Abstract
Keywords
In 1983, the first author was asked to sign the papers that would commit his brother to a psychiatric hospital. Having recently completed his intern attachment at the time, the author wanted to ask whether or not his brother could come under the care of Dr. X rather than Dr. Y. The answer was “No”. However, it was the way in which this simple reply was communicated that remains with the author, quelling as it did his concern for his brother's well being. The Director was 20-30 years the author's senior and stood quietly in front of him, balanced and at ease. The Director's face had a kindness and the way in which he said “No” was both warm and final.
This story came to the first author's mind following his recent year as a locum psychiatrist in the UK. Whilst admittedly working under the soon-to-be replaced 1983 Mental Health Act, the process by which people were made and kept as involuntary patients in the UK highlighted changes that have not yet fully emerged in Australasia. It is a phenomenon that may be described as the democratisation of psychiatry. What is meant by this is that all interested parties are able to contribute equally to the diagnosis and management of psychiatric disorders. An example may serve to illustrate this point. By way of background, and at least in Victoria, Australia, an adult plus a medical practitioner together may recommend a person to a psychiatric hospital. Within 24 hours, that person must be reviewed by a consultant psychiatrist and the initial recommendation either confirmed or the person discharged from the Act. The patient may appeal their decision through the Mental Health Review Board, a panel chaired by a solicitor and including a psychiatrist and a member of the lay community. The process in the UK is different. There, the Approved Social Worker (ASW) begins, organises and coordinates all Mental Health Act assessments, albeit at the request of others. In order for a person to be admitted involuntarily, all three parties, the ASW, a medical practitioner, in preference the person's usual General Practitioner, and only an approved psychiatrist, must agree. They must determine that the person is both psychiatrically unwell, referred to as the nature of the illness, and sufficiently unwell so that he or she needs to be in hospital, the degree of the illness. If any one member disagrees, the committal cannot take place. Equally, the family must agree, having the power to object to at least longer term admissions. Once admitted, the paperwork is reviewed. It is reviewed independently by a person who has not seen the patient. If an explanation is required and is deemed unsatisfactory, the person must be discharged. If not, the patient has the opportunity to appeal to one of two forums – the Managers’ Meeting and the Mental Health Review Tribunal. The Managers’ Meeting is a panel of representatives from the detaining authority to whom the consultant psychiatrist presents his or her patient. The Managers have the capacity to either accept or decline the admission. Finally, and not dissimilar in its composition, the consultant psychiatrist may be required to justify his or her clinical decision to the Mental Health Review Tribunal. This is, however, considerably longer than its Victorian counterpart, lasting 2-3 hours per patient. It routinely involves cross examination of the psychiatrist by a solicitor on behalf of the patient. It is also restricted to the patient's current mental state examination.
Whilst, on paper, these checks and balances may reassure the community that people are not detained unnecessarily, a problem arises if opinions differ. During the first author's time in the UK, a 61 year old man was admitted acutely, having been found by his neighbours semi-naked and mumbling incoherently in his backyard. During his initial days in hospital, he hid under his bed, poured urine over his head and refused medication. With parenteral medication he quickly recovered and appealed on the grounds that, as he was not unwell, nor had he ever been so, he should be discharged. At the Tribunal there were no obvious signs of psychosis or signs that would be expected to be picked up by those who were untrained or inexperienced in the careful examination of the mental state. The first author argued that as this was the third presentation, the patient had a relapsing illness and, untreated, he would deteriorate. As such, he should be afforded the opportunity of having medication continued, and if need be, continued as an involuntary patient. Whether the reader is convinced by this account is of secondary importance to the Statement of Reasons that were given for the patient's immediate discharge. It was argued that although long term treatment by medication and community support may have been in the patient's best interest, the patient did not meet either the nature or the degree criteria on the said day. From a legal perspective, discharge was obligatory. Of greater interest was a further comment. A specific note was made that, as the ASW and inpatient nurse were uncertain as to whether the patient had ever suffered from a mental illness or of the mental state findings, the Tribunal had no choice other than to discharge the patient. The democratisation of psychiatry was therefore complete. That is, the process by which a person could or could not be admitted and/or discharged from his or her involuntary status could be determined by a number of involved parties. Initially this included the ASW, general practitioner and psychiatrist. It involved a person who reviewed the documentation but who had not seen the patient. Finally, it rested on the managers of the hospital, an ASW, a qualified nurse and those members of the legal profession that were involved in the Tribunal. Each contributed democratically in what they believed was the best interest of the patient. Having previously considered the circumstances under which paternalistic intervention may usefully proceed, the first author was left concerned for the well being of this patient. 1 A second incident also occurred in which a separate Tribunal discharged a patient against the advice of the first author and the patient subsequently attempted bilateral enucleation. As a result, the following question arose: Have psychiatrists lost their expert status and, if so, how did this occur?
