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Exposing the insecurities of psychiatry

A Psychiatrist's Full Disclosure: My Insecure Profession

I decided I was going to be a doctor when I was ten years old. My father was a career Air Force officer who had grown up dirt poor in small town Texas during the Depression, and spent all of World War II and the Korean War navigating bombers. My mother was a registered nurse. I was a nerd who loved school, and nothing would have made them prouder than for me to become a doctor. The first doctors I met were pediatricians, so I decided I wanted to be one too—and that was the plan for many years. However, when I went to medical school, and did my clinical rotations in my third year, I found out pediatrics bored me, and that I loved doing psychiatry.

When I told my parents that I had decided to go into psychiatry, my Mom was fine with it, since she was in fact doing psychiatric nursing at the time. But my Dad—um, did I tell you he was an alcoholic?—he flew into a rage, screaming at me that he had always expected me to be “a real doctor!!!” I held my ground, and it was a noisy night. But the next day when he was sober, I told him: “This is my f***ing life, not yours; and I’m going to doing what I f***ing want to do with it.” There was never any further argument about it, because when I spoke to him as a man, he would always listen to me—as long as he was sober.

In my second year of residency at San Antonio, I trained in psychiatric consultation—providing assessment and treatment of patients who were hospitalized on other medical services, but identified as having psychiatric problems.  Problem-solving has always been what I most enjoy about my job—and doing consults presented me with a lot of unique problems, and a chance to interact with staff in other specialties. The director of the consultation service, Dr. David Fuller, taught us that consults often arise from the complaints of the medical treatment team, rather than from the patient.  For example, I might be called in to assess a patient for aberrant behavior—only to find that he had no psychiatric complaint at all, but he did have a particularly nasty disposition, and was giving the nursing staff fits. Or the problem might even be a bossy family member who was badgering the physician about the amount of attention the patient was receiving. The stated reason for the consult could be misleading—so Dr. Fuller encouraged us to keep an open mind, and to note that we were being called in because someone had a problem and needed our help—it just might not be the patient.   His contention was that “there is no such thing as an inappropriate consult”—which is not entirely true, but nonetheless it encouraged us to maintain a positive and helpful attitude for all situations.

Applying that philosophy worked well, and I became friends with some of the physicians.  In the course of conversation one revealed to me that psychiatrists were commonly referred to as “spooks”—as in, “That patient’s weird.  Let’s get a spook to look at him.”  I was more amused than upset, but I knew that it wasn’t meant to convey respect for my specialty.  It conveyed the detachment from “real medicine” that psychiatrists frequently displayed at the time. This was around 1983, when there were still a lot of analytically oriented psychiatrists working—quirkier than most, appearing and then disappearing from their unit, leaving rather abstract assessments that were incomprehensible to the other medical staff. It also may have reflected some hostility held toward psychiatric patients, whose disruptive and self-destructive behaviors were unappreciated by other physicians.  At any rate, it brought home the fact that within the medical community, there were many different kinds of doctors—and then there were psychiatrists.

Psychiatry’s embrace of the biological model in the years since then is generally attributed to the considerable financial influence of Big Pharma. This was certainly a driving force—not many would have bothered to change their clinical practice if it didn’t pay to do so. But another major consideration was psychiatry’s abiding status as the red-headed stepchild of medical specialties, struggling for a sense of its professional identity in the midst of “real doctors” who are dealing with more tangible clinical problems.

You want evidence? When I lived and trained in Texas, I was a member of the Texas Psychiatric Society, a branch of the American Psychiatric Association. In 1986—after the biological revolution—the organization changed its name to the Texas Society of Psychiatric Physicians. In 2001 I moved to Maine, and since that time the Maine Psychiatric Association has changed its name to the Maine Association of Psychiatric Physicians. In the past few decades 13 of the 50 state chapters of the APA have changed their names to include the wording of either “psychiatric physicians” or “psychiatric medical”. No other medical specialty has felt the need to do so.

So let’s take a look at the factors that contribute to psychiatry’s insecurities. First of all, there’s the brain-mind. There’s absolutely nothing in the body as mystifyingly complex as the human brain-mind. Its anatomical focus is the brain—an organ entirely encased in bone.  Underneath the bone are layers of fibrous tissue and fluid that cushion the brain, all of which are vulnerable to infection if intruded upon.  The brain itself is a fabulously complex array of about a hundred billion nerve cells, or neurons, each with numerous junctions connecting it to its neighboring cells.  Cells communicate between each other across these nerve junctions, or synapse, through the secretion of chemical messengers known as neurotransmitters. There are over 100 different neurotransmitter agents identified in the human brain, each of which may have either an excitatory or inhibitory effect on the postsynaptic cell depending on what kind of receptor protein it contacts in the cell membrane.  The location of this intercellular communication is in the synaptic cleft, the microscopic space within the junction which is crossed by the neurotransmitter, where the balance of neurotransmitters is constantly adjusted by the two cells through the processes of release, metabolism, and reuptake—which in turn are regulated by an elaborate feedback network incorporating input from other neurons as well.  In short the raw circuitry of the brain is microscopic, profuse, and unimaginably complex.  

The physiological tasks of brain cells are largely determined by their location within the brain—and the higher functions associated with thoughts and feelings are particularly inscrutable, since they occur within a microscopic assemblage of neurons acting in a meticulously coordinated fashion. Hence studies of brain cells in vitro (i.e. outside of the body in a laboratory medium) tell us little about their psychiatric function. This leaves us with the necessity of studying brain cells in vivo (in the living organism) to gain an accurate understanding of their function.  But doing so would require passing a needle past the skull and through the surrounding nerve tissue, causing irreparable damage to the brain since neurons have little if any capacity for regeneration.  This makes direct observation of living human brain tissue ethically unacceptable—and even if it wasn’t, how many people would give informed consent to participate in such a study? 

