“the distinction between myself as the individual people encounter, and the social role and character they expect to encounter”

I have been reflecting on this of late. It is a truism that “the Therapist” (in the sense Alasdair MacIntyre is using the term and also in the actual, clinical sense) is the locus for all sorts of projections – not just from clients/patients/”service users” but from other professions and society at large.

This is writ large in psychiatry, but is no doubt the case not only in the helping professions but across the board in life. We all encounter each other running the risk of mistaking the social role with the person.

Of course, this is somewhat inevitable in day to day life, especially in briefer encounters focused on a specific practical transaction. Indeed, entering absolutely into a deeply personal encounter with everyone you meet runs the risk of a certain paralysis.

However, I wonder how much organisational demoralisation is due to the dehumanising effect of this in encounter after encounter, especially in work – which is where a very high proportion of our working life is spent?

Why are doctors so unhappy?

From the UK junior doctor’s strike to survey after survey , there seems to be growing evidence that a doctor’s lot is not a happy one. Or is it not so much a “doctor’s lot” as a “doctor’s nature?”

I’ve been interested in this question (quite apart from the personal relevance!) ever since working on this review for the TLS of various medical biographies. As I wrote:

In the Western world, at least, the medical profession generally enjoys high status. For sociologists, doctors incarnate various forms of power disparities. Medical science and medical technology have made spectacular progress since the Second World War; procedures such as LASIK laser eye surgery, to give just one example, that once would have seemed magical, are now near-routine.

And yet an air of discontent is evident in much of the discourse of modern medicine. Like many others, the medical profession is under question, if not attack, on a range of fronts. Complementary remedies are increasingly popular, often with practitioners as well as patients, despite the advent of evidence-based medicine and numerous books that have discredited their claims to efficacy. A succession of scandals in Britain and elsewhere has undermined public trust in doctors and nurses. Lewis Terman’s classic study of “gifted” individuals, published in 1954, found that physicians tended to feel inferior relative to those of comparable attainment in other fields, and the Grant Study, George Vaillant’s epic survey of adult development, following the Harvard Class of 1944, identified self-doubt as the feature distinguishing physicians from control subjects.

There was somewhat more I wrote originally, but for reasons of space, had to be cut

 

. Much was based on my reading of Myers and Gabbard’s wonderful The Physician as Patient – a book I reviewed some years ago . As I wrote then, Myers and Gabbard illustrate the power of the case vignette, a somewhat neglected form nowadays, and I also wondered about the  self flagellation possibilities of audit (linked I guess to the Imperative Voice one gets so much of in medical journals)

I didn’t write in my 2008 review of one of the points Myers and Gabbard make – based on psychoanalytic literature – about the much-vaunted grandiosity and pomposity of doctors – the “god complex.” In their reading, this (when it occurs) is a defence mechanism against the ultimate power of death against all our efforts. Personally, there are only a handful of doctors I have come across – and at this point I must have come across hundreds in various contexts – who in any way lived up to the “god complex” stereotype.

Are doctors less happy than other citizens? Surveys and so forth can no doubt be adduced to prove the point (though I must admit after the US Presidential Election having an even greater scepticism about ANY survey or poll being used as “evidence”)  and the lived experience of doctors is increasingly one of a beleaguered profession overwhelmed by competing and constant demands. Is this because of specific issues – funding, resources, de-professionalisation – of the contemporary world?  Is it because of a cultural shift from doctor-knows-best to consumerist healthcare? Or is it something deeper and perhaps near-inherent to the kind of person who is drawn to the practice of medicine? Or something deeper and perhaps near-inherent to the practice of medicine itself?

There is, on one level, more discourse about health and healthcare than ever before. On another, there is often a a euphemistic, evasive quality to much of it. So many terms – from “evidence-based” to “patient centered” – have become godterms that conceal the complexity and diversity of healthcare (both complexity and diversity are themselves “godterms”, increasingly, but I use them very deliberately here) and the contending priorities at play.

This is an area ripe for pompous theorising about Society and Culture and so on, and perhaps I have done my share of this already. One final thought: the WHO definition of health is:

a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

Do you, reader, really believe that? Do you really, when you think of what it is to be healthy, think of”complete social well-being”?  What is “complete physical, mental and social well-being” anyway?

