Though psychiatric residency training is a year longer than internal medicine residency training in the United States, psychiatrists in training are expected to master a smaller proportion of the knowledge and skills than their internal medicine colleagues are. Worse still, the fraction of diagnoses that psychiatrists are expected to manage compared to internists include pseudomedical disorders, the status of which is suspect even within the profession.1 Given that psychiatrists are charged with the task of caring for the most vulnerable members of society, the basic level of training should equip psychiatrists to fulfill this task. The knowledge base of neurological, medical and genetic disorders with neuropsychiatric presentations, the insights of psychological and social sciences, evidence-based practice, and the philosophy and ethics of psychiatry must become part of the training of every psychiatrist. Many would claim this is already the case, but what is currently emphasized is tantamount to pseudoscience.
The Medical Basis of Psychiatry
The remedicalization of American Psychiatry was ushered in by the publication of DSM-III in 1980.2 The triumph of DSM-III was to firmly establish the central role of psychiatric diagnosis in the practice of psychiatry. As the DSM-5 debacle has shown, psychiatric diagnoses are not the product of nature but common consensus, a consensus that has been criticized for eroding the range of human behavior seen as normal.3 This emphasis on the DSM has marginalized the contribution of descriptive psychopathology,4 de-emphasized the construction of the medical and neurological differential for the psychiatric patient,5 and led to the uncritical acceptance of psychiatric diagnoses whose validity and reliability are questionable.6
In focusing on teaching psychiatric diagnosis à la DSM, psychiatrists are no longer familiar with the rich descriptions of morbid mental life described by Kraepelin,7 Jaspers,8 Bleuler,9 and Schneider,10 who attempted to feel their way into their patients’ experiences and catalog the heterogeneity of human suffering. In contrast, the DSM teaches psychiatrists there are prescriptive ways to suffer or become mentally ill throughout the globe.11 When the psychiatrist meets a patient who has the audacity to have not read the DSM and not present a constellation of symptoms described therein, the psychiatrist is at a loss, and the patient finds herself ‘not otherwise specified.’
Rather than teaching practices that amount to pseudo-diagnostics, psychiatrists should learn more about the infectious, autoimmune, toxic, nutritional, metabolic, vascular, degenerative, and drug-related causes of disturbed moods, thoughts, behavior and perception that lead to psychiatric consultation. The recent discovery of the N-methyl-D-aspartate receptor autoimmune limbic encephalitis has led to a renewed interest from psychiatrists into other medical causes of neuropsychiatric disturbance.12 Yet most psychiatrists learn little about when to order EEGs, neuroimaging, viral, autoimmune, and paraneoplastic panels, heavy metal screens and other investigations that can help diagnose their patients’ maladies, and how to distinguish between these and primary psychiatric disorders. We must be advocates for patients with neuropsychiatric disturbance whatever the etiology and this begins with diagnosis.
One of the most burgeoning fields of psychiatric research is genetics and psychiatrists in training are expected to learn something of this research.13 The research so far has no clinical relevance to the practice of psychiatry. On the other hand, there are number of well recognized syndromes that are associated with intellectual impairment, emotional, behavioral and perceptual disturbances that lead to psychiatric consultation. The majority of these syndromes presents in childhood or adolescence. Occasionally however, these genetic syndromes can present in adult life. Most psychiatrists are familiar with genetic diseases like Huntington’s disease and Wilson’s disease that lead to psychiatric care, but are totally unfamiliar with the inborn errors of metabolism, chromosomal microdeletions, or mitochondrial diseases that can present with neuropsychiatric disturbance. Conditions such as orthnithine transcarbamylase deficiency,14 velo-cardio facial syndrome,15 or mitochondrial encephalopathy16 are long forgotten from medical school if they were ever learned about at all. Many of these genetic syndromes are rare and it would be a waste of time for psychiatrists to learn the ever-growing list, but knowing when to suspect a certain type of genetic syndrome or when to consult a geneticist should be part of the training of psychiatrists.
