Leaving Psychiatry. J. R. Ó’Braonáin. M.D.
often) women who were first schooled in 3 years of philosophy as part of the curriculum, having to prove themselves wise, willing and able to think clearly and critically. Even contemporary medical school ethics becomes an uncritical checklist balancing the so called 4 principles of Beauchamp and Childress (i.e. autonomy, beneficence, non-maleficence and equity). The ethical calculus usually excludes any superficial, never mind deep, analysis of one system of ethics against another as philosophies within the “meta” question of the being and value of ethics itself within the world. And never is it asked where ethics ends and morality (let alone the rest of philosophy) begins. In summary, the game is to uncritically accept what is, remember, answer correctly restricting critical analysis to operations within the accepted system itself, and move on to the next question or the next patient. That is what the mind of the medical student is encultured to do. What hope do they have when confronted with the question what maketh the man and what do I make of his apparent madness and misery?
With the all these wheels in motion, our medical student arrives at their term in psychiatry. Unless they have a personal interest in the subject, they will never have encountered the so called mind body problem (or mind brain problem). Remember that they are accustomed to automatically assume everything they encounter is grounded in physical reality. When their psychiatry lecturer voices a piece of pseudo-scientific propaganda servicing the survival of psychiatry as a profession (e.g. that schizophrenia or ADHD is a proven “neuropsychiatric” or neuro-genetic” disorder, or claiming a delusion is fundamentally and substantively different from non-psychotic beliefs, or that there is such a thing as an “antidepressant” medication in the same manner and with the same nominal justification that we have “anti”-biotic medication), the student will take all of it as a given. Who can blame them? This isn’t a product of a lack of intellectual capacity or an uncritical temperament (though it might be). No it’s a product of pure philosophical inertia and an article of faith on the part of the student that the psychiatric professor is telling them something about the world and the human condition as it is, as real as the broken bone (there is little doubt the psychiatry professor is a true believer in what they are preaching. Always a good quality in one who seeks to convince another is first having convinced oneself). I notice this especially in doctors who have been raised and educated in traditional societies not as historically touched by the Socratic method or the Protestant mood. When our medical student encounters another list of differential diagnoses in psychiatry they will automatically assume these to be as valid in themselves and vs each other as the existence of, and difference between, a myocardial infarct, a pericarditis, a gastroesophageal reflux, an osteochondritis, an aortic dissection etcetera as painful manifestations of the thoracic pathology. They won’t hazard to question if these psychiatric constructs are even ontologically of different categories to each and every other field of medicine. What aids greatly in this will be the logical fallacy that any apparently salutary response to medication proves the existence of what some may call disease that in turn falls under the purview of the doctor. Though why not then make a doctor of a bartender escapes me, for alcohol also delivers a salutary response for many. And so the logic must be that millions around the world have a disease of excess of blood in their alcohol stream.
Along with all this will be the spectacle the medical student will first encounter with the first psychiatric patients they see. In the vast majority of cases, the medical student will first encounter “mental illness” as part of an attachment to large teaching hospitals with acutely and severely disturbed individuals, often the urban poor. They will accompany a consultant psychiatrist and their apprentice resident/registrar on their ward rounds. In one consult or corner of the room will be a girl curled up in a regressed state with more cuts and scars on her forearms than stripes on a zebra. She will say she surely wants to kill herself, and if so the blood will be on any others hands but her own. In the other corner will be the dishevelled and derelict man who mutters and occasionally giggles to himself as if in conversation with another whom he and the student cannot see, and yet whom he nonetheless “believes” is real. It will go unnoticed that in “reality” he probably has no one “real” to talk to, or at least no one caring who is worth listening to. The next might be the young adult liberated from an unenforced law against drug consumption by an overworked and nihilistic police force. He is high on methamphetamine, aggressive and speaking quickly and incoherently as he shifts in the chair and threatens to harm someone if he is not permitted to leave the locked ward to smoke. His aggression is 8 parts mania and 2 parts smokers craving? Or is it 2 parts mania and 8 parts smokers craving? Or is it a mix of the above with 8 parts deficiencies of character? Or is it 10 parts methamphetamine? Who can say? The next patient will be the straight faced person who tells you they are the God of Egypt and will order the CIA to execute the psychiatrist who does not release them from hospital now (they will of course not be able tell you what the acronym of the C.I.A stands for or why the God of Egypt does not use the Egyptian Secret Police, let alone be able to speak any ancient tongue).
For the medical student, this sort of thing can be quite confronting. For whomever has eyes to see can doubt these patients are disturbed and alien to normality, even vulnerable and unable to function in the world as it is unless aided by others who care. Who ought to care and how they ought to care is part of the subject of this book, for nigh on a couple centuries now care for these persons has uncritically accepted to be under the purview of medicine in general, and what has become known as psychiatry in particular. Even if our student vows to steer clear as much as is possible from psychiatry in their future career, I would submit to the reader that it is on the basis of this very confrontation with the greatly disturbed “other” that the medical student has cemented an uncritical acceptance of all they are told thereafter on the matter of madness and misery by their psychiatric masters. They never then will ask what makes the supposedly psychotic unfounded belief different from the supposedly non-psychotic unfounded belief vs a single spectrum with arbitrary differentiation of the normal from the pathological, or why from the meeting point between vulnerability and compassion towards another must flow compulsion towards involuntary hospitalization and treatment. They don’t dare ask nor think to ask the extent to which the psychiatrists own psychological need to perceive themselves as a real doctor influences what they espouse to be true of the person and the world. The student might never ask if criteria for diagnoses is an exercise in carving nature at the joints (to quote Plato) as opposed to being a contrivance no better than a taxonomy of mythical creatures or the zodiac…and so on and so forth many more questions besides are never asked or asked rhetorically, for they have already accepted the answer psychiatry has readily available. A great number of non sequiturs that ought to be in view immediately vanish before they are even brought into focus in the presence of this great otherness of madness and misery. The uncritical turn towards faith is the same for the medical student (or junior doctor) who then decides to return to the same psychiatric ward later as a resident/registrar in the high church of psychiatry. Paradoxically it might be the inkling of the unsolved questions, the mystery that drives them inwards nonetheless. This want to sate the unconscious is a mistake, for psychiatry will constrain the horizon of acceptable answers before the questions are asked. It will invite the philosophically curious cat, and then proceed to kill it and proclaim it to be well all the same. But then of course the apprentice psychiatrist is too far from the shore of what they might have thought to question to swim back without drowning in the mistakes they have wrought on themselves and others in the diagnostic labels they too ascribe, the medications given to be imbibed and the deprivations of liberty prescribed. The junior apprentice has already detained people many a time against their will for treatment they do not want and who protest diagnoses they do not assent to. Who could then look back and call this deprivation of liberty monstrous, for to do so would be to risk calling oneself a monster. They have already put hours of study into “diseases” or “disorders” and “neurochemical circuits” that as explanandum of the psychological world exist more in the textbooks than in the world, or not in the world at all except so far as the textbooks project them outwards onto the person. Who could take this time invested and then easily admit it to have been futile to the cause of knowing what actually “is” in the world that is the person sitting across from them. Hubris and certitude are defence mechanisms one might say, though defence mechanisms are a mirror that cannot be ascribed to patient and physician both simultaneously. Often only the latter is educated enough to assiduously avoid self accusation, ironically without any conscious realization of their double standard.