The point is not to denigrate “well being” in some way – or not to recognise the value of a positive rather than negative definition of health. The point is, this  grandiose definition has consequences – underlying not just health policy and practice but how we think about what it means to be healthy, and also what doctors (and nurses, and psychologists, and OTs, and physios, and everyone else with apologies for those left out) are trying to achieve. I would argue that the WHO definition is something out of a kind of worldly messianiac pseudo-religion rather than a workable basis for a human-scale endeavour.

 

The inspirational imperative

“Inspirational” and its derivatives has replaced “passionate” as a CV-staple. “Inspirational” has also become a clickbait-staple. My Twitter feed seems to sag under the burden of just so many “inspirational” and “inspiring” links. “Inspiration”, “inspiring”, “inspirational” – all join “disruptive”, “revolutionary”, “transformational” in the Overused Lexicon.

Recently a video circulated online (OK, “went viral”) of a woman with terminal illness being interviewed by Ryan Tubridy on The Late Late Show. While her own determination to live every moment is entirely admirable, I do wonder if the cult of Inspiration can put pressure on people in this situation (and many others) to Be An Inspiration. Winston Churchill’s battles with the “black dog” of depression are often held up as inspiring – look what he achieved despite his depression! – but this can be demoralising – look what he achieved despite his depression, so why can’t I? Cue guilty spiral…

Currently Sir Bradley Wiggins is facing serious questions about his use of Therapeutic Use Exemptions. Cycling seems a sport that, even more than others, is bound up with a culture of Being Inspirational (perhaps this is because cycling does seem to small-i inspire many adults to take up the bike themselves, in a way watching professional football, for example, doesn’t) . One of the reasons Lance Armstrong got away with his drug cheating was the Inspirational Story he was able to wrap himself in, and a natural reluctance on the part of many to burst an Inspirational bubble.

Much of the discourse online about eHealth can take a similarly  Inspirational Above All turn. Perhaps this is another example of how the can-do, market-focused, startup culture of tech conflicts with the more restrained, evidence-focused, small-c conservative world of healthcare.

 

 

“The slaves of some defunct economist”

“… the ideas of economists and political philosophers, both when they are right and when they are wrong, are more powerful than is commonly understood. Indeed the world is ruled by little else. Practical men, who believe themselves to be quite exempt from any intellectual influence, are usually the slaves of some defunct economist. Madmen in authority, who hear voices in the air, are distilling their frenzy from some academic scribbler of a few years back. I am sure that the power of vested interests is vastly exaggerated compared with the gradual encroachment of ideas. Not, indeed, immediately, but after a certain interval; for in the field of economic and political philosophy there are not many who are influenced by new theories after they are twenty-five or thirty years of age, so that the ideas which civil servants and politicians and even agitators apply to current events are not likely to be the newest. But, soon or late, it is ideas, not vested interests, which are dangerous for good or evil.” John Maynard Keynes, The General Theory of Employment, Interest and Money (pp. 383–4))

This famous quote from Keynes used to baffle me a bit (or rather, the sentence “Practical men, who believe themselves to be quite exempt from any intellectual influence, are usually the slaves of some defunct economist” which is the bit I had come across)

Medicine and healthcare are the domain of pragmatism.This has always been the case, but is heightened in a wider intellectual world which often sees itself as “post ideological” (although political events on  both sides of the Atlantic, not to mention everywhere else, tend to show that actual populations don’t necessarily believe that) Evidence-based medicine elevates “what works” far above what is physiologically plausible. Models of illness such as Bill Fulford’s “full field” model of mental illness increasingly integrate disparate theoretical approaches with a main emphasis on lived experience. These approaches have an awful lot to be said for them; and I personally have always seen myself as a pragmatic practitioner, not wedded to any particular dogma.

Keynes quote, especially considered in full, extends far beyond economics. Pragmatic practice is always located in some kind of intellectual framework. Medical models in psychiatry, for instance, may seem focused on pragmatic approaches but are rooted in a philosophical approach of great complexity. Mental health policy, it often seems, cam be driven by responses to anti-psychiatry writings from the late 1960s, the formative years of many of those now in positions of power and influence.

