Читать книгу Leaving Psychiatry - J. R. Ó’Braonáin. M.D. - Страница 5

“When we cannot be delivered from ourselves, we delight in devouring ourselves. In vain we call upon the Lord of Shades, the bestower of a precise curse: we are invalids without disease, and reprobates without vices”

E. M. Cioran

What is a psychiatrist?

The UK Royal College of Psychiatrists website “What is psychiatry?” offers a rather laconic description, prompting the question of the boundary between what is a mental health condition and what isn’t. Whatever they say it is I guess.

“Psychiatry is a branch of medicine dealing with people with a huge range of mental health conditions. As a psychiatrist you’ll help people to manage, treat or recover from these.”

The United States American Psychiatric Association, “What is psychiatry?” provides a longer, yet altogether equally prosaic definition. They say…

“Psychiatry is the branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional and behavioural disorders. A psychiatrist is a medical doctor (an M.D. or D.O.) who specializes in mental health, including substance use disorders. Psychiatrists are qualified to assess both the mental and physical aspects of psychological problems. People seek psychiatric help for many reasons. The problems can be sudden, such as a panic attack, frightening hallucinations, thoughts of suicide, or hearing "voices." Or they may be more long-term, such as feelings of sadness, hopelessness, or anxiousness that never seem to lift or problems functioning, causing everyday life to feel distorted or out of control.”

The US guilds definition is equally provocative of questions. An emotion is not a behaviour granted. Yet is an emotion not something “mental”? Are substance use disorders a matter of mental health, or the product of choice? And in what sense is substance use a “disorder”? Is disorder “a thing” in the sense that cancer is a thing? And when I was going to school “anxiousness” was not a real word. My how things change when psychiatry is the lexicographer.

In Oceania the Royal Australian and New Zealand College of Psychiatrists define the psychiatrist thus

“Psychiatrists are medical doctors who are experts in mental health. They specialise in diagnosing and treating people with mental illness. Psychiatrists have a deep understanding of physical and mental health – and how they affect each other. They help people with mental health conditions such as schizophrenia, depression, bipolar disorder, eating disorders and addiction.”

The Royal Australian and New Zealand College of Psychiatrists at least makes an attempt at something more, succeeding at defining a psychiatrist in obviously narcissistic terms, explicitly 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 internally heterogeneous of the specialities in which a doctor may find his/her vocation. (note I do not call it a medical speciality per se, for such would be counter to the thesis that psychiatry is historically and conceptually something of a secular priesthood masquerading as medicine, science and art). The psychiatrist is well aware of this heterogeneity. When challenged, rather than feel anxious they will psycho-defensively reframe their castles built on shifting sand as a badge of honour, saying if one is too “linear and “black and white” one ought to become a surgeon. To properly do justice to just how internally heterogeneous would easily occupy several hundred pages. Herein will be two examples, with a preface to the first.

Unlike every other speciality there is a vast gulf between how public and private psychiatric practitioners diagnose and treat. This is even if the same practitioner works in both sectors, being public hospital one day and private practitioner the other. The differences within psychiatry dwarfs the closest other point of comparison, that of obstetrics wherein private (i.e. small business or large business private hospital) practitioners will often see a dire need for caesarean section more than their public hospital counterparts were they to see the same patient at the same time, and certainly more so than their nemesis nurse midwives would think necessary. Notwithstanding patient preference, the cynic would say this is in virtue of the Caesarean section being more lucrative in private land than that of an old fashioned vaginal birth. In the public system the obstetrician is paid the same regardless of how the newborn enters into the world, so why risk anything under the scalpel?

Returning to psychiatry, take for example this hypothetical case; the young woman named Amburr attends the psychiatrist (funky names and spelling are almost diagnostic). She is emotionally troubled and feels herself to be out of control, causing distortion in her everyday life as the American guild would say. That is to say she is open to abdicating personal responsibility from her actions in the word play of being “out of control” and requiring a locus of control to be placed with the psychiatrist. The psychiatrist asks questions. Do you have a family history of mental illness? Yes, Aunty Bertha was manic depressive (the psychiatrist immediately considers her genetically at risk of the same, and it will be difficult to escape this diagnosis sooner or later given such genetic “loading”). Do they have mood swings, sometimes this lasting days of highs and days of lows? Yes. Do they sometimes have abundant energy and drive, sometimes lacking the same? Yes. Do they spend too much money or engage in promiscuous sex that is out of character, i.e. that they later regret when the chickens come home to roost or behaviours they want you to believe they regret? Yes. Do they sometimes have difficulty focusing and others tell them they flit from one subject to another, sometimes even thinking at an accelerated rate? Yes. Do they sometimes feel like they are on top of the world and can do anything, not literally anything as in leaping over tall buildings with a single bound, not to the point of taking leave of their senses and reality (whatever reality is, please tell me if you find out). No. Just enough of a high mood to have been significantly elated and long to be back there? Yes. And so more than enough of the boxes are ticked. It does not take much more for the psychiatrist to diagnose the patient with type II bipolar disorder, or what might have otherwise been called mild manic depression had the DSM decided to invent a new construct whilst keeping the Kraepelian name “manic depression”. Mild mania, which is pathognomonic of type II bipolar disorder, is called “hypomania”, a kind of state of being almost yet not quite insane of an elevated mood. What causes it? The psychiatrist will say it’s a brain disease of course, albeit a poorly understood one. This is code for there being no evidence of it being a brain disease whatsoever. They will say it’s genetic within an environmental context of events “triggering” of episodes, invoking automatically within the unconscious the vision of victimhood, for who pulled the trigger? “Surely not I”. Consequently, in one stroke and though not explicitly stated, the secular priest will absolve them of the sins of excessive spending and excessive sexing, of impatience and verbal abusiveness and many more besides. This is a pastiche of priesthood; confession and absolution, passing through a muddled dualism. For the sinner is the disordered brain and its fallen nature, perhaps even the “sin” is in, though not of, the father (or mother) and their genes of mental illness. “I cannot be responsible can I, having been dealt the genetic hand” they might say. And so the absolver is not only the priest psychiatrist, yet also the patient themselves. This is to say in the absence of God, the ultimate source of absolution is the ritual between the psychiatrist (qua priest object) and the patient as collectively one agent, the other object being the brain without responsibility as the sinner who never need suffer pain of conscience. In point of fact, no one need suffer pain of conscience. Even substance use will not be seen as co-causative of the problem or heaven forbid a personal choice to befuddle one’s mind. Instead substance use will be framed as a result of the mental illness itself driving them to use. Their only act of penance will be to take valproate, lithium or quetiapine or some other powerful psychotropic medication that is touted by the pharma representatives (we must not be too harsh with pharmaceutical representatives, see elsewhere). Inevitably all these drugs will have a partial effect, insomuch as they all have non-specific sedative and emotionally blunting actions, leaving alone for now the actor that stands on every pharmacological stage, i.e. placebo. But these drugs will not effect any cure. Whatever it is, the basic fault will still be working its way within the psyche, likely created in childhood and cultivated by choices each day of what one wishes to be and become. There will be regular reviews and tinkering with the medication, as the psychiatrist leans over the caldron and adds a sprinkle of this, a pinch of that. There will be further confessions and absolutions under the heading of “psychoeducation”, and “relapse prevention” or exploration of “early warning signs”. And there will be a steady stream of income for the practitioner. Psychotherapy, the so called talking cure, will only ever be suggested as a method to manage the psychological consequences of the burden of the illness itself, not as a remedy suited for addressing the illness directly as a psychological thing in and of itself. Likely the psychiatrist will outsource the therapy to a psychologist. The vast majority of psychiatrists do the ever decreasing bare minimum of psychotherapy during their training, and do as little as possible afterwards.