By the 1980s, psychiatrists became so enthralled with the new drugs that many were no longer identifying as psychiatrists, but as psychopharmacologists. Yet with these new powerful tools at their disposal came the realization of serious adverse effects. Such is the risk associated with these powerful psychotropic drugs that Peter Gøetzsche, a co-founder of the Cochrane Collaboration, recently argued that they should be withdrawn from the market as physicians cannot be trusted to prescribe them.17 Now that psychopharmacology has eclipsed psychotherapy as the mainstay of psychiatric treatment, it seems unacceptable that the study of toxicology in general and a full survey of the potential risks of psychotropic agents in particular is not part of psychiatric training. A recent study found only 2% of surveyed training programs had psychiatry residents elect formal training in toxicology and only 41% featured any toxicology in their didactic curriculum.18 Little to no training is provided on withdrawing psychiatric drugs. It is unclear how many psychiatrists are familiar with the literature on supersensitivity psychosis,19 antidepressant related tardive dysphoria,20 or antidepressant-associated chronic irritable dysphoria.21
Though psychiatrists routinely prescribe atypical antipsychotics, which cause metabolic syndrome, few psychiatrists are comfortable with treating hypertension, diabetes and dyslipidemia,22 and many of our patients are unable to access primary care. It is a shameful state of affairs that psychiatrists are not being trained to treat the very illnesses they cause in their patients and undermines the very basis of psychiatry as a medical specialty.
The Psychological Basis of Psychiatry
Although psychiatry’s love affair with biology long ago made a cuckold of psychodynamics, dynamic theory and therapy still form the crux of psychological approaches to our psychic woes that American psychiatrists learn. Many psychodynamic concepts are useful. It it is hard to argue with the core principles: our past experiences shape our present experience, our subjective consciousness is unique and should be respected, we are less aware of our motivations for actions than we like to think, our past relationships play out in the clinical arena, and our minds have carefully developed methods to help us ignore or avoid that which we do not wish to acknowledge.23
That aside, psychodynamic theory is not scientific, can lead to blaming patients for the atrocities they suffer (for example the domestic violence victim is a ‘masochistic personality’ who needs to suffer),24 often blames patients for not getting better (failure to recover is a ‘resistance’, the possibility that the therapy is simply ineffective rarely entertained), and can lead to fatuous interpretations which cannot be rejected by the patient who does not agree with the therapist (rejection of the interpretation is again, but a ‘resistance’, to the truth and the therapy). Some formulations are so ridiculous as to serve only perfunctory mental masturbation on the part of the therapist.25
As a result of the psychodynamic hegemony over theoretical thinking in psychiatry, most psychiatrists have little awareness of the psychological theories that do have more robust support from research and help us understand our patient’s suffering. For example, cognitive psychology offers valuable explanatory frameworks that can be helpful in understanding depression,26 PTSD,27 and the formation of delusions and hallucinations.28 The role of self-esteem and self-efficacy,29 theories of why different life events seem to trigger difficulties in different people,30 the development of social cognition in childhood,31 the role of attachment,32 and theories of personality33-35 are given cursory attention if covered at all. Even though the same elements that comprise symbolic healing across cultures and therapies has been demonstrated,36 psychiatrists are still learning the basics of psychodynamic psychotherapy, cognitive behavior therapy, and supportive psychotherapy separately, instead of learning how to maximize the effects of contextual healing.37
The Social Basis of Psychiatry
Despite the rich social science contributions to psychiatry that are extremely relevant to clinical practice, most psychiatrists, especially in the United States, are completely unaware of the classic studies in our field. Social scientists conceived of psychiatric disorders as social constructs38 long before the geneticists realized these categories to be cultural rather than ‘natural kinds.’39 Social scientists highlight the role of social class,40 ethnicity,41 discrimination,42 life events,43 expressed emotion,44 the built environment,45 urbanicity,46 and social capital47 on mental health. Goffman’s insights into the toxic effect of the total institution on psychiatric inmates,48 or the stigma of ‘spoiled identity’49 have passed a generation of psychiatrists by, despite being highly applicable to patient care. The damaging and unintended consequences of psychiatric labeling,50 the concept of mental illness in cross-cultural perspective,51 and the lack of validity of psychiatric diagnoses were highlighted by social scientists,52 and yet these studies are not must-reads for psychiatrists in training. Social science research explored why the prognosis of schizophrenia is better in developing countries,53 and the effects of political economy on mental health,54 and yet most psychiatrists are completely oblivious to the evidence for the causal role of macrosocial factors in major mental illness.
