Leaving Psychiatry. J. R. Ó’Braonáin. M.D.
tenure. They will find it almost impossible to publish in mainstream journals. I have even seen up close a case of a patently perfectly sane heretic psychiatrist (not myself) reported to a medical licensure board to be mentally ill themselves, this an act of bad faith in an attempt to slow the agitator down. And this was by more than one anonymous complainant psychiatrist, on more than one occasion!
Finally, bear in mind that the psychiatric trainee/resident (in the UK, Australia and some other Commonwealth countries a trainee is called a “registrar”) is a member of an underclass, though an underclass of a special kind, one which has ample chance of upward mobility. And so mine is far from being a pro Marxist argument of class warfare. This upward mobility depends upon capitulation as opposed to entrepreneurship. On the road to freedom, prestige and a doubling or tripling of income overnight upon completion of training, the proverbial boat shall not be rocked. For if the heretic priest is vulnerable, how much more vulnerable is the heretic deacon or acolyte? After all, unlike Luther, the heretic cannot just uproot and create his own church. The system simply won’t allow it. The state underwrites the power of the psychiatric guilds. In each nation there is but one single guild, one road to the top, with an absolute prohibition to what might otherwise have been a free market. Or put another way, specialist medical guilds are the best example I know of a state sanctioned monopoly of power, this being another proof of psychiatry working hand in glove with the state, as state. To the extent psychiatry has supplanted the church as the minister to mens (and womens) souls in the secular state, there most certainly is no separation of powers, not even in the United States. Despite its vain ramblings as to the holy constitution, freedom ends where psychiatry begins. Returning to the life of the trainee; I have seen a curious thing happen many times. If one psychiatrist does not agree on some matter with another, there might be a debate between the two, usually behind closed doors. Usually there isn’t conflict at all, a kind of ecumenical pluralism within the fraternity. If a trainee were to have the same opinion of one of the consultant psychiatrists and come into conflict with the other, the two psychiatrists would close ranks and put the trainee in his or her place. The trainee would be told they are not considering the complexity of the case, need develop a more sophisticated or nuanced view of things, and so on. The truth be damned if what really matters is institutional power. Were one secular priest to weaken the authority of the other they would weaken the class as a whole, and by extension weaken themselves as individuals and the guilds to which they belong. This will not do! The trainee capitulates easily, for they wish to get a good report and eventually be anointed a priest with all the trappings of power themselves. And so the cycle will continue into the next generation, and the next. Such is the blessing and curse of upwards mobility in providing a disincentive to needed change, a class divide that exists without class struggle. Should some time the trainee be fortunate enough to encounter an honest iconoclastic priest in the church of psychiatry, they will almost always find only a partial, and rarely public, ally. The advice will be “you cannot change it, I cannot change it and I do not wish to. Play the game. Be pragmatic. Pretend if you must. Give them what they want and you shall have your freedom”. But the church of psychiatry itself cannot be raised to the ground, and no iconoclast will leave it. Play it or not, the game must go on.
None of this gives a window into psychiatric praxis itself, a day in the life of a garden variety psychiatrist. In this closing half of the chapter I’ll tell you all you need to know.
Apart from the ontological question of a psychiatrist qua authority with legal power, there is the matter of what they do. And what a psychiatrist does in praxis is nothing more complicated than the praxis itself, and being confident and practiced in the role. This may be summarized in four terms; history, mental state exam, diagnosis, formulation and treatment (I say four terms as formulation is often done poorly or omitted entirely).
History; So you visit a psychiatrist in their private rooms, or find yourself sitting across from one in a state hospital, plus/minus a security guard or two standing by lest you commit a crime from which you will rarely be charged or prosecuted (you are mentally ill after all and what’s the point staff pursuing a charge that will receive little to no sentence). After the pleasantries are hopefully exchanged, psychiatrists begin by asking basic questions of demography. How old are you? Where do you live? etc. This is how I would start, for one achieves a basic skeleton of knowledge of who the person is by where they reside, with whom they reside, what they do for work (if they work), if they have children etc. This gives one an idea of the ties that bind along with functional capacities, if these are being utilized at this point in time or if there has been a drop in function. Then what is approached is the question of why you came for help, your own subjective complaints, i.e. your symptoms and the surrounding narrative. Are you sad or anxious, confused, obsessed, having strange experiences such as hearing voices or has life become mundane and not strange enough? Do you think of killing yourself? Are you here because someone else wants you “to get help”. Have you tried to take your life in the past? What is the impact of the symptoms in terms of work, relationships, sleep, appetite and the like? How have you been coping, i.e. self-managing symptoms? (this can be a guide about how you can generate your own recovery and participate in the process. This can also be an opener to asking about drug use as “self medicating”). Many more questions are asked besides. What ought to be explored in depth is the childhood experience. More often than not a developmental history is not explored in anywhere near the depth that is it’s due, if at all. Psychiatrists Instead often make a big deal about family history of mental illness. They do this under the assumption of looking for bad genes. I ask about family history with a view to looking for experiences of other alleged mental illness in the family and the impact of this upon the patient. As suggested elsewhere, genes (in my humble opinion and having evaluated the evidence) are overrated where they are highly rated (risk of bipolar disorder, depression and schizophrenia for example), and under rated where they are over looked (personality and genetic propensity to anxiety for example). In any case, nothing can be done about them. If you can ask questions of a typical comprehensive history and cognitively apply them to the next three steps to follow, you are on your way to being in practical terms interchangeable with the psychiatrist (though of course without the power invested by the state).
Mental State Examination; Genuine doctors perform a physical examination where they bump you knee (or just south of it) with a tendon hammer, listen to your chest with a stethoscope, and many things more steps besides. Anankastic physicians of internal medicine who take themselves too seriously (and most do) will kick up much of a fuss in favour of following conventional steps of physical examination to the letter, even castigating the physician trainee who approaches the patient from the wrong side of the bed or dares do anything out of order. The psychiatric equivalent is the mental status examination, or MSE. On one hand the MSE is an unconsciously desperate attempt on the part of the psychiatrist to consciously realize themselves to be a real doctor, and so they obviously adopt (or dissimulate) the parlance of the real doctor, having a conversation masquerading as an “examination”. On the other hand, the MSE is simply a list of variables from what you tell the alleged doctor and what they themselves observe. History could easily have dispensed with the MSE and its elements be incorporated in one paragraph of synthesis written about the therapeutic encounter. In any case, the MSE is here and here to stay, for no psychiatrist is critical of why it need be there in the first place. An example of the elements is provided below. The MSE ought to flow from the history and be congruent with the diagnosis and formulation. If not, something is amiss.
A brief and simple example of an MSE might be this, in a homeless schizophrenic IV drug user. For the most part I’ve omitted the specific terminology employed by the psychiatrist, though this is easy to learn
“Patient presents as older than stated, dishevelled malodorous and not attending to self cares of hygiene and grooming. Rapport was poor and he had an irritable attitude to interview, with poor eye contact and stigmata of IV drug use. Occasionally he paced, though was not aggressive. Speech was monotone. Appeared to be responding to non apparent auditory stimuli (i.e. talking to himself) and reported voices telling him to kill himself. Affect (usually taken to mean facial emotional expression) was lacking reactivity and restricted to a mask of seriousness. Mood was subjectively euthymic (i.e. says his mood is fine). Significant thought disorder with tangential responses (i.e. the response might make sense yet do not relate at all to the question asked) and thought content included persecutory delusions