychiatry that is intellectually and ethically adequate to deal with the sort of problems that present to it. As well as the addition of more social science and humanities to the curriculum of our trainees we need to develop a different sensibility towards mental illness itself and a different under-standing of our role as doctors. We are not seeking to replace one paradigm with another. A post-technological psychiatry will not abandon the tools of empirical science or reject medical and psychotherapeutic techniques but will start to position the ethical and hermeneutic aspects of our work as primary, thereby highlighting the importance of examining values, relationships, politics and the ethical basis of care and caring.

Such a shift will have major implications for our research priorities, the skills we teach our trainees, the sort of services we seek to develop and the role we play in managing risk. This represents a substantial, but exciting, challenge to our profession to recognise what it does best. We will always need to use our knowledge of the brain and the body to identify organic causes of mental disturbance. We will also need knowledge of psychopharmacology to provide relief from certain forms of distress. But good psychiatry involves active engagement with the complex nature of mental health problems, a healthy scepticism for biological reductionism, tolerance for the tangled nature of relationships and meanings and the ability to negotiate these issues in a way that empowers service users and their carers. Just as operating skills are at the heart of good surgical practice, skills in working with multiple layers of knowledge and many systems of meaning are at the heart of our work. We will never have a biomedical science that is similar to hepatology or respiratory medicine, not because we are bad doctors, but because the issues we deal with are of a different nature.

Understanding the unique contribution psychiatry makes to healthcare can only increase our relevance to the rest of medicine. All forms of suffering involve layers of personal history, embedded in a nexus of meaningful relationships that are, in turn, embedded in cultural and political systems. Kleinman & van der Geest have rightly critiqued the way in which medicine in general has come to see ‘caregiving’ in purely technical terms. Similarly, Heath has argued for the importance of relationships and narrative understanding in general practice. Psychiatry has the potential to offer leadership in this area. Retreating to an even more biomedical identity will not only sell our patients short, but risks leading the profession down a single narrow alley, when what is needed is openness to alternative routes.
As right as this is, it’s painful for me to read. It’s like having someone put the first chapter of my story at the end of the book. My reaction strikes me as odd. For someone who preseverates on Eliot’s Four Quartets as if they are some kind of divine text, it seems like I should’ve expected to read something like this commentary sooner or later:
    We shall not cease from exploration
    And the end of all our exploring
    Will be to arrive where we started
    And know the place for the first time…
    Little Gidding  T.S. Eliot 1942
And I should feel happy to read it. But I’ve never noticed that should and feel fit very well inside the same sentences. And when I’m being honest with myself, feel trumps should-feel every time. The reason it’s the first chapter of my story is that it’s what happened to me when I finished my Internal Medicine residency and my fancy NIH Immunology fellowship. Instead of going directly to the even fancier post-doc position I was headed for, the government announced that I was going to be a soldier and practice military medicine for three years whether it fit my schedule or not. And my protest that my own planned scientific and academic career were vital to the National Security were ignored.

My assignment was to a base in England where I was paid more than I’d ever made in my life, lived on an estate in a 16 room house on the National Registry, worked less than I’d ever worked, and had ample leave time to travel all over Europe for three years. It was the best conscription scenario ever devised in history. But there was a dilemma, almost from the start. I really liked practicing medicine, something that had never occurred to me. I was a scientist of the hard core variety and fate had played a trick on me. It got me doing what I obviously should have known was what I was supposed to be doing without my even knowing what was happening.

I’ve told this story a jillion times, and it always feels ingenuous to me, to claim that I had an identity crisis when I already had the identity, but I don’t know what else to call it. As much as I enjoyed medical school, residency, and fellowship, I think I had told myself that doctor was a credential. In fact, the post-doc I was pursuing was aimed towards a PhD in Mathematics. Seeing doctor as an identity was as confusing and unsettling a state as I’d ever felt. And over that first year, what I came to was almost verbatim what you read in this commentary – except replace the current paradigm of psychiatry with Internal Medicine practice. So I applied to the kind of psychiatry they are describing in this piece.

I found it, and was beyond pleased to have been so lucky. Flash forward a decade, I was directing a Residency, teaching medical students, practicing. All of that changed in a day, though it took a while for me to know it. For obvious reasons, I’d kept up with Biological Psychiatry being a science guy from conception. But what came was not just a new commitment to hard science, but rather something of a disdain for what the new post-DSM-III psychiatry replaced, and I had been part of that – actually a disdain for everything that’s in that article. It was spoken as a refutation of psychoanalytic theories, but in practice, it was any thoughts about the mind or the "layers of personal history, embedded in a nexus of meaningful relationships that are, in turn, embedded in cultural and political systems." That stuff was too flaky for what followed. When the new psychiatric paradigm came to the street where I lived, it was biological reductionism² and it was apparent to me I didn’t have another identity crisis in me, at least not that one, so I slid into a challenging but cloistered practice as a psychotherapist – and fit there just fine.

I was cloistered, but I’m not blind. And being in Atlanta throughout the reign of Dr. Nemeroff, I watched the transformation of psychiatry from a distance. I interpreted what was happening, the strutting and the crowing, as something like "it’s their turn." I blamed the changes in practice for so many of my colleagues on Managed Care when I thought about it, which wasn’t often. I withdrew from the meetings I’d attended in the past for obvious reasons. And I kept a low profile as people on the wrong side of disdain often do. What I didn’t do was pay enough attention to see the invasion by the Pharmaceutical Industry and the collusion of academic psychiatry – the things I now write about. I still feel no small amount of guilt about what I didn’t see happening, but I also think that if I had seen it earlier, I wouldn’t have been able to do anything but wave my hands. It was a downhill steam-roller with an enormous momentum, and people like me were persona non grata. I knew all of that, but I didn’t know who was pouring the jet fuel into that tank.