Instead ‘social psychiatry’ curricula consider ethnic and sexual minority groups, homelessness, insurance programs, and the structure of mental health programs. Even then, the causal role that minority status may play in collective and individual suffering is minimized. Many psychiatrists still believe that 1% of the population has schizophrenia, without respect to gender, ethnicity, or geography, despite widespread differences in the incidence of psychosis, even within the same city.55 As Kleinman observed, the rest of medicine began to embrace the social sciences at the same time that psychiatry was turning her back on it.37 Lay opinion holds that psychiatric illnesses are significantly influenced if not entirely caused by social factors.56 Psychiatrists risk being out of touch with the public if they do not have a full appreciation of the effects of social factors on the etiology and course of mental illness.
The Clinical Epidemiological Basis of Psychiatry
Evidence based care is supposed to drive up standards, ensure uniformity, establish best practice, guide clinicians and protect patients. This should be celebrated. Instead, evidence-based mental health is openly disparaged,57 and when psychiatrists don’t get the results they want, they ignore them, suppress them, or denounce them. The suggestion that antipsychotics could worsen the course of psychosis19 was such an important one that you would think it would deserve considerable study, yet it has been largely forgotten. The finding that antipsychotics cause significant cerebral volume loss, rather than immediately being published,58 was analyzed again and again, until the reality of this finding could no longer be denied.59 When randomized controlled trials, the gold-standard investigation, showed that SSRIs were associated with suicidal ideation,60 the results were denounced invoking correlational studies showing a inverse relationship between adolescent suicides with SSRI prescriptions,61 despite these studies being methodologically inferior. These attitudes have repercussions on the training of psychiatrists.
All of this is damning enough without calling into question the veracity of the evidence base which influences patient care. The deceptive influence of the pharmaceutical industry, the ghostwriting of journal articles, and selective publication bias, are well known to the public. Yet these concerns sit at the periphery of psychiatric training instead of the core.
The Philosophical and Ethical Basis of Psychiatry
The concept and nature of mental disorder
Most psychiatry residency training programs claim to teach a ‘biopsychosocial’ approach to psychiatric illness, though this approach has been deconstructed and derided as meaningless,62 anarchic,63 and a myth.64 Although most psychiatrists also claim to use a biopsychosocial approach, a number of studies show that psychiatrists have different explanatory frameworks for different patients.65-67 Assumptions about the nature of mental disorder go unexamined. These assumptions filter into the psychiatrist’s approach to the patient. Given that values, meanings and assumptions about the concept and nature of mental disorder, whether acknowledged or not, are at the very heart of psychiatric practice, they should also be at the heart of psychiatric training.
The Mind-Brain Problem
The central debate of the philosophy of mind is the mind-brain problem. Although psychiatrists may wish to remove themselves from the fray, and pretend it has little to do with psychiatric training or practice, it confronts us at every turn.68 Psychiatrists often make contradictory statements about the relationship of mind and brain without a second thought. Whether one invokes substance dualism, property dualism, materialism, explanatory dualism, functionalism, or eliminativism, far from being irrelevant, shapes our approach to patient care and how we frame research questions. Training psychiatrists in the philosophy of mind is neither practical nor useful, but psychiatrists should have an awareness of the different approaches they reflexively use and the implications on their work.
The Ethics of Psychiatry
Psychiatric ethics tends to focus on individual interactions between clinicians and patients, and psychiatrists consider issues of boundary violations, capacity, consent and coercion as part of their training. Given that the ethical basis of psychiatry as a profession is so often challenged, psychiatrists should learn not just psychiatric ethics, but the ethics of psychiatry. The ethics of psychiatry concerns itself with rights: the right to autonomy and self-determination, the right to happiness, the right to (refuse) treatment, and even the right to commit suicide. The ethics of psychiatry can thus be considered from the perspectives of utilitarianism, liberalism, libertarianism, Rawlsian ethics, and communitarianism.69 Again, I am not suggesting psychiatrists be quasi-ethicists or philosophers, only that these aspects so implicit and entwined in psychiatric work be subject to critical examination that must begin with the training of psychiatrists.
