From my admittedly limited understanding, it seems like the basic issue of psychiatry is the tension between 1/striving for the legitimacy of the other medical sciences, while 2/wrestling with a topic that is just fundamentally different. Non-psychiatric medicine deals with the deterministic, the mechanistic and a relatively circumscribed reality. But the pathologies of the brain are a complex web of nature and nurture and epigenetics and some amount of magic.
This all leads to an insistence on psychiatry's 'knowing', or at least the air of knowing. The DSM itself as some holy bible manifestation of this need to know and classify. Which is sad, because it really sounds like we know so so little about the brain. By contrast, every therapist I've known doesn't feel the same need to prove something, and is very willing to admit their own limitations in addressing the needs of clients.
Perhaps the DSM and its classification system is also partly a way to address the cognitive dissonance inherent in the field: how could we ever prescribe major medications if we were ever to admit how little we know about what we are treating?
Anyone more informed than me feel free to correct.
That seems largely right to me. I guess Awais would say that a lot of medicine is much less clear cut than we often think, and I'm sure that's true, but still.
Re: medication my sense is that psychiatrists and other prescribers can still do a pretty good job of treatment even in the absence of a paradigm that's truly coherent. I mean, it has limitations, given what we don't know, but we do actually know a fair amount of what kinds of medications can help people and psychiatrists have a lot of practical experience of working with people to help.
Thanks Daniel. You articulated it well. There is certainly a spectrum of problems. There is a tendency to overlook the messy complexity of general medicine. George Engel in the 1970s with his biopsychosocial model was trying to rectify that. Yet, it is true that there is a difference of degree, and problems at the opposite ends of the spectrum look quite different. Prolonged and complicated grief is a very different sort of problem than chronic kidney failure. Psychiatry is in the extraordinarily difficult position in that it straddles both neuroscience and clinical psychology, with no scientific framework to unify it. The public also has a hard time understanding the reality of mental disorders, and fluctuates between either making them concrete like diabetes or treating them simply as socially deviant behaviors. I see epistemic humility as an important virtue in navigating this.
I loved your anecdote about the eminent psychiatrist. I have a friend who was a leading consultant psychiatrist at an NHS trust in London. He left the profession entirely about a decade ago because of the increasing prevalence of exactly the attitude you describe. It's astounding to me that people that work in this field have such a limited idea of how stories that we tell about ourselves can have a profound impact on our perceptions. The models used to help people understand these stories don't have to be "true" in the way that paracetamol relieves a headache, it's a complicated process that requires practitioners to be able to empathize deeply and have an enquiring relationship to their own perceptions of the world. I heard it reported that some doctors at the Tavistock clinic's gender service (that was closed down) were known to refer to the psychological therapies that The Tavistock is famous for as "That Freudian shit". Again, I really struggle to understand why these people went into psychiatry, what exactly about it are they interested in if not the ways in which people think, understand and perceive?
I didn't get into this in the podcast, because it's a bit too loosey goosey even for me, but my anecdotal experience is that a lot of psychiatrists are characterologically a bit weird. They're nerdy, a bit alien, not particularly intuitive about people, and that some part of what drew them to the field was the prospect of understanding scientifically what was often mysterious to them intuitively.
There is some truth to it, for sure. I think if you look at psychiatrists who are excellent clinicians, the odds are that they are highly intuitive and emotionally intelligent individuals. It's difficult to excel as a clinician otherwise. It is, however, possible to excel in psychiatric research or academia without possessing these virtues.
Yes, and I think their might be a powerful filtering effect in the pathway that people have to follow in order to attain the qualifications needed to be any sort of MD. The type of focus and single mindedness needed to succeed might disqualify lots of people that might have high empathy, openness, and self questioning (doubt). In non-psych areas of medicine this is only a problem when it comes to things like "bedside manner", but in Psychiatry, like Awais said, these skills are essential because the area doesn't deal with the strictly material. I also really identified with the thing you said about being constantly astounded by the fact people don't seem to have the ability to reflect on the past mistakes of the field, and that they repeatedly buy into the latest "evidence" as being definitive time and again. This is a problem in all disiplines! Politics!