Now let’s look at the same young lady from a different angle. Perhaps since her teens and perhaps before she had difficulty keeping a reign on her emotions. Like a cork bobbing up and down in a sea of (usually relational) events without any internal ballast, she is “out of control”. When things go well her mood sits high upon the crest of a wave. When things go poorly her mood falls below the horizon, and cannot see the sun afar. Sometimes paradoxically when things go well her mood is low, perhaps out of fear the good times won’t last, which of course in life they never…..ever….do! In virtue of her dissatisfaction with herself and her lot there may always be a tendency for the mood to drift down, and likely she will have been diagnosed with a ‘major depression” before. Often this “depression” is stated to be a harbinger of the hypomania to come in cases of alleged bipolar disorder, with bipolar disorder a justification for why the antidepressants did not work (no doubt is cast upon the antidepressants themselves, or the veracity of the diagnosis). She may or may not have been sexually or physically abused or neglected as a child, this being arguably more likely than not, yet far from being universal as is often assumed. Often somewhere in her upbringing there was at least some loss or lack of even what Winnicott would call “good enough parenting”, for perfect perfecting never exists and were it to exist would be paradoxically bad parenting in ill preparing the perfectly coddled child for a fallen imperfect world. This basic psycho-developmental fault can come in infinite forms; The parents broke up or were never together, ergo the perceived rejection from one or both (though this being at odds with the politically correct notion that broken homes and single parent homes are necessarily equivalent, my extensive experience would suggest exactly the opposite and the solo parent to face an uphill battle, often to their credit against the odds crafting the well-adjusted child), the perceived rejection of peers might have occurred, there is the parent who hovered too much or hovered at the wrong time and for the parents own reasons, the parent too busy nestling the cannabis bong in their arms as opposed to the child to their bosom. Perhaps the child did not see mirrored in the parents face and heart how and when to be emotionally calm, and when to delay gratification and how and when to delay it. And so on and so forth. The possibilities are as endless as the list of twentieth century theorists and experimental psychologists who did the work giving us all the hypotheses we might map onto this particular person who is Amburr. Yet we mustn’t take up torches and pitchforks and go on the witch hunt for bad parents. Sometimes the parents were perfectly adequate, did their best and the child simply had the misfortune to be born with an insecure temperament or was not insulated enough from media that makes a mockery of parental authority, basic morality and dismantles any message promoting self-control. Life neither guarantees perfect parents or perfect children. In any case, there is something to be lacking in the psyche of the young lady of our example (or young man also), some emptiness looking to be filled. And sometimes it will be filled in its turn. Perhaps a new love or hope or love will enter the scene, as the patient reaches out in irresponsible and often dangerous ways. There is no medication as powerful as infatuation. This will be a time of “high”. Perhaps the “high” follows from simply boredom with being down in the dumps and loathing of the self, the psyche finding time in prison served and time now to throw off the shackles of the superego enough for a little happiness and gay abandon (there’s the “hypomania”). Yet the good times do not last long before doubts and self sabotage creep in. Then back we are in a morass of unhappiness and angst. Or she meets the love interest, soon feels comfortable, then just as soon doubts creep in, acting dramatically as if to hurt the other and force them to prove their love is unconditional, a comfort left wanting from the absent bosom that was her childhood. The object of her affections might weather the storm and his/her apparent reciprocation of love (or lust) might persist long enough for our insecure patient to feel comfortable again. Yet this sense of comfort is not to endure for long. And so the sadomasochistic like cycle repeats, often with some quasi sadomasochism from the love interest, for they often have their own psychological issues. When things go well there might be promiscuity and intemperance of all kind, including mood altering substances, the use of which may or may not be confessed and which certainly causatively upsets the psychological apple cart all the more. When things go poorly the mood will be lower, with or without thoughts of self harm. The reader will note this is the same patient as the first, with identical boxes checked. Only in the latter case with a different psychiatrist she is diagnosed instead with borderline personality disorder (DSM), otherwise known as emotionally unstable personality disorder (ICD).

Both diagnoses, i.e. type II bipolar disorder vs borderline personality cannot be simultaneously correct, for they rest upon entirely different theoretical substructures of aetiology and “pathogenesis”, though there is a growing vanguard of psychiatrists incoherently attempting to meld them as one “bipolar spectrum”. Regarding my own experience, I’d be on safer rhetorical ground to say something like “most patients I have seen fit much better the latter formulation”, i.e. borderline personality disorder, in so doing appearing to be a little more conciliatory, a little less extreme. Yet the truth is that after having seen literally hundreds of (usually female) patients diagnosed as type II bipolar by (usually private practicing) psychiatrists, I have yet to see a single one who is not personality disordered as a crystal clear complete explanation of the case. Not a single one!