The suggestions outlined above are not my own but have been developed from listening to what the public, patients and their families, and psychiatric survivors say they want. Those who don’t call for the outright dissolution of the specialty want psychiatrists to be able to know when a serious medical or neurological illness is responsible for their problems, to not have normal human suffering medicalized, and to avoid applying those pejorative labels that have no scientific basis. They want psychiatrists who not only can start medications but also safely withdraw them, be judicious with their use, be familiar with the inherent risks and respond appropriately to them; who can think psychologically about their problems; who understand what healing looks like; who can see as clearly as they can how powerful social forces and life events can affect mental health; whose practice is based on the evidence as it is and not how they wish it to be; who examine the assumptions and values that underlie their practice; and whose practice is ethically defensible. Current psychiatric training does not adequately meet these needs, and if not remedied, will lead to the continuing criticism and marginalization of psychiatry in medicine.
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Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.
Thanks for this clear and powerfully written post! Now if we can only get lots of professionals to listen to it…..and more educators to design their curriculum with these principles in mind!
In my day,students “sat in”when they felt the university or faculty were in collusion with negative social forces. It worked. Many of the programs at universities now–ethnic studies, women’s studies, etc.–came out of direct action.
Of course, something that is becoming very clear to me in the area of activism is that most activists are terrified of being too effective.
it seems those days are a distant memory. resident physicians are not students, they are employees of the institutions they work at and spend most of their time in patient care. in many ways they are are lot less powerful than students in that their positions are more precarious, they have a lot more to lose, and they quickly find it is in their interests to put up or shut up. Most keep their opinions to themselves. I have often been told that I am foolish for contributing to this site by peers no less as they worry about the possible negative repercussions for me. As a result residents and faculty alike often privately confess they share my sentiments but do not feel able to express them openly.
Excellent article,Very well spoken, Dr. Datta!
And thank you for exposing the pivotal flaw in psychiatry training:
“Most keep their opinions to themselves. I have often been told that I am foolish for contributing to this site by peers no less as they worry about the possible negative repercussions for me. As a result residents and faculty alike often privately confess they share my sentiments but do not feel able to express them openly.”
What you describe is what I have witnessed for over 20 years as a child/adolescent psychiatric nurse at a few renowned academic medical centers in the Northeast. What is this, but indoctrination combined with a heavy load of coercion? The result is that the great majority of psychiatric residents who run this gauntlet and become board certified psychiatrists, have an arsenal of first hand experience that serves to perpetuate the authority based model. They indoctrinate every member of the multidisciplinary teams, as *the* leader. They indoctrinate family members and patients with the same garbage they had to regurgitate to pass exams. They do this with the authority vested in them as the MD . Are they really *medical doctors *or does MD stand for *most damaged* ? I could write an article fully substantiating the latter.
“To refuse peaceful exchange and choose force is to compromise and give in to human weakness; it is to admit defeat of the human spirit… Socrates taught that hatred of language and ideas (misology) leads to antipathy toward humanity (misanthropy) ” (Daisaku Ikeda, President of Soka Gakkai International- the lay Buddhist organization based on the teachings of Nichiren Daishonin.)
You have stated very concisely what lies at the very core of the *anti-psychiatry* movement; that psychiatrists are *trained* to deny and destroy humanity-. This is accomplished by first destroying the humanity in the psychiatry trainee.
You are foolish to contribute to this site *only* to the extent that you do not address the academic psychiatry wardens who have been quite successful in picking off *heretics*.
Currently, the leader of the charge to initiate all of the dialogue and debate that you have so clearly pointed out as non-existent in the academic sector of psychiatry; a leader who has presented scientific evidence for the grave concerns you shared regarding serious to life threatening adverse effects of psychotropic drugs and exposed the corruption behind Pharma’s successful purchase of psychiatry in his book, “Pharmageddon” (2012), Dr. David Healy, Professor of Psychiatry, Hergest Unit, Bangor Wales, scientist, author, psychopharmacologist and creator of Rxisk.org, the first international data base for reporting and publishing adverse effects of *medications*; currently this activist, academic psychiatrist is currently undergoing the “negative repercussions” your peers are worried you may be subjected to, or rather the classic, well documented in the archives of the history of medicine and science in general, *the persecution of heretics*. ( see details @ David Healy.org ) If the plan to oust this formidable enemy of every major pharmaceutical company is successful, what hope do you see for reforming the scourge that is passed off as the education and training of psychiatrists?