Ideas which seem simple and uncontroversial – such as the idea that health care should be less and less delivered by large institutions and more and more “in the community” – are themselves located amidst a massive array of beliefs and assumptions which are rarely unpacked.

“Nitrazepam made dreams everydayish” – searching for “dreams” in the BJPsych

Following on from  my recent posts about dreams and psychiatry (and the changes in how psychiatrists engage in questions of the meaning of symptoms reported to them) I have just searched the British Journal of Psychiatry site using the word “dreams”. As the BJPsych is the journal of the Royal College of Psychiatrists and the third most cited psychiatry journal in the world, it is fair to regard it as reflecting contemporary psychiatry.

 

Using the “Best match” search criteria,  the top 10 results  for “dreams” are all from other decades – with the most recent being from 1974 – a paper which dealt with the impact on dreaming of then-commonly-used sleeping tablets. Haven’t read the full paper yet, but here is the abstract (and I haven’t come across the word “everydayish” before!) :

It was predicted that amylobarbitone and nitrazepam would make dreams less active, and withdrawal would make them especially intense. Dream reports were collected from subjects before, during and after chronic administration of either of the two drugs or placebo. Dreams were rated as conceptual or perceptual, and as visually active or passive. They were also rated for hostility, anxiety, sexuality, psychotic thinking, bizarreness and degree of reality. A variety of other measures of content were made, such as the number of characters, activities, social interactions and emotions in each dream report. An experienced, `blind’ judge tried to assign reports according to whether they came from baseline, drug or withdrawal conditions. Subjective estimates of dreaming were also collected.

Contrary to prediction, dreams were virtually indistinguishable under the three conditions. Two effects were that nitrazepam made dreams everydayish and its withdrawal made them bizarre, and withdrawal of amylobarbitone produced exceptionally vivid dreaming and nightmares at home but not in the laboratory. Consideration of the results suggests that these hypnotics affect the quality of thought processes in sleep, and that in clinical use their withdrawal would be expected to produce unpleasant, anxiety-filled dreams and nightmares.

 

The number 1 result is from 1962. Again I hope to read the actual paper but here is the abstract, again rather “of its time”:

Spoken personal names which were randomly presented during the rapid eye movement periods of dreaming were incorporated into the dream events, as manifested by the ability of the experimental subjects and an independent judge subsequently to match correctly the names presented with the associated dreams more often than would be expected by guessing correctly by chance alone. Incorporation of emotional and neutral names into the dream events occurred equally often. The manner in which the names appeared to have been incorporated into the dream events fell into four categories of decreasing frequency: (a) Assonance, (b) Direct, (c) Association, and (d) Representation. Perceptual responses to the stimulus names, as manifested by subsequent dream recall, occurred without any accompanied observable differential electroen-cephalographic or galvanic skin responses compared with those occasions on which no such perceptual responses were evident. The frequency of recall of colour in dreams was higher than has been previously reported.

The results are discussed in relation to the function of dreams and perception during dreaming.

Using the “Newest first” search criteria does throw up more recent results, but in most of the top 10, the word “dreams” is not referring to a subject of clinical or research interest. The number one result is an article in which a psychiatrist discusses ten books that influenced him. The next result uses “dream” in the sense of “hope” or “aspiration”:

 

The National Institute of Mental Health (NIMH), under the leadership of Thomas Insel, powerfully steered national and international researchers, policy makers and research commissioners to buy into a hopeful dream that one day the basic sciences will afford opportunities to prevent and treat mental illness at its root cause

Of the rest of the “Most recent” top ten, we have three poems, one film review, another “Ten Books” feature, one paper whose mention of dreams is in passing as an adverse drug effect, and just two papers which, from my brief reading, dreams seem to feature as a topic of clinical interest. Both are papers in child psychiatry and both deal with dreams in the context of psychotic phenomena:

 

It has been suggested that there may be shared patterns of neuroanatomical, neurochemical and neurophysiological pathways occurring in nightmares and the positive symptoms of psychosis, for example, the finding that cortical dopamine levels are raised during nightmares41 and the functional significance of sleep spindles in psychosis42 that are consistently reduced in schizophrenia.43 Some studies have also reported a continuity between dreams and psychotic experiences; with overlapping content44 and indistinct barriers between these experiences.45 This is related to the increased interest in dreams46 or REM sleep47 as a neurobiological model for schizophrenia or psychotic phenomena.

