Leaving Psychiatry. J. R. Ó’Braonáin. M.D.
confident in being internal medicine physicians (“deep understanding” of physical health), and having solved the mind body problem (“how they affect each other”). Most disturbing at all is the claim that psychiatrists are experts at mental health. Do they really know what health of mind is, and by extension what it is to be a healthy person? No. Even the great philosophers wrestled upon the question of what it is to be and the life well lived. Turns of phrase betray deeper meanings and motivations. In my experience it is said all the time, “the patient has no mental health history”, which is to say they have no history until the present of being mentally unhealthy. Or put another way, they have no history of involvement with mental health, i.e. psychiatry. There is no paradox. Mental Health is semantically an antonym for mental illness. Mental health is practically speaking, a synonym for mental illness, or the institution of psychiatry.
All these definitions are, in petitio principii, assuming to know what mind is, the existence of what they say is mental illness and these illnesses (plural) being what they say they are (i.e. a question of construct validity), along with the psychiatrist’s rightful place in the world as ministers to the mind (a political question). The Americans, though not as narcissistic as Oceania (on this occasion anyway), nonetheless metastasize out of the hospital in suggesting that the psychiatrist is even the specialist over problems that impact upon “everyday life”, without at least speculating on the possibility that problems of everyday life are sometimes the problems causing (not impacting, but causing) the symptoms themselves. This is to say the so called mental illness is, at least sometimes, American everyday life itself, and what passes for the symptoms of the illness are epiphenomenon. Is this not self-evidently obvious in an Anglo speaking world of relative morality, undermining of personal responsibility, destruction of family and community, wage slavery and a popular psychology that for decades has been all about the “me”, myself and “looking after number 1”? And what totalitarian havoc can be made from taking that tiny step from declaring oneself master over the impact from the problem of daily life to declaring it the business of psychiatry to be master over the problem of daily life causing the impact. The Americans are at least honest in using the word “qualified”, for to be qualified is what psychiatry is all about. True enough they are correct definitions in the sense that a psychiatrist must be a medical doctor first, or at least to have completed medical school before they embark on a radically fast unlearning of all medicine inferior to the neck and outside of what is between the ears (and forget much of what is between the ears also, i.e. neurology). What all these definitions lack is the real sine qua non of the psychiatrist, what actually sets them apart from other doctors, and by extension with every other individual within their jurisdiction (and I use the word jurisdiction deliberately as we shall see). Any common or garden variety doctor can take a special interest in the mind and what passes for “mental illness”, or mental health for that matter. Not every advanced western country even requires a single exam be sat in order to be annointed as a psychiatrist, though all of the examples in the Anglo speaking world do. Historically not requiring exams outside of medical school was even more universal, and not too long ago at that. After all, a psychiatrist was historically simply the doctor who was the warden of the asylum, otherwise known as an alienist. And so specialization is a term wanting of elaboration of the necessary and the sufficient factors and historical context. What it means in the case of 21st century psychiatry, whether in free market USA or in the semi socialist health systems of Australia, Canada and the UK, what really sets psychiatry apart, is simply this; the psychiatrist is a doctor who, in virtue of a the tripartite collusion between the state (i.e. government, particularly the legislature who in part defers to a registration body), a registration body (who defers to the guild), and a professional guild (who defers to themselves as a law onto themselves) is given a qualification that invests them with the legal right to practice independently (i.e. unsupervised) in the community and the legal right to authorize involuntary detention and forced drugging of the person who they assert requires it for reasons of “mental illness”. And the terms of the argument the psychiatrist offers in favour of the deprivation of liberty viz a viz mental illness are set by the very profession and guild who exercises power. To have this authority is to be a psychiatrist. To be a psychiatrist is to have this authority. Other doctors can treat without consent the delirious, elderly with dementia and younger children without any involvement of psychiatry, this hardly being controversial. And other doctors may be able detain and treat a patient thought to be “mentally ill”. Yet this is only for very limited periods of time, usually as an interim measure awaiting psychiatric evaluation. As such these other doctors’ authority to detain is psychiatry res extensa. Some jurisdictions even have it instantiated into law that the garden variety doctor can only exercise powers to detain for mental health reasons under the promise that psychiatric evaluation will be available and forthcoming. The final say is always had by the psychiatrist or necessarily involves a psychiatrist as the key informant in whatever legal panels where a member of the judiciary notionally decides the person’s fate. So you see that no one has the power to detain another for reasons of mental illness if the profession of psychiatry were to cease to be. The necessary criteria towards psychiatry is medical school. The necessary criteria in being a psychiatrist is to the authority to wield a kind of power which is underwritten by the philosophy and advice of the very guild of practitioners that wield it, and anoint the apprentice to be granted the power of the master. This is not to say, or not yet even to ask, how a psychiatrist morally ought to wield such power and if they are doing so correctly. Nor is this to channel (a reading of) Foucault and imply that power politics rule the world to the exclusion of all else. It is to simply say that it is power that defines the limit of the boundary between psychiatrists and all others who might consider themselves practitioners of, or in the case of the patient, objects within, the so called mental health system or medicine. Why is this profession specific capacity to exercise such a powerful authority over person’s liberties not explicitly mentioned in any definition from any of the guilds themselves? Not a single one! I can only conclude from this either unconscious or deliberate desire to dissimulate the truth under cover of talk of helping and treating, or care and cure, of expertise and illogical talk of health when they mean illness. What do they fear by declaring their power? Personal embarrassment or public reaction at the implication?
Writing of psychiatrists as specialist doctors who practice mental health is like speaking of priests as being specialist choir boys with an interest in theology who also like to “help” people. The word help is used in each of the three above mentioned definitions, contra the fact that many patients do not wish to be helped and run across jurisdictional borders to avoid it. Is help not at least potentially something subjective and defined by the one who is being helped? Just as a priest is better defined as the one ordained by a select guild to have the sole power to administer the sacraments, the secular priest could also be defined on the basis of the power he/she wields, and much more so given there is no transcendent authority above the psychiatric guild as there may well be above the priesthood, this transcendence being something that redefines the priest in turn. Would it not be more honest for these professional guilds to state something such as….
“Psychiatrists are that species of medical doctors, who, in virtue of a collusion between the professional guild and the state, have the sole authority to bill certain items to the tax payer and/or insurance companies, work unsupervised in the so called free market, and lock you up +/- administer medication against your will when they believe it is suitable on the basis of a criteria designed by the very same bodies who create the psychiatrist in the first place. Psychiatrists have the additional authority to make themselves immune from challenge in the court of science and argument as guild members control the journals, the narrative and the standard of practice against which both malpractice and the notion of mental illness are measured”
All the above being granted, one might say that psychiatrists are defined by not merely what they are as agents of power, yet also by what they do in practice as specialists of their craft. This would be problematic. Allow me to explain.
Give one hundred orthopaedists the same fracture and one will get one hundred doctors diagnosing the same pathology, doing more or less and with varying surgical skill much the same thing. Being surgeons, they will even all agree that they personally (i.e. individually) did the superior job. Part of the challenge in providing the answer of what a psychiatrist is in being and in praxis lay in the fact that psychiatry is by far and away the most