The Psychiatrist’s Bible

The thing about being a doctor is that it is more than just a job title. The day you qualify, there is an ontological shift. You feel different to how you did before and people treat you differently. You can never stop being a doctor: look at Dr David Owen, Dr Graham Garden and Dr Jonathan Miller, all of whom have retained the title through long careers unrelated to medicine. You can become a retired doctor, or a struck-off doctor, or a dead doctor, but never not-a-doctor-at-all. Even today, in an age when it is said that there is no deference to professionals, there is social kudos associated with being a ‘medical doctor’ (strictly speaking, not a proper doctor anyway). There is a down side too, particularly if you happen to be a psychiatrist. Many people are indifferent about gastroenterologists, but every one has an opinion about psychiatrists.

In my youth, the only doctor I knew was Spence Galbraith, the father of my sister’s best friend at primary school. He gave me tickets for the Royal Society of Medicine’s Christmas lectures for young people. In retrospect, he had a significant effect in deciding my choice of career. I had no idea that he was an exceptional doctor. Spence was founder and first director of the Communicable Disease Surveillance Service at Colindale, a brilliant and inspirational figure in Public Health, who was famously kind and modest. He was not typical of doctors in general. I didn’t know that. I thought all doctors were like him.

At medical school, St George’s in London, I came across other doctors who I found inspiring. Professor Tom Pilkington was one, a man with a mischievous sense of humour and a rigorous approach to science and clinical practice. A small but significant minority, however, were deeply disappointing; narcissistic, childish and arrogant with deep-seated prejudices that they didn’t bother to conceal, including rampant snobbery and racism. Punching junior doctors and throwing telephones out of the window might make for good anecdotes, but who would want to be treated by a doctor who behaves like that?

One of the things that was immediately attractive about psychiatrists during my lengthy student attachment was that they weren’t like that at all (I’ve met a handful of psychiatrists since who are like that, but I digress). They were thoughtful and liberal minded. They were interested in their patients’ lives and in the human and ethical dilemmas that arise in a branch of medicine that sometimes treats patients against their will. They talked about families and psychological factors, personality development and social conditions, psychotherapy and rehabilitation, as well as drugs and ECT. Neuroscience, social science, psychology and philosophy were part of everyday discussion.

Psychiatry seemed richer and broader in scope than the rest of medicine. All these years later, I still think it is. Psychiatry has never failed to engage my interest. I can honestly say that, in 34 years as a psychiatrist, I have never been bored. Although psychiatry can be misused, I have always been impressed by the way that psychiatrists candidly engage with the dark aspects of clinical practice. It was psychiatrists who led the fight against Soviet abuse of psychiatry. It was psychiatrists who advocated the introduction of the Mental Health Act Commission to oversee psychiatric facilities, as a response to scandals in the 1970s over neglect and maltreatment (in my opinion, it is no coincidence that the abolition of the Commission in the ‘bonfire of quangos’ has been followed by new scandals over inadequate standards of inpatient care). It was psychiatrists, responding to what their patients said, who drew attention to the long-term side effects of some psychotropic medications. It was psychiatrists who led the movement to close big, deteriorated, mental hospitals and to develop community mental health teams.

I am proud to be a psychiatrist. Properly practiced, working alongside patients, psychiatry can make a big difference to people’s lives, although badly practiced, it can be harmful. So it really annoys me when people talk nonsense about psychiatry and psychiatrists.

I am not suggesting that psychiatrists are above criticism. On the contrary, our acceptance of criticism has greatly strengthened our usefulness. Good psychiatrists align themselves with their patients and organised psychiatry formed alliances with the service user and carers movements at a time when they were very critical of us (and rightly so). It is galling that psychiatry, arguably the most open minded of all medical specialties, is the subject of so many misconceptions.

