Vintage Psychiatrist

Warning 2748 words, time to read 15 min

Disclaimer 1: The title is probably infringing some copyrights – please Adam Kay don’t sue me, I am sure we can resolve this over a coffee. Disclaimer 2: The views expressed are my own and do not reflect in any way those of the institutions I work for (although it would be nice if they did) or the charity organisations I am involved with. Disclaimer 3: I am mindful that some readers may feel discontent when reading this, please accept my sincere apologies, it was never my intention to be unkind.

It’s Monday, I am cycling to work; sometimes I listen to the radio, sometime to my stream of consciousness: in a few weeks I am going to retire.

Is it going to hurt?

Radio 4 (what else, I am 60!) announces a podcast on psychiatry presented by Horatio Clare, writer and broadcaster, with Prof Femi Oyebode. I am undecided if I should listen to it: is it going to hurt? It all started many years ago, I was still an SHO and I read a short article, I think it was in the BMJ, written by an A&E junior doctor. It was a witty description of a night shift in A&E, the time pressure of seeing one patient after the other, the stress, the frustration but also the sense of achievement in managing complex cases, until…… Until, in the early morning hours he is asked to see a psychiatric patient, to be honest I cannot recall the exact presentation. What I remember well was that the psychiatrist on call reportedly came down to A&E fresh as a daisy, “latte in hand”, saying that that there were no beds to admit the patient. The author of the article was very annoyed, we (psychiatrists and psychiatric patients) spoiled his perfect shift: psychiatric patients don’t belong to general hospitals and psychiatrists do not work hard enough. I have recently met a psychiatric nurse I used to work with, who now works in the A&E department of a highly reputed hospital. Reportedly a member of the acute trust’s higher echelons was seen in A&E, not pleased, vehemently asserting “what are all these patients doing in my department?”, or words to that effect. The patients were psychiatric patients, of course, waiting for admission and breaching every possible A&E target. Luckily my maternity and A&E colleagues have always been amazingly supportive.

A few years later, I came across an article in a widely read newspaper by a well-known writer, one of those with a neocortex a few inches thicker than anyone else, describing his journey out of alcohol and drug addiction. I had to read the article twice (I have a normal neocortex) but eventually I gathered that the private psychiatrist offering treatment travelled with him somewhere outside the UK and they used drugs together. Understandably he concluded that psychiatrists and psychiatric treatments are useless. Eventually he got better by himself, I think. I would like now to invite you to my stream of consciousness: 1) Shouldn’t this doctor be struck off from the GMC? 2) Is one useless psychiatrist representative of the rest of us? 3) Why the writer did not access NHS drug and alcohol services? In those days they were very well resourced.

why among all medical specialities psychiatry is so vilified?

I am sure I am not alone in wondering why among all medical specialities, psychiatry is so vilified. Our practice is so abhorrent as to instigate an “antipsychiatry” movement. Ever heard of the “anti-cardiology” or the “anti-neurology” movement? Neither have I. But we psychiatrists take the matter to an even higher sophisticated level of intellectual debate, we have our in-house antipsychiatry stream, with distinguished academics preaching and teaching “anti-psychiatry”. I am not going to reiterate the arguments, they are well rehearsed. My point is that the psychiatry of the 21^st century is not the psychiatry that any of us would like to practice. We have polarised the fundamental aspects of psychiatric care into “a bad cop -good cop scenario”: the obtuse psychiatrist, blind to holistic care, who sees medication (or hospitalisation) as the only solution versus the psychologist/psychotherapist, defiant of the “evil medical model” who offers true holistic (non-medicated) care. May I draw your attention to an excerpt of the blurb for a conference on Medicalisation of Distress offered by a reputable psychotherapy training agency? “In the US and UK – and increasingly the rest of the world – our language, thinking and responses to emotional and psychological distress have become almost completely framed in medical terms in the last few decades. Along with this shift, psychiatric drugs and limited formulaic psychotherapy have become the default modes of care.” In principle, I agree but you try to decline one of the numerous referrals psychiatric services receive for purely psychosocial reasons stating the above.