I have even seen many dozens of patients falsely diagnosed by many a psychiatrist with the full enchilada of type I bipolar disorder, i.e. that subtype of bipolar disorder (manic depression), where the upward swing of mood renders the person insane and needing hospital admission or urgent intervention, i.e. a full mania. Or so the diagnostic criteria in the bible (sorry DSM 5) would require of me to make the diagnosis. One recent case of many comes to mind where it was uncanny how the mania always occurred when the husband was cheating on his wife, sexting his mistress dozens of times a night and driving recklessly enough to attract the ire of the police. It was truly remarkable how his mania, or depression, would switch off the moment his wife forgave him or the psychiatrist arranged a letter of support for his crime of reckless driving, absolving him of his sins. I guess one could marvel at the power of love and compassion or advocacy or “stress” have been taken off his shoulders. I would marvel at the mendacity on the part of the patient, and fraud (or stupidity) on the part of the psychiatrist.

Or there are the cases where, as a trainee, the patient would sit across from both myself and the supervising psychiatrist, the patient narrating with modulated (non manic) speech and tempo of thought how their “bipolar was acting up”. And so there lay the attribution for the hefty bill received by the credit card company when they spent too much. The psychiatrist would agree their bipolar made them do it. If push came to shove the debt would climb and the psychiatrist would write a support letter in an attempt to absolve the person of their debt, or an application for state (i.e. tax payer funded) assistance with an invalid pension. Some would call this compassion and patient advocacy. Some might also call this fraud.

I ask the reader to forestall from concluding that I don’t believe bipolar disorder exists at all. Putting aside for now the far more interesting question of what it is for any psychiatric diagnosis to “exist”, I’ve been convinced of about a few dozen cases of type I bipolar disorder over the years, where to be “convinced” means a certain level of comfort with applying the construct of type I bipolar disorder to the patient, not to be convinced of any greater ontological truths about the construct itself as a brain disease. These few dozen patients are extremely low numbers as a proportion of population, far below the rate at which a sizable fraction of contemporary psychiatrists diagnose bipolar disorder and far below what the guild intelligentsia state is its prevalence (i.e. its commonality in the community).

But enough of digressions from the point, for these examples are mere illustrations. The point for now is not what “exists” of bipolarity in the world (for this is but an example), but what “exists” in psychiatry in the world, what psychiatry can claim to know, and what psychiatry does. Plenty of my colleagues are uncritical true believers in type II bipolar disorder and see hypomania (if not mania) and mixed mood episodes everywhere they look. And plenty of my colleagues conversely also cast a jaundiced eye on the construct that is type II bipolar disorder and the supposed commonality of type I bipolar disorder. In conversations with colleagues, some of those disbelievers privately admit to using the diagnosis as something to work with, as a pragmatic metaphor to offer the patient who is looking for the comfort of a label, without disclosing to the patient that they lack the faith in the diagnosis themselves. It follows that the patients are not always fully complicit with this benevolent little white lie (actually another fraud), whilst the practitioner is wantonly ignorant of the fact that diagnoses have consequences, these rippling far and wide beyond the immediate comfort of the label to the patient. When I have been bold enough to challenge patients on what they call their “bipolar acting up” when it is obviously their characterological deficiencies acting out, I often get more of an inkling they know the truth beyond the lie, and so their previous psychiatrists (if they are not the more common true believer) have been lying to them and vice versa.

Were the construct of type II bipolar disorder ever to be revealed or discovered to be the fiction that it is, I have no doubt mainstream psychiatry would dodge embarrassment by rewriting its own history, with unanimous claim that the expert class as a whole knew the truth all along, with a couple scapegoats thrown under the bus along the way and only ever if absolutely necessary. Overdiagnosis by psychologists and family/general practitioners will do as a nice scapegoat. The guilds of psychiatric story-tellers are as skilled at managing historiography as they are lacking skill at managing what was once called hysteria. Yet from a patient’s perspective, never will you see a jaundiced eyed psychiatrist tell a patient the colleague who previously made the diagnosis was just plain wrong or likely lying. A diplomatic psychiatrist seeking to revise a diagnosis might go so far as to say something akin to diagnoses being a work in progress evolving over time, which is actually to say the truth can be x yesterday, y today, and z tomorrow, a convenient timelessness where there is no “now” in which to capture and indict the psychiatrist as being wrong or mendacious. This is like Parmenides by the river into which he can never step twice. Nothing ever is the case and everything always is the case in such a state of flux where a diagnosis is never allowed solidify. Conflicts over diagnostic constructs or applications of these to individuals never ever see our secular priests defrocked or schisms within our secular church, unless the church is absolutely forced to. Internal dissent within the guilds is castrated of any real gravitas in the first instance, and smooth on the surface to all outside observers. As several psychiatrists have said to me, the greatest imperative is “we must not bring the profession into disrepute”. Why not? This is a question they never ask never ask and the answer is never provided, for protecting the profession is axiomatic. It is canon.