THE DECLINE IN EXPERTISE
Recently, again in the UK, the National Institute for Clinical Excellence (NICE) formulated a set of recommendations which restricted the use of electroconvulsive therapy (ECT). 2 However, no psychiatrists were included in the process. We have attempted to explore this phenomenon from both a sociological and psychological perspective. 3 Among other factors, the rise of the consumer movement in the 1960s and the subsequent elevation of the patient to the status of expert seemed important. However, the 1960s and 1970s were also a time of unprecedented criticism against the profession. 4 – 9 Rosenhan's classic paper made an important observation – psychiatry was fallible. 9 The study involved 8 pseudo patients, among them 3 psychologists, a psychiatrist and a paediatrician. They presented themselves to 12 separate hospitals across 5 different states on both the East and West coasts of America. The hospitals varied from university funded, research orientated, private facilities to understaffed state or federally funded institutions. The pseudo patients were asked to complain of a single symptom, namely that they had been hearing voices. These were often unclear, but as far as they could tell the voice said “empty”, “hollow” and “thud“. Beyond alleging this symptom and falsifying name, location and employment, no further alterations to their history, background or circumstances were made. They were then asked to behave as they would ordinarily. Should they be admitted, they were asked to cease simulation of their only symptom, their discharge being contingent upon their well being. All pseudopatients received a diagnosis of schizophrenia and all were admitted, their mean length of stay being 19 days. Of particular note was the observation that it was other patients and not trained staff who questioned whether they were actually sick. A subsequent study was undertaken. Staff who had heard about the results were not convinced that it could happen in their facility. They were informed that over the next 3 months one or more pseudo patients would present for admission. Staff would then be asked to determine which patients they were and how confident they were with their choice. Again the results were critical of the psychiatric profession. Of 193 patients admitted, 41 were confidently thought to have been pseudo patients, 23 were considered suspect by at least one psychiatrist and 19 were suspected by both one psychiatrist and one other staff member. However, no pseudo patients had been sent.
Clinically, Cognitive Analytic Therapy (CAT) offers an approach to the understanding of both a person's inner psychological distress and his or her external and/or conflictual relationship with self and others. 10 – 12 Amongst its fundamental tenets are the notions of core pain, an unmet need or an unmanageable or disallowed affect, and reciprocal roles (RR), the ways in which we have learnt to interact with others. The ways by which a person avoids their core pain, shifting into their various and specific roles, are however ultimately unhelpful. They are unsuccessful as they inevitably lead the person back to the pain through a series of traps, snags or dilemmas. That is, we keep making the same mistakes. Clinically, having understood and unravelled an individual's way of interacting, the person is then supported as they begin to explore ways in which they can respond differently. Events in which feelings are experienced as being manageable, and saying and feeling what has previously been unspoken, are important changes. The model has previously been applied at group and systems levels. 11 12 We wondered whether CAT may also be useful in understanding the democratisation of psychiatry. Specifically, if we make the assumption that psychiatrists believe that by careful diagnosis and management, patients will benefit from that contact, then thoughtful and informed criticism will be hurtful. It is a core pain to which a number of options are available. If the profession holds the view that to express any anger would be unbecoming, or disallowed, then we have to escape that pain in another way. We can give up all together, neither contributing to or getting involved in professional debate or challenges. We can retaliate, and criticise our non-medical colleagues. Eager to please, we may acquiesce to what appear to be reasonable requests. Using CAT as a model, it seems that English psychiatry has allowed the role of psychiatrists to be replaced by lawyers, managers, social workers and nurses. As a profession, the face-to-face review of patients has been supplanted by colleagues who review documentation in the absence of the patient, and practitioners have felt bound by NICE guidelines when no psychiatrist was present.
