In order for you to understand where I am coming from, you probably need to know a bit about how I got here.
Nearly 4 years ago I moved with my Finnish wife and children to live in Finland. I had been living and working in London, where after graduating from medical school, I had trained and worked as a psychiatrist. My final job in London was as a NHS consultant psychiatrist in old age psychiatry in South London. Old age psychiatry in the UK, in effect, means dementia care. In retrospect I think I’d found dementia a lot less problematic, conceptually, than the messy world of adult mental health care.
For various reasons I wasn’t particularly satisfied with this work, and in thinking about what we wanted for the future, professionally and for our family, my wife and I began to explore the different options. On a holiday in Finland to visit my wife’s family the idea was born that we could move to Finland. I made it clear early on, however, that I could only do this move if I could find some work as a psychiatrist. At the time this seemed pretty impossible, especially as I didn’t speak the language. On coming back to London, my wife periodically looked at Finnish estate agent websites and I started putting my feelers out regarding work in the Helsinki area.
The following summer we found ourselves in Finland again, this time we had found a house we were interested in, put our own London flat on the market and I had managed to organize a meeting with the lead psychiatrist at a nearby hospital. In the space of a week we made an offer on the house, I’d been given work and an offer had been made on our London flat. It seemed that all the forces of heaven and earth were saying, ‘go for it’.
I remember that first meeting with the psychiatrist well. We spoke in English. It was a hot sultry day. He seemed keen for me to come and work with them. I was offered work in the local psychiatric hospital, on a mood disorders unit, on the proviso that I learn the language. I would be given a period of grace, where I learned the language by shadowing another doctor. At the end of the interview I told the interviewing doctor I was a socially orientated psychiatrist. He said that was fine, as long as I wasn’t against prescribing medication. At the time I had no particular problem with prescribing medication, and I told him so. The irony of this conversation was to come much later, once I had started work.
The following April we moved to Finland and at the beginning of May 2011 I started work. I’d spent the winter taking classes in Finnish but I was in no way proficient. They say Finnish is one of the hardest languages for someone from the Anglophone world to learn and I quickly realized I’d set myself a herculean task. As agreed, I started shadowing a doctor, a trainee psychiatrist. I spent my mornings listening in on clinical encounters or participating in discussions and my afternoons learning the language. And it wasn’t only the language I had to learn but also a whole culture, including a new medical culture. It was frequently frustrating and very tiring. Each day I would feel exhausted in a way I hadn’t experienced since residency days and long nights on call.
There was a flip side. I now had the opportunity to sit back and observe what happened in a busy psychiatric clinic on a daily basis. Having previously completed an MSc in Anthropology, I understood this to be a form of participant observation. This proved to be a very fruitful time for me intellectually. Not only did I question what was happening around me on the inpatient unit, or in meetings but I began to question the very underpinning assumptions of psychiatry. Despite not understanding the language fully I could see, through body language as much as anything, that there was a serious disconnect between the story the patient told (usually of dealing with the chronic fall out of a troubled, abusive upbringing and being confronted in the present with a major life crisis or series of crises) and a medical system that all too often sought to recast the patient’s suffering as a medical problem. Initially I questioned the diagnoses, in the end I called to question the whole system of psychiatric diagnostic classification.
On a book shelf at home I had a book called Toxic Psychiatry by Peter Breggin, ironically bought a long time ago but never read. Seeking some understanding of these observations, I remember, one day, picking the book off of the shelf and starting to read it. It was a warm, light, Scandinavian summer’s evening and I avariciously devoured the book, something within it resonating with what I had been observing. It also began to make sense of a number of conundrums and confusions that had plagued me throughout my training and career. Over the coming months, I read more: Richard Bentall; Joanna Moncrieff; and Bob Whitaker’s books, to name a few. I think I came to a point, as Thomas Szaz once put it, where I saw through psychiatry. This newer understanding of mental health and its care brought with it excitement, but it also brought sorrow and anger. It was as if I now had to relearn everything I’d been trained to do.