So far in our journey I might have succeeded in taking the reader into a state of scepticism with type II bipolar disorder as the appropriate diagnosis, or a diagnosis that exists at all as opposed to borderline personality disorder being the authentic diagnosis that “exists”. But let’s take things further, for we haven’t escaped the DSM and psychiatry just yet, as opposed to simply flipping pages. Let us speculate on what the core of borderline psychopathology might be, or type II bipolar disorder if we choose to check its boxes (the patient may also check the boxes for ADHD and dysthymia, or cyclothymia and a dozen other diagnoses very easily). Without elaboration, nor me being fixed on this speculation to follow as anything more than speculation through and through (which is to say not a fixedness to what we might call attachment theory, and explicitly I say not to devalue the role of what we might call “trauma”, for many of these patients have had horrible upbringings), let us imagine the core problem in borderline personality or emotional instability is something we might simply call unfinished business of childhood. The infant is most certainly and justifiably insecure. And as any parent well knows, the child can behave in a dramatic way to attract and sustain love, connection, reassurance and nurturance. Now let us imagine this insecurity scaled up to one in whom it can be said has reached the legal age of majority, i.e. an alleged adult. When faced with threats to perceived security, loss of love, a painful memory or a million other speculative “triggers”, there may be a drive to drama within the psyche. In the sense of which certain hot headed shallow males might act out their insecurities with bullying others, lusting after things they must steal to “own”, and wanting to acquire security by dominance, they might add to the suicidal ideation some intimidation and beating upon others. And like an infant, their capacity for authentic empathy may be fragmentary or absent. Ergo with the same basic fault, the same insecurity and immaturity, this young man may be diagnosed as having an antisocial personality disorder when what he really has is a borderline character. On the other hand the young woman who usually introjects (that is inwardly directs and quasi identifies with) her insecurity is taken to acts of self cutting and self loathing, relational manipulations and marshalling around her others anxious to help and anxious to save, these others made all the more anxious by her distress (curiously often the two sit in inverse proportion to one another over the course of the psychotherapeutic transaction, as if to imply a transfer of neurosis from patient to the therapist or parent. The unsaid exchange is “when I have given you my problem, it is no longer my own”). We tacitly ignore the fact that she may have harassed and repeatedly texted the love interest, and stated to the clinician that if he/she does not save her from herself the suicidal blood would be on the psychiatrists hands. Can this be thought of as anything other than antisocial behaviour of a kind? The reader should see where I am heading, towards the question if what we usually diagnose as borderline in females and antisocial in males is but a product of sexism, with the core often, yet not always, the same. Yet the approach normally taken, the meaning in practice when drawings the boundaries between these “disorders”, is vastly different.

Now we have diffused outwards, from a justified insecurity of a different kind, i.e. a diagnostic and conceptual blurring between bipolar disorder and between and within two discrete kinds of personality disorder. Let’s not stop there, for there are many other personality disorders besides. The lay reader may not be acquainted with the idea of “clusters” of personality disorders, as is still dominant in the DSM. Borderline and antisocial personalities fall within the so called “cluster B” personality disorders, along with narcissistic and histrionic personality (the other clusters are cluster A; paranoid, schizoid and schizotypal personality, and cluster C, dependent, avoidant and obsessional personality). Let’s imagine a different core problem, one that exists within the person just as strongly as undefined insecurity or a tendency to being a hybrid adult-infant emotional soup with unfinished business of childhood. Let’s imagine that all cluster B personality disorders are different manifestations of the same core, i.e. narcissism itself. In the case of the pure narcissistic personality disorder, the narcissism is directed to the ego or self as self, which is to say “I am superior and I’d like you to accept this fact”. In the case of the histrionic personality the narcissism is directed towards a specific kind of outward behaviour, one of shallow embellishment and being the centre of attention, which is to say “be I better or worse, it is all about me. Look at me”. In the case of the borderline personality the narcissism is directed towards one’s immediate emotional perceived needs and one’s own emotional pain at the expense of everyone else “it’s 2am in the morning but you all be damned I’ll kill myself if you don’t admit me to hospital, the blood is on your hands. No one’s pain is as important as mine. My pain is my world. My pain is the world”. Then there is the antisocial personality, whose narcissism is directed towards having and doing whatever they want, and damn the rules and social harmony “I do what I want, when I want, to whoever I want”. I have not even considered how other times and cultures may formulate peoples behaviours, all of which are as plausible as that offered by the best of psychiatrists. In any case, is a person’s character the business of medicine? This is very strange.

One final example, moving from infantile adults to child and adolescent psychiatry per se. Into the consulting rooms comes the 10 year old boy Jaxxson, his concerned mother and his latest off several stepfathers. He has been irritable lately and stating in various ways and forms that he is unhappy. Perhaps by the side table upon which sits his enticing smartphone is the bed where he has a troubled sleep. Perhaps his appetite is reduced. Never excellent, his grades have slipped and his teachers are noticing some conflict with peers and the teachers themselves (always the royal road to mental illness is being a nuisance to others and embarrassed parents searching for an excuse). He might have even become anxious at the prospect of going to school, the last few weeks playing video games instead of attending to studies. Things may have come to a head when he started talking about death and drawing himself in the stick figure way a 10 year old draws himself as hanging from a tree. Various shades and permutations of cases such as this are typical and we need not dissect this hypothetical example, missing the forest for the trees. It does not matter really whether the child is 8, 10 or 12, boy or girl, white or black, rich or poor.

Let us imagine a multiverse. Exactly the same child presents on exactly the same day and says exactly the same thing to exactly the same questions to 5 different child psychiatrists, only in each of 5 different universes. The psychiatrist observes the interactions with the family, speaks to the mother/stepfather alone also and consequently takes the history and examines the mental state.

Child psychiatrist number 1 might formulate the case thus; the child is weighed down by a major depressive episode. At the hands of a sufficiently skilled sophist psychiatrist, major depression in everyone is quite a protean construct when attached to a person to whom we might say is “unhappy”. But it’s malleability is especially the case in that of children and the aged. As one can see in that enormously successful best seller of fiction that is the DSM, a child need not be depressed in mood to be depressed for reasons of diagnosis. They can merely be irritable, for somehow it is thought depression only then appears as depression. His lack of recent success in school is seen to be a product of the cognitive deficits that are part and parcel of the depressive illness. Similarly, his recent lack of hearty eating and the difficulty falling asleep are “neuro-vegetative dysfunctions” of the illness. These add to the diagnostic criteria in our checking of the boxes, and given the “neuro” prefix by extension taken automatically (though it is a non sequitur and semantic play) that the depression is a biological disease. Suicidal thoughts check another box. Psychiatrist number 1 may explain to parent and child alike that there is some brain mechanism for the depression and the remedy is, principally and in principle, an “antidepressant”. There are no shortages of first and second degree relatives also having been diagnosed with a mental illness. Up to a third or more of the females on both sides of the biological tree had been diagnosed with depression and/or bipolar disorder. This lubricates the mind of the psychiatrist into immediately assuming genetic vulnerability, and each generation the likelihood of diagnosis is made greater from the labels applied to those of the past. Like a pebble against the gravitational power of the sun, I have seen thousands of patients drawn into an almost inescapable orbit of attracting some diagnosis or another simply on the basis of what their parents, grandparents and Aunts and Uncles have been diagnosed (or diagnosed themselves) with. I guess in Salem witches had family too, and God help the family of the alleged witch if the diagnosis is made more probable by the idea of it being “genetic”. And so the script is written, the money exchanged and the subsequent appointment booked. And the show goes on.

