Sunday, August 3, 2008

Past is Prologue

Is psychiatry worth doing, and if so, why and how? I suppose those questions are the point of this blog. The last few years haven't been very kind to the profession. The diagnostic system remains an object of derision to many, the medications have become ever more suspect in terms of both safety and efficacy, and sleaziest of all, more and more psychiatrists have been discovered to be in bed with pharmaceutical companies. And it hasn't only been individuals whose integrity has been questioned--psychiatry's leading professional organizations and journals (and by implication its methods of research and publication) have come under increasing suspicion.

So the point of this blog is to explore what remains vital and worthwhile in the field, and to my mind that requires drawing on broader traditions, of history, philosophy, religion, and the arts. Any psychiatrist ends up being asked countless times why he or she chose such a peculiar and, to some, appalling line of work. Perhaps psychiatrists get this more often than other therapists because of an assumption that the former, had they wanted to, could have become "real doctors." At any rate, one answer for me is that in medical school psychiatry seemed to have a breadth far surpassing other disciplines; instead of poring over laboratory results or doing the same procedures over and over again, psychiatry seemed to offer a chance to engage with some of the great questions in life: the distinctions between health and illness, the nature of happiness, the definition of the worthwhile life. Particularly in the context of psychotherapy, the field seemed the most flexible and genuine, and the least coldly clinical. Being at risk of being called a shrink for the rest of one's life, or of being coolly dismissed by surgeons (or heck, by family physicians, who may be glad to be one discipline up from the bottom of the totem pole), seemed a modest price to pay for more authentically interesting work.

I can certainly say that I still would choose no other branch of medicine, but the field seems flatter and narrower than it once did. I know that some of this is due to the kind of acculturation that anyone goes through--much of it is "old hat" to me now. But in the case of psychiatry it goes further, I think, largely because of the inexorable pressures of economics. It is not only the case that psychiatrists very rarely do therapy any more--that change has been going on a long time now. But in my experience people, both inside and outside of medicine, are increasingly surprised if a psychiatrist has anything at all insightful to say about anything beyond medication issues. I think that trend has to be resisted. Anyone who is not only diagnosing people with mental illnesses but also prescribing mind-altering medications should strive to have the broadest (dare I say wisest?) view possible of the endeavor. And this is not merely for the benefit of the patient--it should make the activity much more interesting to the psychiatrist as well.

So I will comment on ideas, cultural trends, and the arts as they influence psychiatry and are influenced in turn. I claim curiosity more than I claim expertise or comprehensiveness, and I welcome comments, objections, and suggestions.


Michael said...

Hello Neil, good luck with the blog, I think it is a worthy endeavor. In some ways, I think it is not such a bad thing that psychiatry is trending toward becoming a narrow technical specialty. We suffered from too many years of psychoanalysts and their hubris. Of psychiatrists can still obtain some wisdom on the human condition, but as just one among many people viewing the condition. And I think many of perceived problems in psychiatry are simply the result of a new wave of antipsychiatry. None of these problems are unique to psychiatry, but you don't here people about to give up on "western medicine," just psychiatry. It is just another cycle in our field. Actually I think it is a good time to be in psychiatry, in 20 years we will be just another part of neuroscience, but of course you know I am the optomistic one.


Anonymous said...

That's one of the main reasons I didn't go into psychiatry - it is really really scary to prescribe a drug or try to give therapy that messes with someone's mind. Let me fool around with their blood pressure, their glucose...but I don't want to change anyone nor mess with their BRAIN. You're brave.