Читать книгу Leaving Psychiatry - J. R. Ó’Braonáin. M.D. - Страница 4

"Ideally a book would have no order in it, and the reader would have to discover his own."

Raoul Vaneigem

"Education no longer has a humanist end or any value in itself; it only has one goal, to create technicians"

Jacques Ellul

In the beginning, or in this beginning anyway, was the medical student. Only the medical student is far from being without form or void. Quite the contrary. By the time the medical student has their first encounter with psychiatry they are thoroughly encultured in a way of approaching whatever subject matter comes their way, and these cognitive (if not ideological) schemata have gathered such a powerful momentum that it can quite easily launch them into their psychiatric term and spit them out the other side without them having the faintest idea just how alien and even mythical was the species that passed into view for those 10 or so weeks. I include amongst them even the medical student who rejects psychiatry at the outset, for they know not what they reject. They are the ones whom, later as physicians and (especially) surgeons will politely describe their clerkship in mental health as “interesting’ and “valuable but not for me”, this being the most charitable descriptor they will offer to the psychiatrists face. What is said behind the psychiatrists back is, as usual in human nature, another matter entirely.

Broadly speaking, medical students pass through two pedagogical pathways nowadays, both reaching a considerable convergence in the latter phase of studies. The first is a more traditional form, starting with the basic medical sciences of anatomy, physiology, biochemistry and the like. If not stated explicitly, what is certainly taken up implicitly is the notion that one’s vocation is as an applied engineer of a biological machine and, post Virchow, the fundamental patient is the cell, if not some subcellular molecular unit below cellular life or some organ system above it. Granted there will be plenty of lectures from plenty of health sociologists and public health physicians restating endlessly and to the point of tedium various definitions of “health” and “illness” and UN charters of this and that human right (and rite), all the while the student sits there yawning in the most justified assumption that their intuition as a human being informs them when they are well and when they are sick, and when they are making a mess of themselves qua a multicellular ship of Theseus as their soul voyages from birth to death. Granted there will be plenty of lectures and reminders of lectures that we are treating a whole person with whom we must communicate “empathically”. Yet even these lectures on communication are, if to be honest, part of a micro-social engineering strategy. How do I get to the cell and physiological system “through”, as it were, the person? How I might gather the data their body wants to tell me through what might otherwise be a brick wall of personality, should I not first gain “rapport” by uttering some comments here and there “that pain must have been hard for you” as we lean in a little, chair placed adjacent to the patient as we were taught in the class on proxemics (as opposed to on the other side of a desk). How might I charm the patient to take the pills if I don’t empathize with their “lived experience” of side effects and “stigma” whilst pointing out the inevitably (or so it would seem inevitably) higher risks should they flush those very same pills down the toilet. It can be very disconcerting being a physician patient of another physician communicating in taught empathy. It’s just too predictable and quasi-robotic and leaves the doctor who is patient looking in turn to find the person through, as it were, the physician who “cares for” the doctor who is the patient. Thankfully most patients live in blissful ignorance of feigned caring, and many a physician has first deceived themselves that they care. These will be the physicians taking the greatest umbrage at my analysis. No, the patient is the machine that is the body, and more to the point, an abstraction constructed from the machine, for even the body eventually is ignored in the age of information. Psychiatry is no different, though the castle it builds on the body is a castle built on sand.