Child psychiatrist 2 formulates the case thus; the child has developed an anxiety disorder. Anxiety is the kissing cousin of fear. When we are afraid we take flight or fight, i.e. in fight mode we manifest aggression under a range of behavioural and affective modes which includes irritability, if not frank violence. In flight mode we may simply withdraw. Anxiety explains the recent truancy, the inattention, the neuro-vegetative dysfunction and, given the unpleasantness of the anxious child’s inner world, can lead to thoughts of suicide. Anxiety isn’t fun and can lead to feeling depressed under the weight of fear. In any case, all roads lead to Rome. Another script of antidepressant is written, for as luck would have it, so called antidepressants are also anxiolytics. Or so they say. This psychiatrist might also refer to a psychologist skilled in the childrens version of CBT, depending on age and maturity.

Psychiatrist number 3 will diagnoses little Jaxxson with ADHD, attention deficit hyperactivity disorder (which is actually an umbrella term which should read attention deficit and/or hyperactivity disorder). How will our psychiatrist manage to accomplish this diagnosis? Actually it’s a simple affair, for if you read the literature of academic and clinical fans of the diagnoses, ADHD can be had in those who are high achievers or low, in those who are dreamy absent minded introverts or rambunctious spinning toys of boys tearing around the classroom like a whirlwind. With a pinch of imagination and an ounce of inclination (the latter of which I lack), I could easily formulate about half of my child and adult patients with ADHD, including of course most drug addicts. With Jaxxson, we could say his recent lack of attentiveness and drop in academic achievement is merely an unmasking of the so called “neurodevelopmental” disorder that has always been there. Perhaps they will justify the diagnosis on the basis of being “unmasked” in virtue of the growing mismatch as schooling progresses between expectation and capacity vs his peers. Perhaps things will be explained in terms of the current teacher being less entertaining, for ADHD kids respond better to novelty and wither on the vine of routine unless domesticated with medication. On a similar vein, we can explain how the child can sustain attention for prolonged periods on videogames and other devices, and not on schoolwork. These little machines are enjoyable. Small victories along the way of the game provides the little squirts of dopamine that the childs brain lacks in virtue of the chemical imbalance they are thought to have (though the savvy clinician won’t use the term “chemical imbalance” now the critical psychiatric community has run it out of town….…for now). Why the apparent depressive symptoms? Being hyperactive or inattentive leads to conflict that can lead to a challenge in ego strengths, a sense of knowing one lacks academic competence or comparative social successes. The child is irritable (or downright depressed looking) on account of these frustrations and failures. Psychiatrist number 3 will prescribe a powerful stimulant that is illegal in recreational use, plus/minus the antidepressant for the mood symptoms. As a footnote, I might add that the criteria from which ADHD is formulated in the child can also be seen as a reflection of immaturity per se. There is abundant evidence that the diagnosis is overrepresented and can be predicted by the child simply being the youngest in the class. The diagnosis can also be explained by a certain mix of what psychologists call the “big 5” personality traits and, in boys at least, a “pathological” mismatch between the child’s needs for stimulation and rough and tumble activity of village or tribal life and the schools demands for moulding the cog in the machine as he is told to sit for 6 hours. It is worth noting in closing that ADHD is the example par excellence of the fallacy of the response to medication proving the existence of a diagnosis. Amphetamines (and methylphenidate) have psychotropic effects on persons taking them, be they diagnosed with ADHD or not. And these effects can be notionally salutary to both in similar domains of behaviour and function. This has been known since the time of Smith, Kline and Frenchs early marketing of benzedrine and Bradleys early experiments with stimulants on the grab bag of traumatized, rejected, intellectually delayed, delinquent or basal gangliopathic children he treated. Amphetamine aids the concentration of all up to the mind it renders them only thinking they have improved cognition, this being the mind they are half way to drug induced madness. Finally, it is worth noting that the evidence does not support the conclusion of long term benefit to children of taking stimulants. Over the long term they are either useless or harmful.

Psychiatrist 4 faces an uphill task vs the first three, though let’s see if he/she can manage it anyway. To the proverbial hammer, everything is the nail. Just as there are the psychiatrists and paediatricians who are known to diagnose many, if not most, of whom they see with ADHD or depression or bipolar disorder, there are also the psychiatrists on the lookout for autistic spectrum disorder (ASD), or what might in little Jaxxsons case been called “Aspergers” or “high functioning Autism”. You see if there is the slightest sense in which he can be said to be alienated from his peers, by which we mean a subjective sense or behaviours where he is awkward, lacking in social acumen, misreading or not reading body language, response cues, irony etcetera, Jaxxson is on the radar of such a psychiatrist or paediatrician as the free spirited girl dancing in the forest was on the radar of a Salem witch hunter. This is also the case if the psychiatrist is unable to click with the child, the countertransference of alienation being projected outward from clinician to patient (or in other words, “if I don’t connect with you, the fault is not my own or tough luck. It is a diagnosis”). Our childs interest in videogames is not a bad habit or the outcome of bad parenting. It is interpreted a symbol of his autistic alienation from flesh and blood people and towards their digital counterparts. And just as the social and self-evaluative sequelae of ADHD can result in mood disturbance, the high functioning autistic child may also feel frustrated and be irritable, down in mood and even threatening suicide. He may even want to connect with others, yet cannot. The more he and his family are educated as to what ASD is and the funding support packages available driven by the diagnosis, the more they will come to take on the part of what they have been diagnosed to be (I say “they” as the childs behaviour and the parents interpretation of it are in toto one phenomenological reflective system of meaning and becoming in the family unit). In addition to opening the door to various supports, Jaxxson will likely be prescribed some medications, including an SSRI antidepressant and perhaps some medication usually given for high blood pressure to calm his irritability. If he is especially irritable and misbehaving it will be difficult for him to avoid powerful tranquilizers usually reserved for those patients with “psychosis”. These are powerful medications often difficult to wean off, and often ironically pharmacodynamically completely at odds with the ADHD medications co-prescribed. It makes as much sense as rubbing faeces in a wound of ones making and then washing it out.