From my admittedly limited understanding, it seems like the basic issue of psychiatry is the tension between 1/striving for the legitimacy of the other medical sciences, while 2/wrestling with a topic that is just fundamentally different. Non-psychiatric medicine deals with the deterministic, the mechanistic and a relatively circumscribed reality. But the pathologies of the brain are a complex web of nature and nurture and epigenetics and some amount of magic.
This all leads to an insistence on psychiatry's 'knowing', or at least the air of knowing. The DSM itself as some holy bible manifestation of this need to know and classify. Which is sad, because it really sounds like we know so so little about the brain. By contrast, every therapist I've known doesn't feel the same need to prove something, and is very willing to admit their own limitations in addressing the needs of clients.
Perhaps the DSM and its classification system is also partly a way to address the cognitive dissonance inherent in the field: how could we ever prescribe major medications if we were ever to admit how little we know about what we are treating?
Anyone more informed than me feel free to correct.
That seems largely right to me. I guess Awais would say that a lot of medicine is much less clear cut than we often think, and I'm sure that's true, but still.
Re: medication my sense is that psychiatrists and other prescribers can still do a pretty good job of treatment even in the absence of a paradigm that's truly coherent. I mean, it has limitations, given what we don't know, but we do actually know a fair amount of what kinds of medications can help people and psychiatrists have a lot of practical experience of working with people to help.
Thanks Daniel. You articulated it well. There is certainly a spectrum of problems. There is a tendency to overlook the messy complexity of general medicine. George Engel in the 1970s with his biopsychosocial model was trying to rectify that. Yet, it is true that there is a difference of degree, and problems at the opposite ends of the spectrum look quite different. Prolonged and complicated grief is a very different sort of problem than chronic kidney failure. Psychiatry is in the extraordinarily difficult position in that it straddles both neuroscience and clinical psychology, with no scientific framework to unify it. The public also has a hard time understanding the reality of mental disorders, and fluctuates between either making them concrete like diabetes or treating them simply as socially deviant behaviors. I see epistemic humility as an important virtue in navigating this.
P.S. More on the medical model here: https://www.psychiatrymargins.com/p/the-medical-model-of-psychopathology
thank you for this one ♡
I loved your anecdote about the eminent psychiatrist. I have a friend who was a leading consultant psychiatrist at an NHS trust in London. He left the profession entirely about a decade ago because of the increasing prevalence of exactly the attitude you describe. It's astounding to me that people that work in this field have such a limited idea of how stories that we tell about ourselves can have a profound impact on our perceptions. The models used to help people understand these stories don't have to be "true" in the way that paracetamol relieves a headache, it's a complicated process that requires practitioners to be able to empathize deeply and have an enquiring relationship to their own perceptions of the world. I heard it reported that some doctors at the Tavistock clinic's gender service (that was closed down) were known to refer to the psychological therapies that The Tavistock is famous for as "That Freudian shit". Again, I really struggle to understand why these people went into psychiatry, what exactly about it are they interested in if not the ways in which people think, understand and perceive?
I didn't get into this in the podcast, because it's a bit too loosey goosey even for me, but my anecdotal experience is that a lot of psychiatrists are characterologically a bit weird. They're nerdy, a bit alien, not particularly intuitive about people, and that some part of what drew them to the field was the prospect of understanding scientifically what was often mysterious to them intuitively.
There is some truth to it, for sure. I think if you look at psychiatrists who are excellent clinicians, the odds are that they are highly intuitive and emotionally intelligent individuals. It's difficult to excel as a clinician otherwise. It is, however, possible to excel in psychiatric research or academia without possessing these virtues.
Yes, and I think their might be a powerful filtering effect in the pathway that people have to follow in order to attain the qualifications needed to be any sort of MD. The type of focus and single mindedness needed to succeed might disqualify lots of people that might have high empathy, openness, and self questioning (doubt). In non-psych areas of medicine this is only a problem when it comes to things like "bedside manner", but in Psychiatry, like Awais said, these skills are essential because the area doesn't deal with the strictly material. I also really identified with the thing you said about being constantly astounded by the fact people don't seem to have the ability to reflect on the past mistakes of the field, and that they repeatedly buy into the latest "evidence" as being definitive time and again. This is a problem in all disiplines! Politics!