Abstract
DEAR SIR
I write in relation to Dr Paul Coombe's letter about the clinical practice guidelines in the March 2003 edition of Australasian Psychiatry. 1 Like Dr Coombe, I read these guidelines with a sense of dismay and concern at the sheer mindlessness of it all.
Towards the end of Shakespeare's The Tempest, Miranda, having grown up on an island with no human contact other than Prospero, her father, and Caliban, a somewhat brutish slave, is exposed to a variety of human beings. Seeing other people for the first time she exclaims in delight, ‘Oh brave new world that has such people in it’. In this line, Aldous Huxley was to find the title for his novel Brave New World. Of course, the irony of Huxley's novel is that the brave new world depicted is one where every attempt is made to expunge the human person and especially the person's propensity to experience an emotional life. Huxley depicts a mechanistic world, from standardized reproduction to standardized experience. Should anyone be threatened by unruly emotional experience, they can fall back on ‘soma’, a socially sanctioned mindnumbing and pleasure-inducing drug. It is considered socially irresponsible not to take soma when instability threatens; ‘A gramme [of soma] is better than a damn’, is one of the many oft repeated propaganda slogans that help to prevent thinking in this essentially totalitarian state.
If these published guidelines are anything to go by, the human person is also at risk of being gradually expunged from the brave new world of psychiatry. Psychiatric practice, it seems, is no longer anything to do with understanding the complexity of human experience, or forming a relationship with a patient in order to facilitate emotional experience and understanding.
As Dr Coombe points out, the guidelines seem to suggest that the ‘bulk of patients are expected to be free of trouble after the application of CBT and/or drugs.’ In the guideline for panic disorder and agoraphobia, for example, the authors point out that ‘these conditions are chronic and disabling in nature’, 2 yet go on to suggest that in terms of treatment some sessions of cognitive behavioural therapy (CBT) might do the trick! They specify that approximately 12 sessions might be expected to be effective but more may be necessary. In the depression guideline, 3 it is 6–8 sessions plus 3 monthly ‘booster’ sessions! If agoraphobia and panic are ‘chronic and disabling’, and because depression also is often a chronic and disabling state of mind, do the authors really believe that the psychological roots of these conditions can be effectively treated in this manner? The problem is that although the strategies outlined in these guidelines may have some influence upon symptom presentation (hence their endorsement in ‘evidence-based’ studies that focus on symptoms) they have little impact upon the psychological disorder as such. As Dr Coombe writes, the guidelines suggest that ‘all one needs to do is prescribe a course of this or that, send the patient to a CBT specialist or prescribe a course of drugs, throw in a little “supportive psychotherapy”, and these problems are solved. Quite simply they are not. It may be sufficient to remove a patient from a waiting list or even to provide some symptomatic relief …’. His view that ‘these people go on suffering in one form or other when such superficial approaches are applied’, fits with my own observations.
Except for a brief reference to the value of ‘other forms of psychological therapies’ for those ‘with major interpersonal difficulties and severe past trauma’, 3 the guidelines do not suggest the possible value of psychotherapy. The psychotherapeutic endeavour, at least as I understand it, seeks understanding of the nature of the person's inner world, their emotional realities and conflicts, and the meaning of the patient's symptoms in the context of their life and relationships. It seems to have escaped the notice of ‘modern’ psychiatry that, for example, panic disorder and agoraphobia generally represent the symptomatic expression of an emotional conflict, often specifically related to issues of emotional dependence and independence. An emotional conflict cannot be cured by medications and CBT (as the term ‘cognitive behavioural therapy’ suggests, this approach pointedly ignores the emotional dimensions of the patient's experience). In reality, the concept of cure is barely relevant. Emotional conflicts have to be worked through, usually slowly and painfully.
One could be forgiven for concluding that these treatment guidelines are designed with the intention of plunging psychiatry further into the black hole of mindless oblivion, but hey, maybe I just forgot my soma; remember, ‘a gramme is better than a damn’!