A sudden turn of heart towards critical psychiatry didn’t, of course, come out of the blue. This had been a long journey already. Throughout my training I had struggled with much of the theory and practice of adult psychiatry, and for this reason I had gravitated towards old age psychiatry, where at least I felt on firmer ground when dealing with a bone fide brain disease like dementia. I remember sitting in academic, grand rounds as a trainee psychiatrist wondering why everyone got all hot under the collar about ‘finding the right diagnosis’; surely it didn’t matter, I thought, particularly as the treatment will end up being the same; it usually meant the difference between a mood stabilizer or not!
As I mentioned earlier I had done an MSc in Anthropology. Specifically this was an MSc titled, Culture and Mental Health run by Professor Roland Littlewood at University College London. The MSc provided me with my first real critique of psychiatry: I think Roland Littlewood (1990) puts it most succinctly, where he suggests that trans-cultural psychiatry should not primarily be comparative i.e. finding goodness of fit between western psychiatric categories and local forms of distress but rather an investigation into how psychiatry itself is constructed. What Littlewood questions is whether the idiom of pathology and disease in psychiatry can ever be fully independent of the cultural, political and social context in which that system arises. In other words the very labels we use to label mental distress are not biological entities but rather social constructions, laden with cultural baggage. This is something I aim to return to in a later blog post. Another important influence had been my wife. In the years before moving to Finland, she had completed a doctoral clinical psychology training at the University of East London (UEL), UK. The course was set up by Mary Boyle, arguably one of the pioneers of critical psychiatry. UEL is one of the few places in Britain where you get training in critical psychology. During the years my wife was in training, I remember having many challenging discussions about psychiatry.
It was, however, my own personal experience of suffering a breakdown that was perhaps the greatest significant influence on my thinking. Whilst at medical school, there was a time when it felt my inner world fell apart. I won’t go into details here except to say that it encompassed a range of symptoms of which massive fear was the central feature. At the time I resisted all labels. I was sent by the university to see a psychiatrist but refused the treatment he offered. Eventually a friend pointed me in the direction of a psychotherapy service called the institute of self-analysis, based on John Bowlby’s work. Through them I found an affordable therapist and started the long journey from the very dark place my life had become. I survived medical school and becoming a doctor by putting on a brave face, and masking my symptoms as much as possible. My recovery remains an ongoing project, though these days I consider myself sane and happy.
Throughout my psychiatric training I had always, in the back of mind, this question: What is the difference between my suffering and those of my patients? How come they get all this treatment and I got none? Why do they have a ‘brain disease’ (there was a time when I tentatively believed in this sort of thing), whilst I, who was at times symptomatically severe enough to warrant medication, have no brain disease? Or do I have a brain disease? It was partly these questions that Peter Breggin’s book and others began to answer. The answer seems plain to me now. I had suffered exactly in the same way as many of the people I see every day do, but I had been lucky enough to avoid labeling and drugging. I had never fallen into the trap of psychiatry. There never was anything wrong with my brain, and likewise my patients – in all likelihood – have normal brains, save for the changes the medications have caused. What they struggle with (like all of us) is the stuff of life: their own histories; failed relationships; loss; identity; belonging; and self-acceptance, to name a few.
This understanding has had a profound effect on me and my clinical work. For myself it was part of my own healing and recovery. I’ve understood how different my journey might have been if I had gone along with the psychiatrist. I feel lucky to have found a way through the dark night of my soul. And as for my patients, I’ve stopped seeing them as some ‘other’ with a definable problem. I’ve stopped trying to work out what the diagnosis might be. I’ve started to see them as persons, each with a unique history. I’ve stopped trying to separate myself too much from their pain. The clinical barrier has come down. “Thou art that,” as the Upanishads declare. Most of all I know a full recovery is entirely possible, but as the late singer songwriter, Nick Drake, once put it, “it may take a little while to find your way in the end.”
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Littlewood. R, British Journal of Psychiatry 1990, 157, 294-297.