Returning to the more traditional model of medical education; in learning by rote the almost endless list of facts of the basic medical sciences, which are of their very nature philosophically materialist, for there is never a hint of a mention of mind or telos or value in the cells that constitute the body let alone the body as a whole, the student hopefully acquires the raw materials to appreciate the clinical problem when they take up their stethoscope and are unleashed upon the hospital. An example of the clinical problem might be the matter of chest pain. The student has learned from basic anatomy that the heart is in the centre (more or less) of the chest, the lungs either side, all enveloped in a sheath of muscle, bone, skin etcetera. They learn this in great detail, or at least they did when anatomy was taught properly. By the mid 2000’s even the best medical schools had replaced long hours of expensive invaluable dissection with very limited “dissection experiences”, for flesh and blood and time gets in the way of abstraction and assembly, and corporatized universities have become a business or mass production factory churning out as many medical students as the hierarchy will allow, whist specialty guilds pull up the drawbridge that might otherwise challenge the exclusivity of their own little clique. The student will have learned from basic physiology and cellular biochemistry to appreciate that the heart is a (kind of) muscle, and as such requires a constant supply of oxygen or lactate will accumulate, this triggering certain nerves to a state of activation that eventually be followed by the conscious phenomena of pain. The clever student may adduce from first principals what might be the cause of the pain, and from this what might be the remedy. To elaborate; the clever student may conclude that given the pain oscillates with a periodicity of breathing and is phenomenologically experienced as a pain spatially located to the chest wall, then it may relate to some structural pathology or inflammation of the chest wall itself. On the other hand, the pain may be steady and central, varies with exercise intensity and by extension the demands placed upon the heart. And so they may conclude the pain is that of angina of the cardiac variety. The really clever student who excelled in embryology might infer from first principles why the chest pain is perhaps also experienced as pain referred down the arm, or why pathology about the diaphragm (the muscle essentially dividing chest from abdomen) might be experienced in, of all places, the neck also. But these clever students are, believe it or not, very much the exception. In the majority of cases, the prior study of the basic medical sciences simply provides the raw materials from which to understand the reasoning and evidence behind vast lists of diseases and diagnostic reasoning that they are not expected to generate by their own synthetic cognitive devices, as opposed to simply remember and apply in a kind of algorithm/flow chart. Nowadays they are not even expected to generate the algorithm themselves from studying multiple sources. One will have already been published for them. They will learn that chest pain can be a manifestation of X, Y or Z pathology. They will memorize which signs (what can be seen/heard etc) and what symptoms (i.e. what the patient reports) correspond to narrowing the differential diagnosis from X, Y or Z to a single explanation of X (OR Y OR Z). And from the diagnosis of, say, angina what will follow is another memorized algorithm or pathway of what to do next, a treatment pathway. To this end the basic medical sciences are nothing more than lubricant to move through a pathway.

The same pedagogical journey towards pathway/algorithm arises from the more contemporary method of medical education known as problem based learning. Only in this case the student is confronted from the outset with the clinical problem (e.g. chest pain), perhaps in some cases with no prior learning of the basic medical sciences whatsoever, much less the basic or first order sciences of chemistry, physics and so on. What follows, without either word of an exaggeration, let alone a lie, is for the medical student to first learn what the chest is precisely, what is within it and so on. Often the student is almost expected to teach themselves, with lectures and such renamed as “learning resources” and the very structure of the students learning plan left to the devices of the student themselves. They may even be placed in “problem based learning” groups, with a facilitator at the helm who is explicitly instructed not to instruct, and rather sit there as the blind lead the blind, much like the marriage counsellor who sits, listens and asks each spouse what they think, all the while gagged from telling anyone what they (i.e. the counsellor) thinks or what they (the couple) ought to think, much less what they ought to do, though it may well be blindingly obvious. The hope of such a model of education is to cultivate an internal locus of self-organization, motivation towards so called “lifelong learning” and finally the capacity to think critically and synthetically, much like the clever students alluded to above. The reality is that such a model of education is just another road to pathway and algorithm, albeit from a different starting point. The student starts with clinical problem and the pathways to diagnose and treat it, reaches back into conceptual space to teach themselves the basic medical sciences (albeit never deeply) before returning again to the problem, this time with a greater understanding of what the clinical problem “means”.