The game Jenga comes to my mind when I reflect on how our role in mental health services evolved over the past two decades

Wait a minute. Freud was a neurologist, was he not? Winnicott a paediatrician, Beck a psychiatrist, Bawlby a psychiatrist, a psychologist and psychoanalyst. They were dissatisfied with conventional medical practice precisely because they realised that it did not capture the nuances and shifting intricacy of clinical cases but most importantly it did not equip doctors to tolerate uncertainty and their own emotions. What attracted me and I assume many of my colleagues, to psychiatry is the “renaissance” quality of this speciality. We study the body, including the brain, we explore cognitions and emotions and the behaviours instigated by them, we master the interventions to revert or alleviate the changes induced by pathological process. Psychiatry is a vintage medical specialty because we rely mainly on the narrative the patient chooses to give us, rather than tests and diagnostic procedures. We are the “uninvited guests at the christening” (if you have not read Ghosts in the Nursery by Selma Freiberg, this is the time to do it), we sit and we wait: maybe we get just a glass of water, maybe we are allowed to participate to the banquet. Taking a psychiatric history is a fine art, like a specialist surgical skill. You may not believe in the 10,000 hours rule of mastery by Anders Ericsson, but a few thousand are definitely necessary. Winnicott professed that the skills he acquired in listening to the patients’ medical history were instrumental in his psychotherapy training. No decent psychiatrist – or doctor – can prescind from exploring the relationship the patients have with themselves and with others, let alone our own relationships. Psychotherapy modalities are an integral part of psychiatric training, which to my knowledge has a good quality assurance framework. In many European countries newly-qualified psychiatrists are automatically registered as therapists; some may decide to specialise further in the therapy modalities of their choice, but everyone has the basic skills to offer therapeutic sessions.

In 2005 “New ways of working for psychiatrists” concluded that there weren’t enough of us, so there was no choice (apparently), we had to diversify our practice. The game Jenga comes to my mind when I reflect on how our role in mental health services evolved over the past two decades. I think the first to disappear were the medical psychotherapists – sounds a bit ominous I know, but it was – then the clinical skills of other psychiatrists were silently eroded and outsourced. My obstetrician colleagues do antenatal and gynaecology clinics, ultrasound examinations, labour ward shifts and of course are on the operating theatre rota. Instead, we have been forced to outsource physical health checks to the GP, initial assessments to the multidisciplinary team, psychotherapies to IAPT, prescribing to clinical pharmacists. Risk is hard to outsource, nobody wants it, so we can keep it. “Choose psychiatry” chimes the RCPsych. “I don’t think so” is the reply I got from 99.9% of the FY1 doctors working in my team since 2017.

Not once at these meetings I heard “we need more psychiatrists”

I have attended many local and national meetings to discuss service development and transformation(s). A few were helpful and hopeful; the rest were a circus of rhetoric. The NHS is not Ikea. It’s all well to have all these different providers and partnerships promoting DIY, ultimately somebody needs to assemble the furniture and coordinate all these agencies. If any of you have tried to assemble an Ikea cabinet, you know what I mean. It’s fine if one has a mild condition, but not if one is debilitated by a severe mental illness and some people are, in defiance of the higher management edicts proclaiming recovery at all costs. The poet and broadcaster Lemn Sissay summed up my state of mind when he tweeted that the Children’s Commissioner was “producing so much fudge I could set up a stall”. Make it two please. Not once at these meetings I have heard “we need more psychiatrists”. Actually, at a CAMHS transformation meeting one of the attending Child & Adolescent Consultant Psychiatrists (I refuse to define my colleagues as CAMHS consultants, they treat children and adolescents, not the “services”, even they work “in” a service) affirmed that the vast majority of the young people accessing CAMHS did not need to see a doctor: “we do not need doctors”. Really? The UK has the lowest number of doctors among the main European countries (OECD 2020) and the highest shortage, to my knowledge, is in general practice and psychiatry.

I never thought that one day I would be working side by side with experts by lived experience, and it is a humbling experience.

And then at these meetings, there were extensive discussions on the themes of compassion, dignity, respect – all of which we healthcare professionals are impervious to, especially psychiatrists – and equity of access. All perfectly valid points and nobody disagrees with these. But does anyone really believe that healthcare professionals commute long hours to work every single day thinking: “let’s see, how can I be un-compassionate, uncaring, disrespectful and mean to the patients today?” You will always find a proportion of bad and stupid people from every walk of life, healthcare professionals are no exception. But the vast majority (including the hardly even mentioned NHS cleaners) are decent people, who often put patients before their families and their own needs, working long hours under relentless pressure. When I was in medical school, I never thought that one day I would be working side by side with experts by lived experience, and it is a humbling experience. My old clinic letters were written in Miss Trunchbull style, they made sense, but they were not nice to read if you were a patient; now they look more like written by Miss Honey and are addressed to the patients. When we are under stress our brain bypasses those circuits underpinning our socially sophisticated responses, we operate in fight or flight mode and if the pressure keeps on (and it does, believe me), we disconnect, we become Miss Trunchbull. Experts by lived experience want less Miss Trunchbull and more Miss Honey, quite rightly so.