For those who grasp the principles and values that are being violated continually by the methods psychiatry employs to silence and exile *heretics*, I suggest joining the activists who are writing directly to the UK’s equivalent of the President of our APA.
Dr Simon Wessley, Professor of Psychology at King’s College London is the President of the Royal College of Psychiatrists. The goal of this letter writing campaign is to inform Dr. Wessely that the actions taken against Dr. Healy are hardly a secret maneuver. The mechanisms themselves are signs of the *failure of psychiatrists* to employ rational, respectful, humanistic means for dealing with their own conflicts, many of which have resulted from the all you have shared in your well researched article. This is ostensibly very poor role modeling for a profession that Dr. Wessley has highly acclaimed as capable of supplying even more of what *society really needs*.
Please share this with your oppressed peers who probably also envy the therapeutic value you are gaining thru your writing. I
Professor Sir Simon Wessely
21 Prescot Street
I believe you are wise to publish your thoughts and insights, which you have thoroughly supported- on this site. I hope that you receive affirmative validation and crucial support from everyone who believes there is a purpose for psychiatry. As I continue to ponder this question myself, I am drawn to offering enthusiastic support for your endeavors to *humanize* our critically ill profession.
Thank you for your reply.
I commend you for speaking out here on MIA. My experience is that there is no freedom asserted that doesn’t result in blowback from somewhere, but if we are all so afraid of blowback, nothing gets asserted, or it gets asserted very quietly and passes unnoticed.
The students who protested (and some are still doing so on campuses around the nation for various causes) were sanctioned and some of their lives took different paths as a result. My life has been diverted when I refused to continue working for people who were breaking the law or being unethical, but I see those diversions as a valid path, as well. If we define our success as pleasing the oppressors and getting what they have, how can we ever change anything? You don’t end up with much money, but take a look at those who have money in our society. All I can say is, Yuck! I wish you luck and a path with a heart.
This is one of the most uplifting pieces I’ve read on the MIA site! One little side note: changing the way we train psychiatrists means changing the way we raise the funds to build and endow teaching chairs and fellowships at these institutions. I noticed you won a fellowship. Do you mind if I ask how your fellowship is funded?
thank you for your comment. you raise an important point of how large organizations have corrupted the research and educational agendas of institutions. i have been awarded a number of fellowships over the years, and they have not always had anything to do with psychiatry or medicine. the money has come from philanthropy typically. I have not been awarded any fellowships where the funding has come from industry.
Thanks so much for this brutal deconstruction of the current psychiatric mythology. I appreciate the multiple references to research in multiple fields that all impact on what we call “mental illness.” I wish all psychiatrists were as well-educated and honest as you appear to be. Can we run you for APA president next year?
haha thanks for the vote of confidence. you have to be a nearing the end of your career to be APA President, hopefully my career is only just beginning!
Why bring that up as a good thing ? These things are part of a problem just like psychiatry is.
Look at this as an example :
This is what “gender studies” gets us ? Yeah keep drinking the kool aid.
Sorry that reply didn’t go where it was supposed to and I meant to quote “women’s studies”
I already posted this in the forums on rethinking psychiatry. Sorry for the horrible grammar.
Mainstream therapy, psychology or whatever name you want to give it, is by it’s very nature, cold, uncaring, and cruel and does little to actually change people, the way they feel about themselves or there circumstances.
I believe the core problem underneath so called “mental illness”, is the belief by the person suffering is that they are not loved, valued or excepted for who they truly are. The symptoms of this may be manifested in different ways. Some will create a reality of their own to escape into a imaginary world , some will become extremely depressed, in others they may be violent or have intense hatred for other people, Some will become narcissistic to make up for the core belief they are not good enough. The reasons for developing this belief can vary but many in cases it stems from childhood abuse, physical or sexual, neglect, or all of the above. For others it maybe that some just can’t live up to societies standards of attractiveness, financial success, or relationships. The reasons can be complicated.