Several points arise from the above. The first is that medicine and what it is to be a doctor becomes almost mechanized, even cybernetic in a sense, and notions of intuition, individuality and such become antiquated and silly, if not reproached as dangerous. Such a mechanized state of affairs becomes the case in virtue of the cognitive schemata of lists and pathway alone, without even approaching the influence of so called “evidence based medicine” dogma on the student’s psyche, or even the reliance on standardized diagnostic and treatment approaches not so much for cognitively expedient reasons, yet rather as a group survival mechanism in a litigious world. That is to say, we do things so that the patient will recover. This is granted. But often we do things more so as to avoid getting into trouble by instead locating ourselves in the centre of herd activity. Often these two goals and their outcomes only weakly overlap.

The second is that the medical student deals with the physical body as a kind of engineer of sorts. Despite the drive to abstractions they become in some sense at least grounded in something that has a material basis in reality. The more classically trained medical student will learn that there really is something called a heart. After all, they poured their concentration over it over a lengthy dissection process in some basement of an anatomy department where their olfactory apparatus was partially killed off by formalin, and their fingers became pickled like the cadavers if the gloves weren’t up to the task. Parts of my thumbs remain hardened still. The same student will see under the microscope the cells that comprise it and what a heart looks like when necrotic (i.e. dead). They will learn about processes by which the heart muscle needed and utilized oxygen, and see the arterial and microvascular roads of supply for cellular demand. The same student will take the ECG, and quite rightly so, as the electrical representation of activity of the organ that’s sustains them in its beating from the moment of birth (indeed from only weeks post conception) to the moment of death. After anatomy classes the medical student may never actually see a heart again as a material thing in the world, as opposed to an abstraction in a diagnostic or treatment pathway. All they might encounter is a patient in pain, what the blood investigations shows, what the physical examination finds etc. They will know what this probably “means” and be sure of the horizon of potentiality. No one would be foolish enough to question the existence of a heart attack qua dead or dying heart muscle as something concocted or confected by some vested interest group, a pharmaceutical company or as some “social construct”. They know all too well that if push comes to shove (and it often does), the cardiologist will run a dye up the leg and demonstrate that there is a heart there just as they remember and that this heart is perfused with less than its fair share of blood. Beyond this the pathologist will have the final word in the pronouncement of the physical groundings to disease. In summary, the medical student becomes complacent in the justified confidence that in all that might be called disease, pathology or illness, they are working with the reality of a material, albeit biological, machine.

These symptoms, signs, investigations to be ordered, potential diagnoses and so on (all the many pathways and elements of pathways) amount to a formidable information overload to even the best and brightest of medical students, who are usually the best and brightest at school and college. The task is to survive, remember, regurgitate, and apply correctly. Though all this requires a mind of above average intellect in the sense of short term memory for “cramming” exams and superior information processing capacity, there is nothing remotely approaching authentic critical thinking of the philosophical kind, let alone to recline in the garden of academe pondering the metaphysical questions that might, nay should sometimes, be applied to the vocation of medicine. There is neither the time nor the energy nor the compulsion, much less the inclination. Long gone are the days of the appropriately famous medieval medical school of Salerno, the Schola Medica Salernitana, which only accepted men and (just as 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. Freud after all would see a cigar as a phallic symbol, but sometimes a cigar is a cigar, especially when it was in his hand. Having mastered the psychiatric projection onto the world, the psychiatric trainee is too far from the great works of literature and the humanities they likely never read at all or at least not deeply, literature that might have provided a different more illuminating view of the human condition. They have given themselves over to the grace of a special kind of human indoctrination towards a special kind of secular priesthood. Welcome to seminary.