So when I read this commentary that mirrors the beginnings of a career that I actually feel like I got to have, I feel a sadness in the place of the sense of joy and hope I would like to feel reading it. Some of the sad is altruistic, thinking about damage done and opportunities lost. But I think a lot of it is personal – about having finally found an identity that fit but then no longer having a place at the table. If you read this blog, you know that my attachment to the ways and means of hard science are clearly still living and well [I never met a graph I didn’t like]. And I completely agree that the pre-1980 psychiatry had to change, but if this hasn’t been an example of "throwing the baby out with the bathwater," they ought to retire the saying. I wish this group the best in their attempts "to develop a different sensibility towards mental illness itself and a different under-standing of our role as doctors." If they see that as a new discovery, so be it. But it has been a long and lonely wait for it to come back around…
    June 24, 2013 | 11:48 PM

    A profession that could and did help so many people realize how normal it is to feel pains and insecurities—-

    you’re not alone in your sadness, but I trust you’re helping people now in the 3-d world and that you have your whole life.

    You may actually, at this stage in your career, be both cutting edge and experienced.

    June 25, 2013 | 1:27 AM

    What a moving, thoughtful, and insightful piece. Being on the opposite end of you career-wise, I’m very encouraged by these developments. I’d like to think that psychiatrists who finished training in the last few years are more clearly able to see the flaws of biological reductionism than those who were caught up in the biological psychiatry boom of the 80’s, 90’s, and early 2000’s. But that’s probably a bit too optimistic…

    June 25, 2013 | 1:52 AM

    I am actually hopeful “that psychiatrists who finished training in the last few years are more clearly able to see the flaws of biological reductionism than those who were caught up in the biological psychiatry boom of the 80?s, 90?s, and early 2000?s.” It reminds me of a similar phenomenon in the tumultuous 1970s. Those of us in analytic training were a different breed from the old guard in control, but were unable to have much impact. People like Robert Spitzer, Aaron Beck, Mel Sabshin, Allen Frances, etc. had to flee and go their own way to escape that rigidity. I think the problematic bastion in psychiatry right now is much more vulnerable because the pharmaceutical bank-roll is evaporating at a brisk pace, and the forces for reform are more powerful. More importantly, they’re finally beginning to come from inside psychiatry itself. So, I would see your optimism as justified but still far from assured. Keep writing. You’re on the right side of the wind…

    Philip Thomas
    June 25, 2013 | 8:47 AM

    This is a deeply moving, powerful piece, and as a co-author of the ‘Beyond the Current Paradigm’ paper I want to thank you for writing it, and having the courage to do so. Your piece has an important lesson for us all – the value of looking honestly at ourselves and our lives. Once again, thanks for posting this, and best wishes.

    Steve Lucas
    June 25, 2013 | 8:50 AM

    Wonderfully said, we all seem to return to where we started, regardless of our field, with a deeper understanding of that old phrase: You can never go home again. There is too much life between the start and the return.

    Steve Lucas

    Roger Pumphrey
    June 25, 2013 | 5:25 PM

    Thanks for your thoughtful comment.I stopped going to our local psychiatric meetings when they became only a platform for pharm talks. I am not encouraged by anything in the recent past concerning my profession, which thankfully has many branches to the main trunk of the psychiatric tree. However, I entered the profession because of a calling to help others in their suffering and a need for self awareness. In the journey of now 40 years I feel I have brought the biological aspects, the spiritual and the humanistic ones, as well as the analytic aspects of being human into my work. What more can be done? Possibly to just continue with honest self examination so I can be of better service to others in the future.

    June 25, 2013 | 7:16 PM

    It doesn’t hurt sometimes to recognize that big pharma’s bad influences is not limited to psychiatry.

    June 25, 2013 | 7:16 PM
    June 25, 2013 | 7:29 PM

    What is psychiatry emblematic of? “Hear the lie enough and it becomes truth.”

    The arrogance and frank defiance of the “old guard” is pathetic. I still get this stupid APA Psychiatric News periodical now over 1 year and reading in this week’s issue about Lieberman’s front page extort of “I’m mad as hell and won’t take it anymore” claiming to be outraged like the character of “Network”, yet, outraged about what?

    Oh, it gets mentioned in the inside pages. Big pharma is bailing on psychiatry, and these pimps and whores are outraged their funding is drying up. What a bitch!

    And yet there are still too many members who should know better than to be members. Not the entrenched, retired, “what’s in it for me” mentality crowd, but the new members at least. Are they that easily brainwashed?

    Oh yeah, that “hear the lie” thing, I guess it works still.

    Happy June.

    June 25, 2013 | 8:19 PM

    I read that Psychiatric News article today too. The “I am outraged” Lieberman article was depressing. But what really got me was how he kept on saying that Psychiatric Neuroscience has produced “astonishing” and breathtaking insights into the causes of mental illness and novel treatments. Seriously?

    Sandra Steingard
    June 26, 2013 | 8:45 PM

    Thanks again for a great post. This is a link to my blog which is in part about/inspired by this post and much else that you have written.
    I hope I captured your perspective reasonably well.

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