Psychiatrists alleviate mental illness – don’t attack them

Taking in the bigger picture. Mrbill78636, CC BY

Psychiatrists are here to try to make sense of the complexities of human behaviour in those who see them, and to help them get better. Many of those who are seen by psychiatrists are very ill indeed, and suffer greatly – hence the battles psychiatrists face are in understanding the causes of mental illness, treating their patients, and convincing others in society that mental illness needs to be taken seriously and adequately funded. This is needed both for research and clinical service, and to a level that equates to its huge burden on people and society.

David Pilgrim’s recent article in The Conversation argued that the profession is in crisis because the President of the World Psychiatric Association announced a commission into what psychiatrists in the future will look like. He referred to a mental health industry, where players jostle to have pre-eminence in diagnosis and treatment.

Serving people with a mental illness is not really an industry, in the sense of production and the implication of making profits. Pilgrim uses terms such as “winning the battle” when referring to the different professions –psychiatrists, clinical psychologists and others – emphasising rivalry between them. But the really important battle is the one that faces the psychiatrist every day in the hospital, clinic or community – and it is fought alongside his patient.

Biology and eugenics conflated

Services to help those who suffer tend to evolve and are often led by those who are most motivated to help and those who have expertise to do so. Here, as part of a medical profession that’s ethos is to alleviate suffering, it was historically natural for psychiatry to take over the care of those who were mentally ill. This began at a time when many from various walks of life were motivated to help those in dire need when there was little effective treatment.

Pilgrim conflates biology with eugenics. This is most unfortunate, given that an understanding of biology of the brain and behaviour has contributed enormously to our understanding of the mental mechanisms that lead to serious mental illness. This has enabled the development of medicines that alleviate suffering, such as antidepressants and anti-psychotics. We should remember that the advent of the anti-psychotic chlorpromazine (also known as thorazine) in the 1950s and the improved mental states of patients that followed was a major factor in facilitating the later closure of mental asylums. People got better.

As powerful treatments, it is important that these are used appropriately, and given to those who need them, with expert guidance. Diagnosis is therefore vital as it guides treatment for illness.

Psychiatrists are at the forefront of medicine generally, and as medically-trained physicians, in incorporating psychological explanations for the complex clinical problems they face. They take account of social and cultural context to try to understand the personal experiences of a patient who is often facing multiple problems: illness, disability, financial hardship, social isolation and so on.

Appliance of science

So, psychiatrists have the job of applying a scientific and medical training to understand biological processes of ourselves (as biological organisms where genes interact with environment), family circumstances, life story of the individual and the psychological impact of all events that form part of that story, within a social and cultural context. They then have to come up with a series of hypotheses that explain the problems that the patient faces. Among these, diagnosis is important, as it guides the implementation of evidenced treatment and other support needed. But it is supplemented by evaluating all the other dimensions and a raft of other measures to help support the sufferer.

Psychiatrists may need to asses a patient’s risk to themselves and others – so of course in any civilised society, we need an option to invoke legislation to keep people safe. Often patients are grateful after recovery that this was used to save their life.

Working together for patients

Many psychiatrists have led the way for psychological therapies or collaborate with those who give them. Notably, Aaron Beck has long been considered as the pioneer of cognitive therapy. It would be a mistake to exaggerate the divide between those psychiatrists and psychologists whose genuine aspiration is for the well-being of patients.

However, it is important that all treatments (medical and psychological) are given a fair trial in the evaluation of their potential benefits. In this regard, one could legitimately ask whether all treatments or interventions are (actually) evaluated with the same degree of rigour. For instance, is comparing a novel treatment or intervention with “treatment as usual” a fair comparison? How do we know that adding something to the usual treatment is not going to show some kind of benefit? Does this type of comparison allow for, among other things, the enthusiasm of those administering the novel approach? One could argue that all clinical trials (whether of a medicine or psychological therapy) should have an equivalent control, whether it is a placebo or carefully controlled equivalent intervention without the active ingredient.

Essentially, if we apply the medical ethos of putting patients first in everything we do, then we won’t go far wrong. Here, the psychiatrist as doctor is very well placed to help those with mental disorder.

You can read David Pilgrim’s article, to which Peter responds: ‘Physician heal thyself’ may be impossible task for a psychiatry profession in crisis, here.