In our fifth and final universe, our child encounters the final psychiatrist (though there might be many more examples). He or she might eschew over-diagnosis and be more “family” and “systems orientated”. True enough the low mood or anxiety and the various other signs and symptoms won’t be ignored. Yet this psychiatrist will look for other explanations such as the child’s symptoms being a reaction to the disconnect between parents and child, e.g. in virtue of the parents cannabis use and being too stoned to parent. The parent/s of course won’t realise this themselves and not be inclined to continue paying the psychiatrists bills if told something they do not wish to hear. After all, they will say they are only “self medicating” their own mental illness. (the term self medicate is predicated on there being a medical illness, which as I will argue does not exist in those who make the claim their illness is mental. Psychiatric diagnoses are not medical illnesses, and every drug user can be said to self medicate something within their mental selves they wish were not the case). Or perhaps the child being bullied? Or they are reacting to the parents separation? Or there may be any number of other reactions and reasons in the child’s world of relationships and groaning towards and through maturation. Usually psychiatrist number 5 will prescribe an SSRI also, if for no other reason than “pragmatism” and its use as a therapeutic object they can hold in their hand, though usually the parents want something prescribed anyway and medication is the purview of the psychiatrist. To prescribe it is a ritual of protecting the interests of the profession against the psychologists and social workers who need compete with inferior products (psychologists for example will fight back and market the utility of certain trademarked psychometric tests that only the psychologist is authorized to administer). It’s a very rare psychiatrist who won’t offer the family the symbolic power of a diagnosis at all, along with the medication the family and/or the psychiatrist crave. Why? Drugging the child and providing an easy answer is, well, easy. Effecting cure by treating the child alone is difficult. Effecting cure in the child by having to “treat” the parents also is extremely difficult. Effecting cure in the child by treating the child, parent, school and society is nigh on impossible. Sooner, rather than later there is something or someone out of the psychiatrist’s hands. How does the child get well then? By the psychiatrist’s gentle hand of course. Or so they will say, though I’m reminded of the old adage that medicine is the art of amusing the patient whilst nature (or time) effects the cure.

The above examples of Amburr and Jaxxson are but tiny drops in the ocean of the same heterogenous muddle of snake oil. My point is not to say that there won’t also be vast chunks of homogenous agreement within psychiatry. There certainly will be in cases of what passes under the banner of chronic schizophrenia for example, and the DSM is intended to be an aid towards increased interrater reliability (i.e. enabling different psychiatrists to diagnose the same person with the same thing, though the empirical evidence and my experience has failed to show it increases reliability, and this says nothing on the subject of construct validity, i.e. if the disorder exists as they say it exists in the first place). Nor is my point that any of the above psychiatrists are more correct than any other. Though I could argue that those who believe in type II bipolar disorder are delusional, and though I have some sympathies with psychiatrist number 5 above in Jaxxsons case, I have seen some patients lives turned around for the better under the care of the ADHD guru who prescribes them legally sanctioned and otherwise illegal amphetamines (or a life turned around for a while anyway). No. My point is saying that psychiatry is a church so broad as to be stretched beyond the breaking strain of its own credibility, inhabited by persons blindly fumbling around in the dark with a Rumi’s elephant of person in the midst of the human condition in a fallen world. The same deconstructive critique could be levelled at any of the diagnoses, and future chapters will cover some of these. My point is that psychiatry does not have any epistemological foundation for any of psychiatrists one through five to lay claim to being correct. We might as well include in the example above a psychiatrist number 6 who formulates the case as a boy with Sagittarius disorder. A star sign is also a physical referent as much as a gene, and as equally convincing as a determinant to those who do not approach the topic of genes (or celestial bodies) critically so far as determining the psychology of the individual patient who sits across from us. With regard to the first patient example (i.e. the young emotionally unstable woman), my point is not simply to argue the non existence of type II bipolar disorder as to argue the non-existence of it and the cluster B personality disorders as anything more than convenient descriptors that all fail to adequately capture the person. And so they do more harm than good, or at least no better than the obvious fact of emotional dysregulation, a fact for all to see who have eyes to see. If the core problem can be almost whatever I argue it to be, then what really do we grasp in our intellectual hands? And if, as narcissism implies, the real “pathology” is, at least in our example, a “me, myself and I”-ism, might we have sailed so far from the shore of science and medicine that we are more in the misty lands of the humanities, of moral philosophy and even theology as ultimate formulations as to what maketh the man (or woman) in good cheer and bad? Yet another example might drive home the point. Following the suicide of the nu-metal rocker Chester Bennington of Linkin Park, I overheard some learned psychiatrists talking of his “depressive disorder” killing him via suicide, as if he succumbed to recurrent infections with some foreign agent. This was certainly the theme of all the many articles written in the wake of his passing, the infection of depression that he caught, the disease of depression he carried. I never once read or heard it pondered if the lyrics were not entirely the outward reflection of some mental illness as claimed. Deeper still were these lyrics to hold oneself in a constant choice of becoming not simply depressed, but were the lyrics within the world the beingness of depression itself, a constant meditation uttered over countless concerts, the aural dark cloud spreading out into the world again and again and reflecting back upon him. To quote only one of the songs,

“I tried so hard and got so far. But in the end It doesn't even matter I had to fall, to lose it all. But in the end It doesn't even matter”.

If so, where is depression? In some simple causal medical model? In the voiced expression of depression? That is to say, the tautology of one suffering from depression because one says they are depressed. How banal. Is it in some deranged neurochemical system? I can assure you no such “chemical imbalance” or serotonin or bio-amine deficiency has been found, and I doubt it ever will. Is the depression in the lyrics themselves? No. These can be interpreted as depressive nihilism or a beautiful poetic and liberating retelling of the book of Ecclesiastes. Rather I think that in the appetite for the potential nihilistic interpretation of the lyrics, is attached the mood that speaks to a sickness in mood of the world, an ever present proclivity in man to something destructive that the collective mind of psychiatry is hopelessly ill equipped to apprehend.