Therapists are taught never to reveal anything about themselves so there’s no relating with the client. They can never be friends with the client even if they want to. They can’t give or except gifts. In other words a therapist is supposed to have a wall between the person their suppose to be helping and themselves. True love and compassion is to never be shown. Some will attempt to show these things during the sessions but love without any action is dead and meaningless. Sometimes the client will come away from the session feeling a little better but ultimately they know deep down inside the therapist probably doesn’t really care about them or at least that’s the message communicated by following these ridiculous rules. Maybe some therapists actually like it this way since it means they don’t actually have to do anything except prescribe meds and listen to the client. Some therapists are extremely fake and can’t stand the client and laughs at them behind their back even after the person has opened up to them about embarrassing personnel traumas. In the real world pretending to be someone’s friend showing fake concern for someone especially if that person is very lonely with no friends or has no real connection with other people would be called cruel but psychotherapy considers this ethical standard practice.
In many cases the client will come away feeling even more hurt, uncared for, and even traumatized after going to therapy. Sometimes the client may even commit suicide. But psychology is never held accountable, it’s always the clients fault. In someways it’s almost similar to a abused victim being blamed for their own abuse.
This is just my opinion of why therapy is often ineffective and even harmful.
I am sorry to hear you have not had a positive experience from psychotherapy. I am not sure if that is because you want psychotherapy to be something that it is not (it is not friendship for example) or because you have had bad luck. It really depends on the kind of therapy and the therapist what kind of frame their is. In more psychodynamic or analytic therapy, there will be little in the way of self-disclosure, and no gifts are typically accepted. However I do accept gifts from patients in other therapeutic settings, especially where the cultural background of the patient is such that this is how they pay their doctor and/or show gratitude. I also self-disclose all the time in order the facilitate the therapeutic relationship but there has to be a balance and there have to be boundaries. Depending on the kind of therapy, the boundaries may be different.
Befriending by non-professional volunteers may be more the kind of thing that you are thinking of as helpful. There is good evidence that befriending is a useful intervention for women suffering from chronic depression and in fact the evidence is better than for non-directive counseling interventions!
In 1621, Robert Burton in The Anatomy of Melancholy noted:
“It is the best thing in the world…to get a trusted friend, to whom we may freely and sincerely pour out our secrets; nothing so delighteth and pleaseth the mind, as when we have a prepared bosom to which our secrets may descend, of whose conscience we assured as our own, whose speech may ease our succourless estate, counsel relief, mirth expel our mourning, and whose very sight may be acceptable unto us.”
There are only two ways I can think of that psychotherapy could be helpful:
– teaching people some useful techniques to understand/control their emotions/behaviour (“mind hacks” if you like)
– serving as independent observers/counselors who can give one an independent, objective view on their problems if someone feels stuck or doesn’t trust or have someone close to confide in (with the caveat that this is also of limited use since the therapist will only know one part of the story from one perspective)
Plus psychology forget that it takes two to make a relationship and 1+n to make a social context. Taking to that 1 person won’t do much.
“Therapists are taught never to reveal anything about themselves so there’s no relating with the client. They can never be friends with the client even if they want to. They can’t give or except gifts. In other words a therapist is supposed to have a wall between the person their suppose to be helping and themselves. True love and compassion is to never be shown. Some will attempt to show these things during the sessions but love without any action is dead and meaningless. (…) Some therapists are extremely fake and can’t stand the client and laughs at them behind their back even after the person has opened up to them about embarrassing personnel traumas. In the real world pretending to be someone’s friend showing fake concern for someone especially if that person is very lonely with no friends or has no real connection with other people would be called cruel but psychotherapy considers this ethical standard practice.
In many cases the client will come away feeling even more hurt, uncared for, and even traumatized after going to therapy. Sometimes the client may even commit suicide. But psychology is never held accountable, it’s always the clients fault. In someways it’s almost similar to a abused victim being blamed for their own abuse.”
You have just beautifully spelled out my problem with the whole psychotherapy bunch. It’s exactly, 100% correct.
As a practicing psychiatrist, I completely agree with everything you say. I think psychiatric training is woefully inadequate for the task at hand. Many of the proffessors leading postgraduate training are the very key opinion leaders beloved and, indeed, created by the pharmaceutical industry. I worry at the lack of depth of understanding of patients’ suffering that many of my junior collegues have.
I would add some Anthropology to your list of what is needed in education. I did an MSc with Roland Littlewood and one of his (and Arthur Kleinman’s) core concepts shook my world i.e. Cultural psychiatry should not be about trying to find goodness of fit between western categories and the various forms of mental distress around the world, but to take the lens of cultural and social anthropology and look at our own culture and realise that the very catergories we have created and rarerefied reflect the cultural values and norms of own soceity. They are in other words just social constructs.