Language matters

A blog on the NOS website in May 2021 was titled “Are we facing a mental health pandemic?” I should hope so. The WHO defines mental health as “a state of mental well-being that enables people to cope with the stresses of life, realize their abilities, learn well and work well, and contribute to their community”. What we do not want is a mental illness pandemic. What’s wrong with saying mental illness or psychiatric condition?

Language matters. People don’t say “I have a blood glucose issue” or “a cell proliferation problem”, they say I have diabetes, I have cancer. I have been called to see patients in A&E because they were “mental”, I doubt the medical SHO was ever asked to assess someone because they had become “physical”. The brain is an organ and when is affected by an illness, changes happen; we do not have the tools to quantify them or measure the outcomes of treatment, and we never will unless we give mental illness the dignity and respect it deserves. And just to be clear every illness is affected by psychological and social factors, the bio-psycho-social model, for better or worse applies to all medicine, not only psychiatry. De-medicalising mental illness by defining it as an “issue” is not constructive, it does not help decreasing stigma for patients and mental healthcare professionals, it hinders research and innovation, it reinforces the divide between physical and mental illness, it confuses mental illness with physiological and psychological responses to life events. One of the “top of the pops” moments of Radio 4 was the introduction by a journalist of Prof. Simon Wessely, as “ Professor in Psychology and President of the Royal College of Psychiatrists”. No further comment is necessary.

It’s the end of the week. The podcast “Is psychiatry working” did not hurt, I managed to listen to all five parts; I do not know anybody who dislikes Prof Oyebode and the presenter is balanced and kind. The sentence “we should have a debate” comes up when things get a bit tricky. Absolutely, let ‘s have a debate. In fact , while we psychiatrists have all these thoughtful and mindful debates, the rest of medicine specialities leap ahead in research, treatment, management. Think about HIV or cancer. I am still using the same medication I was using when I was an SHO, I spend a third of my time writing housing letters or other support letters for benefits or processing referrals requesting “support” for people overwhelmed by overcrowding, financial problems and other difficulties, none of which is related to psychiatry. Officially, even if I had the time, I am not allowed to offer therapy sessions or even discuss CBT cases with a band 7 psychologist. I have never had a psychiatric trainee, except for a few wonderful registrars devoting their special interest session to perinatal psychiatry; some are now consultant colleagues. I am sure I failed some patients and colleagues, and I hope they will forgive me. But I did not give up, I never missed a chance to advocate vociferously for increasing the medical workforce in mental health services and restoring our professional remits: I am happy to be the bad cop, but please don’t send me alone to the frontline, it’s not good for me and not good for the patients.

Building respect for psychiatry

I can see a nice photo of the newly elected president of the RCPsych Dr. Lade Smith on the BMJ cover (25.02.23) with the quote “building respect for psychiatry”; tackling inequalities is a recurrent theme of her manifesto. The first inequality I would like to see tackled is the one with the rest of medicine, drawing lessons from the rest of Europe. In some European countries neurology trainees must complete a placement in psychiatry, and vice versa. Wouldn’t it be good if trainees willing to pursue a career in perinatal or old age psychiatry could spend six months in O&G or Geriatric medicine? I suspect it would help reducing the stigma psychiatrists face from other medical specialties and improve the quality of care and patients’ experience. At the end of the day, how complex and severe the illness is does not matter as much as how the patient relates to the illness and takes responsibility for it.

We fear and avoid what we do not know, if we want dignity and respect for us and for our patients, we have to offer a competent professional role model integrated with the rest of medicine. Maybe, to paraphrase the great Carl Sagan, the rest of medicine lives in an uneasy truce with psychiatry like the cerebral cortex with the more primitive parts of the brain, the reptile and the mammal brain. But “the mammal brain is the source of our moods and emotions, of our concern and care for the youth”. Our survival depends on how well these parts work together.

I am optimistic. Policy Exchange research indicates that a doubling of places in medical schools is challenging, but achievable. The £1.2 billion investment required over 5 years, in the medium to long term would pay for itself with increased student loan repayment and income tax returns.

My colleagues very generously said that I leave big shoes to fill. I am not sure, size 6 is not that large. But my Ferragamo ballerinas are definitely out of fashion, I am ready for Louboutin stilettos to take over.