Here to, we see that interest in dreams is confined to their possible utility as a model for psychosis – an interesting topic, but one from which issues of “meaning” are excluded.One of this paper’s references is worth reviewing – and I find it  interesting that a projective test (the TAT) was used in this study:

Many previous observers have reported some qualitative similarities between the normal mental state of dreaming and the abnormal mental state of psychosis. Recent psychological, tomographic, electrophysiological, and neurochemical data appear to confirm the functional similarities between these 2 states. In this study, the hypothesis of the dreaming brain as a neurobiological model for psychosis was tested by focusing on cognitive bizarreness, a distinctive property of the dreaming mental state defined by discontinuities and incongruities in the dream plot, thoughts, and feelings. Cognitive bizarreness was measured in written reports of dreams and in verbal reports of waking fantasies in 30 schizophrenics and 30 normal controls. Seven pictures of the Thematic Apperception Test (TAT) were administered as a stimulus to elicit waking fantasies, and all participating subjects were asked to record their dreams upon awakening. A total of 420 waking fantasies plus 244 dream reports were collected to quantify the bizarreness features in the dream and waking state of both subject groups.

Two-way analysis of covariance for repeated measures showed that cognitive bizarreness was significantly lower in the TAT stories of normal subjects than in those of schizophrenics and in the dream reports of both groups.

The differences between the 2 groups indicated that, under experimental conditions, the waking cognition of schizophrenic subjects shares a common degree of formal cognitive bizarreness with the dream reports of both normal controls and schizophrenics. Though very preliminary, these results support the hypothesis that the dreaming brain could be a useful experimental model for psychosis.

 

Vampirism as Mental Illness: Myth, Madness and the Loss of Meaning in Psychiatry

This  is certainly the academic paper I have been involved with which has garnered the most media attention. Brendan Kelly and myself intended to write a nuanced paper on how psychiatry conceptualised vampirism, when it occurred as a clinical presentation, and how this changed over time. This reflected wider changes in psychiatry (and probably, though this wasn’t part of the paper, society itself) in that the meaning ascribed to symptoms was increasingly devalued in favour of a “checklisting” approach. Something similar has happened to dreams, in the psychiatric context.

Did we succeed in this? Here is the abstract :

 

Vampirism, as a clinical presentation, was formerly much discussed in psychiatric literature. In recent years this has not been the case. This article begins by exploring the history of vampiric phenomena and the various medical theories of vampirism. It discusses the change in emphasis in psychiatry from a psychotherapeutically-influenced exploration of the meaning of a particular symptom to a more ostensibly evidence-based, checklist approach. This reflects a wider shift in psychiatric culture. Articles from the psychiatric literature dealing with vampirism are reviewed in depth. The article argues that the clinical interpretation of vampirism may be useful as an indicator of shifting attitudes within psychiatric discourse.

And here is how The Sunday Times covered the article:

2016-07-27

Perhaps not that surprisingly, this provoked a backlash from the online vampyre community, none of which seemed based on actually reading our article but on the Sunday Times and Irish Central’s even more misleading take. (most of the links to the vampyre forums where we were attacked seem to have broken.

Brendan has talked further about the paper in various forums such as here , and has discussed this media and online reaction.

I know How Journalism Works. I know that the headline is chosen by a subeditor, not the author of the article. I know that “Doctors write nuanced article on changes in how psychiatrists see vampires over time” is not a headline.

In a way, this coverage illustrates that for the media as well as in day to day a life, a psychiatrist is character with a somewhat predetermined role and that, if a psychiatrist is writing about vampirism, it must be through the prism of mental illness and of treatment. Even in cases where the psychiatrist is trying to do the direct opposite. Alasdair MacIntyre wrote (quoted in the blog post linked immediately above):

Contrast the quite different way in which a certain type of social role may embody beliefs so that the ideas, theories and doctrines expressed in and presupposed by the role may at least on some occasions be quite other than the ideas, theories and doctrines believed by the individual who inhabits the role.