Open letter to Scottish Psychiatry 

20-11-17

Whither Scottish  Psychiatry? 

 

 

Summary

Medical science is not a static entity, and if we want psychiatry in Scotland to be dynamic and forward looking, and crucially, perceived as such by those who are considering joining our ranks, we must be willing to engage with what might lie beyond the limits of our current understanding, and become more open and transparent in examining our assumptions and the grounds of our opinions. The question asked is whether we can engage with our colleagues and with what is not yet understood in a spirit of openness and true dialogue, with the assumption being that development and progress in our discipline will depend closely on these crucial variables.

 

 

 

 

 

Dear Colleagues,

 

I am writing this open letter to my Scottish psychiatrist colleagues to share some real concerns about our specialty which are not only my own, and in raising the question Whither Psychiatry? I am focusing here on the quality of dialogue and debate in contemporary psychiatry, and on the question of whether we can engage with ideas and experience which might lie beyond what we currently know in a spirit of openness and dialogue?  

 

For whether we like it or not, disagreement is, and always has been, at the very heart of the enterprise of science.  And the prospective health and development of our own discipline will depend in large measure on how we negotiate such perennial disagreement, which will have as much to do with the subjective, as with the more objective variables which relate to our understanding about how things are, and how they should be.

 

 

 

The neurophysiologist John Eccles, like Karl Popper later knighted, and becoming himself a Nobel Laureate in physiology, was originally a  “jumper”, believing that transmission across the neuromuscular junction was electrical, rather than chemical, and he was closely involved in research focused on substantiating this hypothesis.  Of course it was the “soupers“ in the other camp who won the day.  An epiphanous conversation during the Second World War in the university common room in New Zealand with Karl Popper radically changed his life, as Popper  helped Eccles understand that the focus and intent of his research should be on discovering what is true, rather than defending a particular theoretical position, and one could say that in this way he learned and committed to being truly open to, and so in a sense able to dialogue with, what might lie beyond his own understanding.  Such an attitude is intrinsically integrative, understanding integration as a continuous dialectical process of openness to what might lie beyond our own (necessarily partial) views at a particular time.  

 

Thomas Kuhn, the author of The Structure of Scientific Revolutions (and who brought the word “paradigm” into the vernacular), points to another essential tension of attitudes by juxtaposing what he calls “normal science”,  where we use a body of established fact to do a particular job, with “creative science”.  The essential tension arises here because “creative science”, outward looking in the sense of being open to engaging with what might lie beyond our current understanding or paradigm, doesn’t necessarily help us in our pursuit of a rigorous and efficient “normal science”, and at times might actually be experienced as interfering with that activity.

 

Many of my colleagues feel that a real and pressing question now facing us in psychiatry is not whether such “essential tensions” characterise our day to day struggle to make sense of what we engage with as psychiatrists - because they do! - but rather, firstly, whether we are fully aware of such tensions, and secondly, whether we are willing to engage with such tensions or conflicts in a manner which is open and transparent, and based on a willingness to engage in real dialogue with others and examine the grounds of our own opinions and allegiances.   Socrates called this attitude dialectical, διαλεκτική, referring to debate or discourse where there may be different points of view about an issue, but characterised also by a willingness to pursue the truth through reasoned argument;  and thinking about psychiatry, this might mean committing to a radically phenomenological attitude, aware as we do of how easily our Procrustean impulses can distort our perception and thinking.  Such a dialectical attitude can lead to what Socrates called, metanoia, μετάνοια, or a “new mind”, a position new to both parties, betokening movement and growth, rather than stasis and stagnation.  (As an interesting historical aside, the concept of repentance in the Greek New Testament is rendered with this same word, pointing to a noia, or mind, or understanding, which is meta-, beyond, where we started).  

 

Discussing this recently with an experienced consultant psychiatrist colleague, who with respect to fundamental questions of aetiology, phenomenology/nosology and treatment is actually very deeply and openly engaged in such an examination, she allowed herself an ironic sigh as she conceded that a large part of her just wants to get through the week, deal with her increasingly heavy caseload, and reach another Friday afternoon without having to engage with first principles and examine and perhaps challenge assumptions long cherished.  Not her questions, these, but any of us might ask: where do I find the energy to do that, and what might the implications of a shift in my viewpoint be in terms of treatment and teaching? 

 

And so we should recognise and understand why the following remarks about schizophrenia, for example, might elicit a variety of reactions even within one individual.  Sir Robin Murray speculates :  “I expect to see the end of the concept of schizophrenia soon … the syndrome is already beginning to break down, for example, into those cases caused by copy number [genetic] variations, drug abuse, social adversity, etc. Presumably this process will accelerate, and the term schizophrenia will be confined to history, like “dropsy””.   And Jim van Os, a professor of psychiatry in Holland, proposes that the term schizophrenia “should be abolished”, being replaced by the concept of a “psychosis spectrum disorder”. 

