Abstract
DEAR SIR,
Psychiatry has, since its earliest years, steadfastly sought validation and recognition as a reliable science, as good a medicine as any other. It is surprising then to find the science suddenly relegated to a supporting role, even more surprising perhaps to find art, its old enemy, muscling in on its territory. Psychiatry here1 is re-packaged and presented as high art, as the art of selfexpression and as the activity of selfexpressing psychiatrist-artists.
It ought to be reassuring that psychiatry can see itself as a creative endeavour, yet somehow it is not.
To be creative is, at the very least, to be open and responsive to the individual circumstance, the apparently random, to appreciate the unexpected, the peculiar, to be willing to see things differently. Creativity too is about doing things differently, about risk taking. These are not attributes for which psychiatrists are generally noted. Certainly, many patients remain unconvinced and describe a psychiatry that, into the 21st century, continues to convey a message of life-dulling chronicity, severely reduced aspirations and a sense of hopelessness. The best that psychiatry predicts for most of its patients is usually a lifelong accommodation to, and self-management of, the illness, reinforced by supervision and with little hope of eventual discharge. This is a process dominated by strategies to minimize the likelihood and severity of acute relapse: a matter largely of risk avoidance, of not taking a chance, of not offering hope. It is perhaps more of an an-aesthetic remedy.
It is recovery that has challenged the intimidations of this particular version of psychiatry and is increasingly doing so with compelling evidence to support its claims. It is the patient movement that has introduced, promoted and insisted upon hope. And it is the patient movement that has shown that a truly creative approach is possible. Yet psychiatry, in this version, maintains its hegemony. Most patients willingly (some reluctantly) accept the illness in mental illness as self-defining. For many, of course, there is little choice.
Yet the creative possibility continues to haunt our expectations. It touches our experience of something beyond human experience, something unsayable that grounds human experience, our dream of a humanness, a radical and romantic self-justification, inaccessible to science. It encourages our resistance to the fearful coldness of a scientific fatalism. It answers our yearning for a spiritual encounter, or, at the very least, for recognition of an essential human spirituality. The psychiatrist as self-expressing artist beckons us: wrapping the cold body of science in the multicoloured coat of art and promising the excitement of healing through self-discovery.
Alas, enter the administrator (bad cop): dull, drab, dim-witted, a gradgrindian character, grey and unforgiving, whose perpetual cry is for outputs! Outputs! Nothing but outputs! A meddling mindset, with little, if any, interest or care for the delicate work of psychiatry. By intruding themselves, and their dull suburban worries, into what are seen as intimately and intricately medical matters, the administrators create a ‘dangerous work environment for the psychiatrist’. Whenever the psychiatrist's authority is questioned, whenever the clinical hold is loosened, it seems, patient outcomes are likely to be adversely effected. Indeed, ‘the physician is treated as a commodity to be used and patients are channelled among the commodities to be used’. This would be a laudable concern were it not that what is being mourned here is the psychiatrist's reduction to the role of technician, and the consequent loss of an opportunity for selfexpression.
The picture painted is one of huddling in unheated garrets, deprived of even the most basic means of self-expression: pen, paper, computer access, misunderstood as only artists can be, expected to meet the mundane and sometimes malignant agendas of others, their assumed sovereignty over their relationships with their subjects overruled, their essential compassion dismissed to a peripheral importance.
It is true, of course, that psychiatry is about relationships, as indeed is mental health. However, whether or not the ‘relationship between patient and physician is the single most important factor in determining favourable patient outcomes’ is debatable. This relationship is certainly crucial, although it will be most effective when it contributes to a network of collaborating relationships, not all of them clinical, and not when it exercises sovereign authority over all others.
But it is not the fact of the relationship that is crucial (there is almost always a relationship of some kind anyway; it is a bit like that other old saw: it is not possible not to communicate). It is the nature or quality of that relationship that counts. It must be one that promotes and preserves trust, commitment and collaboration. It must be one that privileges the patient. It cannot be a relationship in which one party claims the other, authorizes itself to speak for the other, seeks to own the other: ‘make no mistake, they are our patients. We claim them and they claim us as their doctors… and we propose to speak for our patients’. Nor can it be one in which one party uses the other as an occasion for self-expression, in which one party is the artist and the other necessarily reduced to subject, the artist's model, albeit an imperfect one, for they have been diagnosed with a mental illness. Butthen ‘out of the crooked timber of humanity nothing straight can be made’. For an instance of self-expression to be able to claim any authority it must, first of all, resonate with its creator. It must be self-referring. If the art of psychiatry is then the expression of the psychiatrist's ‘deepest self… expressing ourselves through our tools’, then it is hardly surprising that ‘being a mental patient in New Zealand must be close to impossible’. Unsurprisingly, such a patriarchal relationship generates resentment or resistance (reactions that so perplex and disappoint psychiatry), or resignation from the patient. Resignation, of course, is often seen as compliance, insight into one's illness or agreement with one's doctors. Another word for such a surrender is institutionalization. Rather than a sincerely felt collaboration, it is more likely to be the natural reaction of the colonized. This is about as far from recovery as it gets.
Psychiatry may well be an art, as originally understood: ‘techne’, art as skill, art as the-art-of, but this does not add much, although the mantle of art may well give it a friendlier look, the appearance, at least, of a meaningful experience. However, art as self-expression is a recent and romantic conception. Psychiatry can be an art, in this sense, only insomuch as it is not yet science. To claim that psychiatry is already an established science is to overstate the case somewhat. Mental illness remains theoretical, the likeliest explanation consistent with the currently reigning paradigm of human being. Indeed, psychiatry is necessarily grounded in an ethical notion ofwhat it is to be human. Without such a notion of being human, or perhaps of human being, psychiatry becomes impossible, its catalogue of disorders rendered meaningless. However, to say this is not to deny the possibility of a successful science of psychiatry. Nor, of course, is it to claim that art supplements, fills in, or humanizes (poeticizes) the science. Psychiatry begins in metaphysics, finds itself in ethics and ends in science. Art rescues it from bewilderment.