But I wish not to mix my metaphors too much here, and certainly not to the point of contradiction. To be sure I see the psychiatrist as a secular priest of a kind. To the end of convincing you of this fact I will provide evidence aplenty in the chapters to follow. Yet all the above talk of algorithm in medicine and psychiatry leads one to something perhaps more sinister, that being the mechanization of humanity. You see when the patient is situated upon the algorithm the patient ascends to the realm of abstraction and ceases to be as a human being. This is not to imply the malady in psychiatry is the misplaced primacy of the biological over the psychological, or a lack of kindness or apprehension of the pathos in the heart and mind of the psychiatrist. Heaven forbid I suggest anything so banal. What I am suggesting is that looking upon the patient as an object situated upon an algorithm or a bookmark to be placed in the appropriate page of the DSM is a red herring for the concerns of the humanities in psychiatry (or medicine in general for that matter). For what is assumed not to be lost, this assumption being entirely false, is that the psychiatrist has themselves retained their humanity. You see when the psychiatrist sees you as an object of a flow chart they must first have taken into themselves the being of “flowchartedness”, of “differential diagnosis”, of DSM and all that makes for the method. Having identified on too deep a level with their method, they are like Heidegger’s carpenter where the hammer is ready at hand, and indeed the hammer is an extension of himself, and he of it. And the method of squashing humanity out of psychiatry is an essential part of psychiatry itself, for how can it be otherwise. The method being what it is, without it psychiatry would cease to be. Even the psychiatrist cannot escape the technocratic method of approaching the person, for the method sits “meta” to he (or she), in the body of knowledge and the bureaucratic imperative for how the patient is processed through their own mind just as their body is processed through the hospital. These metastructures, like Adam Smith’s unseen hand of capitalism, take on a life of their own that in turn reflexively sets to mould both the psychiatrist and patient alike. The imperatives are efficiency, comprehensive “mental health assessment” and documentation, “risk assessment” and risk minimization, accurate diagnosis according to the accepted nosology and so on. Each one of these is a place upon which the patient is situated. And then the psychiatrist feeds the method and bureaucracy in its insatiable need to consolidate and expand itself, to sustain its own lifeless being. And in each and every psychiatric transaction there is nothing but method as far as the eye can see. Unless one is inoculated by a congenital hatred of it, one fails to see technocratic slavery save in such examples where the method approaches absurdity. Take for example the adolescent in state care. He is wilful and violent, this in some way related to adverse events of early childhood, chiefly being witness to violence from adult others. It does not take a genius to recognize the developmental connection which is its own explanation. And his supposedly psychologically trained residential care workers follow their method when he is violent, the method as directed by their own cognitive schemata and the directive of their hierarchy. They call the police or paramedics, for he requires a mental health assessment, or so says their method. And the police or paramedics dutifully respond, bringing him against his will to the hospital with the powers invested in them by the state and its mental health legislation. Their motive and orders too are the same. And all look to the psychiatrist to “assess”. What is the diagnosis, this is one question? What is the risk is another question? What might the treatment be for this condition is yet another question as the adolescent is placed upon the assessment machine? The answer, alien as it may seem to some readers, is no answer at all. The child is badly behaving. There is nothing to explain that has not been already. There might be corrective action in order, likely not to be successful in his march towards criminality yet not to be considered “treatment” in any sane world inhabited by those who have retained their humanity and good sense. Yet these simple answers simply do not compute. All involved, from the emergency physicians to the police to the care workers look doe eyed and baffled when I say there is nothing to be explained that is not known to any competent adult, and no recipe to a remedy that is medical and not the analogue of good parenting. But what is the “diagnosis” and how might we treat it? What psychological therapy will “change him”? Let’s talk medication another says. Good sense falls on deaf ears. The child settles. Most hot heads do. And he returns back to their care. And later that week he returns again under similar circumstances, the action activated by the method, and returns twice more the following week, and three time more the next. The humans who behave like stupid robots act reflexively. The questions are the same. The assessment is demanded by the method. My (non) answers are the same, as I refuse answer as an agent of the psychiatric machine. The failure to compute is thoroughly recalcitrant to good sense, for the person has given themselves, their mind, their individuality, their good sense, all given over to method. And on goes the circus. Even to negate the method by appeal to personal psychiatric authority as opposed to good sense of an adult human being is itself to fall victim of the subtly of the technocratic machine. There is no escaping it save to escape psychiatry. So yes welcome to seminary. Yet welcome also to the machine of what a technocratic psychiatry has wrought on the world. Only the joke is on you, for if you enter into psychiatry the machine is you.