Funny, as I wrote this a nurse came in to my room and told me a patient had told her I was the best doctor she had ever met. Nice feedback. I didn’t do much apart from treat her as my equal, listen to her concerns, give her careful, informed advice about what her ‘illness’ really is, to my mind, and how to reduce her medication sensibly and carefully, and I also gave her list of some self help books that I thought might help her.
I’ve had similar feedback from a fellow member of a mental health day centre. I ran a discussion on surviving Christmas and I said to this motor mouth fellow member, “Shut up, it sounds like your Dad is old, ill and fragile and you are concerned about him, but when you were a child he was violent and that frightened you. So you are confused about all this.” He said I understood him more than his key worker or psychiatrist. It only took half an hour of askign some pertinant questions, listening and asking him to be quiet to stop his motor mouth and then reflecting back the important bits for him to say that. He then asked me to be his therapist. I turned him down, being a fellow member of the day centre it didn’t seem right
Anthropology is included in my article under the heading of social sciences, and I did mention and cite work by Arthur Kleinman, Erving Goffman and Jane Murphy above.
Gret article, reads more like an argument for aboloshing psychiatry rather than humanising it though
Not to mention the logical analysis of synthesis of forming the concept of a mental disease, like it’s for example ”Schizophrenia” concept. If you do not have the correct concept, than you cannot pursue a correct research towards a cure. Not to mention the stupid theories which underlies Psychology too.
Your article is great. It points in the correct direction. Unfortunately, we’re still experiencing Middle Age when it comes about Psychiatry.
Interesting what you say about genetic disorders. I saw a woman who clearly had Angelmans’ Syndrome in a hospital. Her psychiatrist and the hospital staff had no idea what I was talking about when I mentioned it. Tried with Happy Puppets Syndrome, nope still no one knew.
Made me realise how limited their knowledge was. I would have loved to seen her file as to what the diagnosis was. It’s not even a mental illness, but an intellectual disability lol. Still, I don’t know how much difference it would have made to her treatment, or if being placed in the care of those who deal with intellectual disabilities would have been an improvement.
Great writing, hope to hear more from you.
Thanks for the post Vivek. I’m also amazed by the absence of awareness in psychiatry that much of the world has moved on. Most psychiatrists appear limited to psychoanalysis along with some information on Pavlovian conditioning (which does somewhat explain anxiety and PTSD). Usually psychiatrists also know about Rogerian reflective listening, although they are more likely to call it “mirroring’ in deference to Kohout. But, the world has much more to offer.
Since the 1970s up until now, I have attended seminars on just about every new treatment being developed. Some of the new ways of proceeding are grounded in Social Psychology, although most often the exponents for these approaches don’t know that they are effectively applying axioms that are well grounded in the empirical, experimental social psychology literature. I’ll explain what psychiatry, and many psychologists, have missed.
My dissertation mentor, Robert Cialdini, is famous in schools of business and throughout the world. When the US Census wants to know how to get people to complete census data, they call Bob. When the British government wants to know how to get people to conserve water, they call Bob. When the US military wants to learn how to influence others, again they call Bob. But, many psychologists, social workers, and psychiatrists don’t know about Bob’s work or even his name.
Cialdini wrote his famous book, Influence, in the late 1970s. His book draws heavily on self-perception theory with a seminal axiom being that what a person believes to be true about himself/herself will determine his/her goals and behavior. One way to change self-concept is to get the person to imagine himself/herself behaving in a new way or, better yet, to highlight a time when the person actually behaved in that way. This principle is highly consistent with Daniel Kahnman and Amos Tversky’s availability heuristic, for which they won a Nobel prize. Basically, according to the availability heuristic, if persons imagine a particular event, they will believe that it is likely. People who are solution-focused therapists make use of these principles all the time. They ask, “tell me about a time when your problematic behavior wasn’t present” (search for exceptions). “What is the first thing you will notice once your problem is no longer there”. “If a miracle happened overnight and your troubles were gone, how would you be different.” “How would others be different toward you?” The late Jay Haley, who studied with hypnotist Milton Erickson, also made use of these principles. A lot of therapists know about Milton Erickson, but psychiatrists don’t.