Whilst not as striking as the UK example, similar trends are emerging both symbolically and practically in Australasia. Notwithstanding a subsequent apology and retraction, it was of note that a former politician and representative from beyondblue felt able to offer a diagnosis concerning a parliamentarian. 13 Nurse practitioners are now being recruited and trained to admit, investigate and medicate patients, albeit within clear confines. 14 This seems reasonable, particularly in rural areas where the recruitment and retention of psychiatrists is difficult. However, this and other well intentioned suggestions also erodes the expert role and contribution of the psychiatrist, both clinically 15 and administratively. 16 The failure of psychiatry to contribute to resolving the recruitment/retention problem colludes with and exacerbates the erosion of the psychiatrist's role.
BEING CLEAR
Even when we know what is right, too often we fail to act. More often we grab greedily for the day, letting tomorrow bring what it will, putting off the unpleasant and unpopular. Bernard M. Baruch
How then do we move beyond this? In some way, I feel it is linked to the experience with my brother. Being told “No” by an expert, rather than democratically in the manner described here, has stayed with me. Rather than leaving me at odds with the decision, it left me quietly reassured that somehow my brother will be alright. Perhaps we have lost this ability to say “No” to what seem to be powerful antagonists. Fearful of criticism, of being labelled autocratic, vengeful or of being protective of the market place, we have failed to comment. In contrast to psychiatry's lack of response, Victoria's recent Chief Justice has said, “No”. She also spoke quietly and clearly. Specifically, Justice Warren cautioned against persistent media attacks on the legal system. She sees these as not only damaging to the Office of the judiciary, but also for its capacity to undermine the role of the court in the community. 17
Occasionally, there are glimmers of hope. Practitioners are beginning to ask whether the Emperor's new clothes are as they might be. 18 – 21 Halasz 18 looks at diagnostic expansion and the influence of the pharamaceutical industry, Parker 19 at real life research, and McGorry 20 and Pring 21 at appropriate reform and investment. Returning to Victoria's Chief Justice, Warren also argues for accountability and impeccable behaviour in both one's professional and private life. Maybe this has also been missing - the profession has lost its professionalism and all that that entails. Again, the tide may be turning as we begin to raise questions about our own behaviour, 22 23 medical education's delegation to industry and the unprofessional interpersonal behaviour of doctors.
It seemed that during the first author's year in the UK, there was the familiar fatalism that is apparent here, that of being ‘crushed’ to use the language of CAT. Although perhaps well intentioned, criticisms of psychiatry have also led to an erosion of the specialty. This has created the belief that all involved can contribute equally. Perhaps it is time that we also said, “No”. We have the opportunity to speak up and do so in Australasia, quietly and confidentIy. The democratisation of psychiatry affects all disciplines. It is occurring seemingly without an awareness of the unintentional but accompanying devaluation of expertise. It behoves us to attend to our own behaviour as a professional body and as individuals. If we expect respect as professionals, we have to behave as such. We do so by being ethical, available and by remaining clinically focussed on the well being of our patients. Criticism and resource restraints have, all too often, tempted us to devolve our responsibilities to others. In doing so, we have lost our respect and the respect of those around us. In contrast, we need to stand up, balanced and at ease, and when required, be able to say, “No”.
Thank you to Lesley Hopkins for typing the manuscript and to Drs. Richard Tillett, Mike Metcalfe and Angela Rouncefield for their support and encouragement whilst in the UK. The first author's brother consented to publication of this article.