The other medical specialties (besides neurology, of course) focus on organ systems that are infinitely less complicated than the brain, more physically accessible, and able to withstand a needle biopsy without irreparable loss of function.  Chemical markers associated with these systems are typically measurable in the peripheral blood, unlike those of the brain; other intrusive diagnostic procedures such as endoscopy are available as well.  Access to this sort of information allows physicians to be reasonably sure of what’s going on inside the patient—a feeling dreadfully unfamiliar to any prudent psychiatrist.

Then there is the conundrum of its duality—the brain in the physical world, the mind in the ethereal. As I explore in another video, it’s entirely reasonable to assume that the mind functions much like the software in a computer—a body of information coded to create virtual machines, which in turn process information from the environment, and act upon the environment. I believe that the secrets of the brain-mind constitute a last frontier of science far more daunting than astrophysics—which, after all, is just the study of a bunch of dumb particles that happen to be very far away.  In the realm of medical science the mind stands out as a uniquely remote wonder, a bottomless enigma that we haven’t begun to crack. 

If this wasn’t enough to justify our insecurity, there’s the historical fact that once a psychiatric disease does become treatable, it usually is reclassified as a non-psychiatric disease. In the 19th Century a large proportion of asylum inmates were diagnosed with general paralysis of the insane (GPI)—a psychiatric disease characterized by manic symptoms or other behavioral problems, followed thereafter by the onset of dementia and progressive paralysis.  It was noted that this presentation was more frequent in men, especially those with “debauched” lifestyles.  Eventually this problem was identified as neurosyphilis, an advanced stage of syphilis that takes ten years or more to manifest itself in infected individuals.  Once antibiotic treatments were developed it became a “medical” illness, and thus no longer the concern of psychiatrists.  Similar paths were followed by epilepsy, the thiamine deficiency and hepatic encephalopathy associated with alcoholism, Parkinson’s disease, Huntington’s chorea, and other neurodegenerative diseases.  It would seem that psychiatry is in part a specialty defined by its futility—since any disease that can be readily treated then becomes someone else’s responsibility.  This sequence of events pretty much dooms us to clinical failure, which is a pretty darned demoralizing state of affairs.  (No wonder we have a complex!)

Yet another distinguishing characteristic of psychiatric disorders is that they typically present with behavioral symptoms—which inevitably drags us into the murky arena of patient will.  Nearly all patients who go to a non-psychiatric doctor for a medical complaint are doing so on their own volition, for unwelcome symptoms that are imposed on them by disease.  Relief of these complaints may require medication, changes in lifestyle, and/or entry into rehabilitation—all of which require motivation and compliance on the part of the patient for clinical success. The patient may choose to be noncompliant, but the original distress will usually continue to motivate them toward compliance.

The motivation of a psychiatric patient to pursue treatment of a psychiatric disorder is often more complicated.  At one extreme you have patients who are involuntarily committed by court order because of dangerous behaviors, or who have other extenuating circumstances coercing them into treatment—like the demands of a spouse or legal concerns. Treatment of such cases is often complicated by lack of earnest investment in the process. Even patients who are internally motivated for treatment may be conflicted, struggling with feelings of guilt, shame, or fear. People with depression often succumb to their symptomatic lack of motivation, and fail to follow through with treatment. Patients struggling with mania often chafe at the drudgery of reconstructing their broken lives, and stop their meds so they can fly back into the fantasy world of their illness.  In short, the issue of patient will arises over and over again in the treatment of psychiatric disorders.  In order to enjoy practicing psychiatry, it really helps if you’re OK with ambiguity, and you don’t mind not being in control.

Thus, psychiatrists regularly struggle to attain the degree of authority and trust needed to motivate treatment compliance—a problem that’s largely unfamiliar to other medical specialties.  In my first year of psychiatric residency I spent several months in a neurology rotation under the supervision of a rather cocky senior neurology resident.  Shortly after that rotation I ran into him at a party, where he proceeded to chide me for going into psychiatry since “in a few years neurologists will be treating all your patients.”  I fired back, “Are you kidding?  You guys will never be able to stand working with patients that don’t do what you tell them to!”  Little did I know at the time the enduring truth in that tipsy utterance—the practice of psychiatry is indeed defined by the compliance issues inherent to treating disorders of behavior.

And finally, there’s psychiatry’s history. Psychiatry is so ashamed of its history that it has deleted much of it—enough so that a collection of essays called Discovering the History of Psychiatry was published in 1994 to explore the subject of our self-censorship.  The reasons we’ve done so are complicated enough to warrant a book of essays—but the collection of quacks, fools, weirdos, and even criminals that litter our history is reason enough. Beyond all that, psychiatry has habitually underestimated our scientific challenge, and overplayed our clinical hand.

Having achieved a tenuous foothold on medical legitimacy, it’s natural to feel insecure about a history that challenges the legitimacy of that stature.  The new technologies are indeed powerful, and some of the resultant treatments are certainly more effective than our old ones.  But it would be foolish to overlook our historic tendencies to overreach, and bend science to suit our will—and to discount the possibility that our current dogma is just the latest manifestation of that established pattern.

And on this matter, I wish psychiatry was more unsure of itself.

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