Psychiatrists are neither scientists and God forbid they be considered philosophers with the will to truth. They are narrators, story tellers, salespeople, engineers with medical degrees and medicinal tools and, to the degree they are bound together at all, a kind of secular clergy of a materialist faith. I’m amazed at how some patients wait months for an appointment with an in demand psychiatrist and walk away actually believing they were just diagnosed with something as solid and true as lung cancer or the Rock of Gibraltar, when the psychiatrist is more like an epistemological Wizard of Oz, all puffed up beyond the optics of the real image. Psychiatric stories are like the proverbial turtles, it’s convenient pragmatic stories all the way down. We are back to where we started. The ties that bind the definition of what a psychiatrist is, is the power itself to tie and bind, and the fallacy of authority makes the bondage stay tight.

Now the reader may wonder how such potential for (and often real) heterogeneity of opinion does not implode into infighting, psychiatrists cannibalizing each other’s credibility to mutual death. How do they stay strong and appear so coherent for so long? Guilds have evolved several mechanisms to counter this, and perfected these practices over decades. Some examples are included or implied within the text above. I will give three additional examples here…

Firstly, the Guilds control the publications and the conferences. True science and true philosophy are intellectually brutal endeavours, something akin to Spartan midwifery. The strong infant lives. The weak infant is cast out to die. In a similar vein, one knows in advance that an idea or hypothesis will be tested against either a dialectical process or an experiment. And that idea might too have to be cast out and die. The very statistical methods employed in data analysis in what passes for scientific method nowadays place the cherished idea as guilty until proven innocent. By way of a different analogy, the scientist must adjust their thinking and take on the role of an attorney for the prosecution against their own cherished hypothesis. Only in attempting to prosecute against their idea and failing does the idea have the right to walk out free into the sun. In philosophy the idea placed in peril might be philosophy itself. Several philosophers have laid claiming to ending the whole philosophical enterprise and been given their chance to do so. Some might argue otherwise, yet I would historically connect the scientific method as above described as in turn connected to that Christian drive to dying to oneself so that theosis, like scientific verisimilitude towards the truth, might take the place of self instead. One will never find the same glorious attitude in psychiatry. In the church or corporate body of psychiatry, what passes for robust debate always passes first through a filtration or screening process of guild and professional self interest. If critique is presented in a way that threatens the psychiatric church doctrine and its power, it will not even be declared anathema. It will simply not be published and will disappear in silence. They will probably allow the DSM to die in time and mock it in generations to come, but only when they safely have something else.

Secondly, renegade psychiatrists are like heretic priests, only worse in a sense. For if one studies the true history of the early church from which I make my numerous analogies, the patristic fathers who advanced what was called heresy were by and large left to their own devices. Even Galileo was not imprisoned in a tower as opposed to the family vineyard, and story of him being tortured was a myth. Renegade psychiatrists who criticize psychiatry in a substantial sense will not be tortured of course. They will be alienated and find it impossible to gain employment except in private practice or where they have the already secured the firmest 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 of being followed by the CIA, leading in turn to thoughts of suicide. Lacks insight into his psychosis and non-compliant with treatment (i.e. denies having a mental illness and does not take his medication). Fully conscious”

Diagnoses; It is not at all uncommon to find psychiatrists with genuine disdain for the DSM or the ICD 11, these being the diagnostic nosology in use throughout most of the world. Often they might parrot the usual party line that such diagnostic manuals or criteria are “just guidelines” and be critical of some diagnoses, choosing to value the criteria as enunciated in the DSM for research purposes and consensus of what makes for a name for purposes of inter-practitioner (and often international) communication. Occasionally one might encounter a psychiatrist who would rather the DSM go away. But what is extremely rare is the psychiatrist who attempts, in practice, to do away with the DSM entirely and explain the patient as a formulation alone, or a narrative akin to that one might read in literature. However much a psychiatrist might pretend to be “anti DSM”, when taking the history their mind is invariably ticking over as to what DSM and/or ICD 11 checklist criteria are included and which are excluded. All psychiatrists almost always implicitly use it and almost always are explicitly required to. To not do so and not do so well for many years would render it impossible to complete training and enter the priesthood. If we could conceive of a modified Turing test where the robot was to take the history and record the mental state exam, each congruent with the resultant being diagnoses as per DSM or ICD 11, then this robot would be indistinguishable from almost every psychiatrist I’ve ever known (the exception being the one I am not permitted to be).

Formulation; Formulations are explanatory little statements of a few paragraphs, linking the patient’s presentation with the symptoms and some speculative link to a “theory” of mental illness most applicable to the case. Formulations are a game for true believers of the theorist and sophists alike. The five different explanations of the child’s case (vide supra) are crude approximations of formulations, to which one might add a comment on what may foreseeably make the patients mental state worse in future, and what strengths and resources the patient can draw upon. A tongue in cheek example of a crude formulation for now might be this fiction…

“Sigmund presents with suicidal ideation symptoms and the full suite of symptoms consistent with a diagnosis of major depression. The current episode seems to have been precipitated the revelation his brother likely had sex with his stepmother, Sigmund being angry he himself did not succeed in the conquest, this anger introjected (i.e. turned inwards) and transmuting itself into the depressive symptom complex itself. An additional contributor to his depression may well be the ambivalence Sigmund has towards his father, enjoying the fact his father qua Laius object has been slain, this satisfaction not sufficient to overcome the punitive superego against his psyche in response to the enjoyment itself. Thankfully Sigmund is functionally quite strong, has an excellent capacity for insight and is agreeable to taking the therapies prescribed (principally opium, along with, of course, analysis), though there may be countertransference issues with the therapist whom Sigmund believes is of inferior mind.”

Developing a robot to construct a formulation would not be as easy as developing one which could take a history, document a mental state exam and narrow to the point of choice from the smorgasbord of diagnoses in the DSM or ICD 11. Nonetheless there are now artificial intelligences that are amply up to the task. A program has now been developed to replace journalists, beginning with the first paragraph it can mine the internet and complete the article from there. Psychiatric formulations are the same, fake news that might be real, and real to the trainee to the extent they might dialectically defend its use as applied to the patient (as opposed to it being the truth of the patient), and real to the patient to the extent it is convincing. No one really cares how or what the formulation is. Providing it is done well, you could complete two or more disjunctive formulations and choose your favourite. One can formulate according to a biopsychosocial, or object relation orientated or Freudian or systems minded or Jungian or existentialist or Eriksonian or anywhere up to another dozen other theorists/theories I can think of. Psychologists often do formulations which are almost entirely bound up in numerical scores of psychometric testing, and appear more like summaries of finance reports rather than something about a human being living amongst other human beings.