In the wide range of nonsense that you read and hear, there are four statements that are frequently repeated and which are palpably ridiculous:

  • “You must know what I’m thinking” “I’d better be careful what I say” This has come up with monotonous regularity through the whole of my working life. I’ve known my dental hygienist for many years, and we get on fine, but he said something to this effect last week. Denial has no impact. I have found that the best response is to look people unblinkingly in the eye and confirm that I do indeed know their inner thoughts. When I’m asked to demonstrate my powers, I say “People think you are confident, but inside you’re a bag of nerves”. The questioner usually goes quiet, in case this profound insight is followed by a more embarrassing disclosure. It works well under most circumstances, but not during dental consultations, where eye contact and speech are both difficult. However, I am aware that I am teasingly colluding with a component of stigma. The interaction touches on that element of stigma that relates to frightening secrets and the fear that psychiatrists can penetrate the mind in some way.
  • “I don’t believe in psychiatrists” For future reference, if you are introduced to a psychiatrist in a social situation, you should bear in mind that this is not an adept riposte. Furthermore, it isn’t a very original or engaging rhetorical theme for an evening of conversation. What does not believing mean in this context? “I reject the validity of everything you do in your work” might capture it. In a social context this is undoubtedly rude, but it is not necessarily a reflection of ignorance. It neatly captures the theme of the public works of certain media psychologists, some of whom I count as friends. They should know better. I’m not suggesting that there are no significant problems with psychiatric treatments and practices, but a blanket non-belief in psychiatrists is not logical. It implies that someone with no medical training would be better at delivering those psychiatric interventions that are safe and effective. I wonder how that works.
  • “DSM V (III, IIIR, IV) is the Psychiatrists’ Bible”. This drives me to distraction. It is predicated on the belief that psychiatrists accept the doctrinal truth of a document that is written by a committee every decade or so. The Bible is the Christian psychiatrists’ Bible, so we can exclude them straight away (no one could adhere to two Bibles, one the product of divine inspiration and the other devoid of inspiration). DSM isn’t even used in the UK. We use the International Classification of Diseases 10th edition. American psychiatrists have their own system because exceptionalism is part of US national identity. Documents like ICD and DSM are glossaries, a way of making sure we mean the same thing when we use the same terms. Before we had them, everyone used diagnoses to mean different things and the resulting confusion was an obstruction to understanding the epidemiology of mental ill health. Rigorous science can help improve lives, and the use of reliable classifications has helped us to understand the relationship between social adversity and mental illness. Obviously these systems can be misused, and they are. Diagnostic coding is sometimes used in the commodification of mental health care. Service providers get a fixed fee for treating particular ICD/DSM codes (rather than people). The logic is that this encourages efficient treatment. Should your first intervention fail, you get no extra money to make a second intervention for the same condition. The practice has spread from the USA to England, and it is highly problematic. There is a perverse incentive to avoid complex and persistent interventions, because the service provider’s financial interests and the patient’s best interests are then in conflict. It would be more accurate to describe DSM as the accountant’s Bible.
  • “The treatments don’t work” “No one ever gets better” In 2012, Stefan Leucht and colleagues published this thought-provoking paper, comparing the evidence on the comparative efficacy of psychiatric and general medicine medications. Psychiatric medications came out of this very well. Although the evidence base is flawed by factors such as publication bias, and it is hard to factor in adverse effects, the limitations apply to both sets of treatments in equal measure. It is not that medication is necessarily the most important thing we do, but it is definitely one of the things we do. When we take standard non-psychiatric treatments as a benchmark, it is simply wrong to say that in psychiatry, the drugs don’t work.

So I don’t believe that there is any such thing as a Psychiatrists’ Bible. Psychiatrists are too independent minded and argumentative for that. If we accept the “Psychiatrists’ Bible” metaphor at all, then DSM and ICD are like the book of Leviticus, with its prohibitions against burning yeast, telling lies and eating rock badger. Most psychiatrists use the bits that seem appropriate and ignore the rest.