I was also impressed by Transactional Analysis, which was a big movement in the 1960s and 1970s. Transactional Analysis therapists also view a person’s self-concept as paramount. Given particular self-concepts, people set themselves up for tragic outcomes. This is very consistent with some social psych experiments in which subjects were assigned to one of three future tasks: come in and eat worms; come in and be shocked; come in and work math problems. The next day, when subjects showed up to complete their task they were told that enough people had already performed all the tasks, so the subject could choose which task to perform. The results were that the people who believed they had been assigned to eat worms or receive shock, actually more often volunteered for these tasks when given a choice. The experimenters were interested in those cognitive changes that were correlated with the decision to volunteer to suffer. Some had taken pride in their sacrifice for science. Some had pride in their capacity to tough it out. Some believed that if they suffered voluntarily now, they would not be required to make a future sacrifice. Consistent with the little experiment, TA therapists believe that human beings cut the best deal they can given the limited options available to them as children. Once the deal is cut, human beings find pride in whatever role they have agreed to. The insight here is that in order to change, a person has to acknowledge the positives in the status quo. Whatever the problematic behavior pattern is there is probably some positive aspect for self-concept that is maintaining it.
While the self-perception literature and the choosing to suffer literature are important, the critical social psych literature for any therapist is the literature on emotions. The Freudian notion that expression of emotion will dissipate the strength of the emotion has been contradicted by many experimental findings. If persons are mistreated and they are allowed to vent as opposed to being distracted by, for example, working math problems, they get angrier. Moreover, to some degree, William James has been vindicated. People decide what they feel by observing their behavior and getting peripheral feedback from their muscles or other bodily responses. So maybe sometimes clients, who are very distressed, should not be encouraged to share, and therefore rehearse, their feelings. Let me be clear. While a therapist should be supportive of clients, therapists can focus on client’s triumphs and direct the work to “what’s right with you” rather than “what’s wrong with you” as psychologist Barry Duncan would express it.
There is also a pretty big literature on the relationship between expressing anger and outcome for the individual. One of my students asked the other day, isn’t bad to “stuff emotions”. (This platitude I think derives from Freud.) In terms of experimental findings, the motivation for failing to express emotion matters. Intimidation is not a healthy emotional state. Suppressing emotions is taxing and shifts attention so that salient aspects of social situations are missed. Believing that others are interested in hearing about one’s emotions fosters mental health. However, learning to think about irritations in such a way that one avoids feeling trapped and angry has the most experimental support.
There is also a big literature on misattribution of emotions. People are easily manipulated into believing they are experiencing a particular emotion through manipulation. For example, if I get a person to talk about his/her mother in a group, the individual will transfer the arousal from being the center to attention to the emotional event he/she is talking about. Beware of those who report “I got in touch with my emotion in therapy.” It is highly possible that the therapist created the emotion through some misattribution process.
Beyond the theories and principles, TA, gestalt therapy, psychodrama, and David Burn’s with his externalization of internal voices, have provided a wealth of techniques. I wonder how many psychiatrists know what “two chair work” is. There’s a lot one can do with people, other than talking as one would with a neighbor.
As time moves on, I wonder if people will remember Eric Berne, Fritz Perls, or Milton Erickson. The social psych people are well represented at the Association for Psychological Science. (The Association for Psychological Science was formed by psychologists who were grossed out by the lack of scientific rigor at the American Psychological Association.) But, I’m always amazed about the lack of dissemination of information. What is an “of course” for many is totally unheard of in other circles. It’s a wonder that the culture ever gets transmitted.
Well, Jill, as much as any of these theories and practices may work very well, there’s not a one that can be patented and sold for a huge profit. Not to mention, if you start actually making people BETTER, well, there goes your client base…
“Yet most psychiatrists learn little about when to order EEGs, neuroimaging, viral, autoimmune, and paraneoplastic panels, heavy metal screens and other investigations that can help diagnose their patients’ maladies”
Or if forced to by regulations they happily ignore them. Your patient is depressed and has subclinical anaemia? Let’s start him/her on “mood stabilizers” which not only won’t help anything but will also adversely affect the dopamine system which already is struggling with low iron levels. And then be all surprised the patient develops restless leg syndrome. If you care to acknowledge that at all that is.