Many formulations nowadays are banal statements composed of the “5 P’s”, i.e. the presenting complaint, the precipitating factor, the predisposing factors, the perpetuating factors and finally the protective factors. A fictional example that may match many patients

“Krystyll, a 20 year old mother of three (all children are at all times in their grandmothers care and the fathers are nowhere to be found) arrived in the ED via ambulance after over dose whilst having an argument with her boyfriend, this within the context of intoxication with alcohol and cannabis, and on background of multiple past overdoses. Krystyll has a genetic diathesis (i.e. family history) of manic depression. Thankfully Krystyll is help seeking and well supported by her grandmother, though has limited other supports having become estranged from her parents and the fathers of her children due to drug use for which she is pre-contemplative to change. I’d speculate that much revolves around her early attachment, this being anxious avoidant.”

Notice how I cover the “5 P’s” without actually using the “P” words. When I was training and this method of formulation was coming into vogue, explicitly stating the 5 P’s was considered insipid and lacking sophistication, I can only conclude for reasons of a drive to dissimulation, appearing to be something literary, something greater and tailored to the individual, while being something systematized and technocratic.

Insomuch as formulations are a choice of theories, they are the art of the sophist and a pretence to sophistication, and nothing more than pastiche. The greatest authentic formulators were Dostoevsky and Shakespeare. Read their works, their descriptions of people. Neither of these were psychiatrists. Psychiatric formulations are, in comparison, quite embarrassing really. They are, like the symbolism in the cover of this book, a taking apart of a beautiful thing, subsequently unable to put it together again whilst horrifyingly thinking they have all the same.

Treatment; This last step is rather easy, and I could teach any junior doctor the basics in a few weeks of on the job training. Start with the guidelines into the disorders as published by the local guild machine APA (USA), CPA (Canada), NICE (UK), RANZCP (Australia, New Zealand) etcetera, and apply this to the patient. For all of the many pages and for all the appeal to expert judgment, these guidelines are just glorified flowcharts. Actually it is simpler still for the psychiatrist, as most will have their favourite few drugs or drug combinations for each of the disorders, be it the so-called antidepressants/anxiolytics, mood stabilizers or antipsychotics. For example, take the depressed patient. If the depression is mild start with CBT. If it is moderate add CBT to the SSRI. If unsuccessful move to a tricyclic, if unsuccessful still augment with lithium or antipsychotic. The end of the line if all else fails is ECT or an MAOI, or both

Granted the doctor need be aware of dosing considerations, if and when to test serum drug levels, exclusion of organic causes of depression (i.e. medical causes of depression such as underactive thyroid), when and how to switch medications and so on. Yet this is not too daunting, also just a memorization or reference to flowcharts. The psychiatrist might be able appear more erudite by justifying specific medication choice on the basis of what receptor systems they act upon and which they do not. These are by and large convenient stories, mirages of oasis that vanish when one looks closer at the literature. The psychotherapy is more often than not outsourced to psychologists as psychiatrists take upon themselves a managerial mantle, this being convenient for psychiatrist is by and large as neither competent at, or interested in, the “talking cure”. If they are, they will have their pet little approach that is also easy to learn in practice. Surely this fact is not controversial.

My example is a deliberate one, for it is worth digressing at this juncture to hurl grenade at the myth of the power of so called antidepressants, these also often marketed as first line for anxiety. Once again my little spiel will be unreferenced. Suffice it to say for now that these agents correct no chemical imbalance in the brain, for no chemical imbalance has ever reliably been found, nor any other biological pathogenesis accounting for any but a tiny subset of depressed (or anxious) patients. It is the same also for schizophrenia. What these medications do is run the risk of creating a chemical imbalance, for the brain reacts to an excess of neurotransmitter with altering its neurochemistry such that it then becomes imbalanced, as the brain “fights” what the drug is ‘attempting” to do. Oft times the consequences of imbalance is not recognised until one attempts withdraw from the SSRI or SNRI (or any psychotropic really), and whatever attendant symptoms emerge is reinterpreted by the psychiatrist as a relapse of the imaginary biological illness, not a withdrawal phenomenon pure and simple, i.e. a side effect of the drug. And so they wind up on the medication yet again, and the circus continues. But you might say that you, or your patients, have an undeniable salutatory effect. Irving Kirsch, the Harvard psychologist and doyen of the placebo effect, has provided us the best evidence yet that the vast majority of what might be considered the drug effect is actually placebo, what beneficial effect there might be being below what a psychiatrist will subjectively judge as the minimum possible discernible improvement. This is the best evidence that evidence based medicine has given us, and Kirsch’s deflationary findings have ben replicated at every turn to date over now more than two decades. As it happens I am disposed to the view that SSRI’s and SNRI’s have a function that extends beyond the placebo, though this hardly offers any consolation. I have lost count of the number of patients whose anxiety is substantially reduced in correlation with the takings of these drugs, and who claim to not be as depressed as they were. Indeed the anxiety may be so reduced as to be negated altogether. Where once they were crushed by anxiety over public speaking or an exam, now when the train is late and they walk into the exam an hour late they take it in their stride. They can sometimes tell me, when one is so bold to explore, that they wonder if they would react with even a tint of worry if a bomb were to explode in the quad. And the patient who might have been labelled depressive no longer feels as depressed, their mood has moved from 2/10 to 6/10. Bravo. Yet they are not moved by anything. No longer depressed, they no longer feel the suspense of a thriller and the tears no longer well at the reading of melodrama or the attendance at the opera. And if they were anxious about their job, their battering husband or whatever the mood is now is more “Hmm cest la vie”, untouched they are from the passions that are a signal to change, and the driving force behind change itself. The battering husband no longer feels the pangs of conscience on mind altering drugs, and so on goes the circus. Were I to be a dictator of a docile minimally functioning people, the first thing I would do is commence the populace on an SSRI, plus minus some cannabis. The children I would give low dose stimulants. Some adults, or children also, I would administer so called antipsychotics. And no revolution would ever disturb my sleep.

Having returned from digression, let us return to what defines the psychiatrist, as an adjunct to the police with powers to deprive persons of their liberty. To the reader who is a non-patient, there but by the grace of God (or good fortune) go you.