 

It’s understandable that many of us, or maybe better said many parts of all of us, hanker after relatively less of of the uncertainty of creative science, and relatively more of Kuhnian “normal science”, with its greater certainty and its fixed and familiar co-ordinates which allow us to know where we stand, and to stand on what we know.  At the same time, and using the words of the cognitive/relational challenge with which I confront my patients regularly, unless we can reflect or STEP BACK and LOOK at what’s going on, REFLECT on what we’re doing and on how certain familiar patterns of thinking, feeling, behaviour and perception can and do drive us reflexively, we will often simply remain in the same place, driven and dominated and limited by those same patterns of response, or perhaps better said, of re-action.  And of course it’s often very difficult to STEP BACK, and there may be many reasons why we are rather less able, or willing, to do so and to LOOK.  As Burns implores, 

“O wad some Pow'r the giftie gie us,
To see oursels as ithers see us!
It wad frae mony a blunder free us...”

 

For example, are we willing to ask, because such questions are being asked anyway, whether in psychiatry we accord adequate aetiological weight to adverse experience? Do we reliably ask the right questions here? What might “trauma informed care“ mean and indeed look like, and are our criminal justice social work colleagues stealing a march as they roll out a 2 day training of “trauma informed care” for every criminal justice social worker in Scotland? In terms of phenomenology, how willing are we to acknowledge, let alone think about and contribute to the process of, the shifting nosological landscape adumbrated by Robin Murray above in his comments about schizophrenia, and suggested by the prospective introduction of the diagnosis of complex PTSD in ICD 11? And if it is indeed the case, as an excellent and seasoned CPN colleague averred the other day, that “the bread and butter of psychiatry is emotional dysregulation“, does our generally poor understanding of the somatic manifestations of such emotional dysregulation sometimes lead to overdiagnosis of Bipolar Affective Disorder in such cases (because we don’t adequately understand and recognise the polarity of the neurophysiology of the hyper- and the hypo-arousal responses to traumatic experience held in implicit memory, as they are triggered and so replay again and again many years later....)? And further, when considering emotional dysregulation, how adequately do we understand and ask about the protean, and not uncommon (unless we don’t ask about them!) manifestations of dissociation?

 

And less theoretically, where might such questions lead us in terms of thinking about treatment, where these considerations become very practical and can really impact on outcomes?

 

For example, a currently prominent question in the psychotherapy world in Scotland, referring to the so-called Matrix, is whether we are happy with the way in which the shibboleth of the “evidence base” is often easily invoked without considering carefully, or indeed at all, whether the patient group to which that evidence base refers is the same as the patient group one is discussing, which would be inadmissible in other areas of medicine?  And is there not anyway also a danger that an over-rigid adherence to the dictates of such a document, and particularly when characterised by considerable confusion around the crucial issue of patient groups alluded to above, can sometimes stifle development and debate around vital questions of principle?  Alongside consideration of evidence for what works, should we not also talk about the principles of what approaches seem to be effective?

 

As the “Cinderella“ specialty of medicine, we could indeed languish among the cinders for many years, and Nick Clegg’s contention that Psychiatry “is in the Dark Ages“ is perhaps echoed by the NIMH’s dismissal in 2013 of DSM-V as “not fit for purpose”, and their withdrawing of funding for research focused on DSM-V diagnoses.  At the same time, many of us feel that the destiny of psychiatry is not to remain below stairs, and the shifting of the NIMH research focus to “bio-markers” may well be an important turning point in allowing psychiatry to take her place at the ball and lead the way in the development of a truly integrative medicine of the future, a medicine based on a solid and integrative understanding of both mind and body; the integrative intent denoted by a term like Daniel Siegel’s Interpersonal Neurobiology suggests that psychiatry could indeed lead the way here. Because general medicine would certainly benefit from a better understanding of the mind in day-to-day practice, and of the effect of our feeling life in the body, following more closely what happens downstream as our emotions manifest through the endocrine and autonomic nervous systems and beyond. And psychiatry would likewise do well to take more account of what happens in the body, particularly when considering the effects of psychological trauma...

 

I applaud the recent November 2017 editorial in the British Journal of Psychiatry on the challenge of recruitment in psychiatry, and on the need to “rebrand” psychiatry, and I concur with the authors’ sentiment that “we need to be clear that we are interested in the small number of doctors who can embrace the fields of science and the arts and also be confident enough to handle uncertainty and ambiguity“.  As well as recognising the importance of rebranding psychiatry, however, I think that many of us believe that there needs to be some refashioning of attitudes in contemporary psychiatry before we could assert with conviction that psychiatry is indeed “confident enough to handle uncertainty and ambiguity“.  And if “we need the most special of them to come into our profession so that we can help develop them into a rare and exciting breed of doctor“ who might “possess the mental agility to jump from biological to psychological to social paradigms within a single consultation…“, do we not also have to ensure that psychiatry itself can live up to this ideal?  While I wholeheartedly support the view that, “we need to inject confidence about what psychiatry is and does in everything we do“, and do this myself with unbridled enthusiasm, a complementary imperative must surely be to ensure that our discipline, whether rebranded or not, is truly worthy of that confidence. I sincerely hope that it will be, and that we will be able in the future to attract the open and eager young minds who assailed me with an hour’s worth of wonderfully stimulating questions at a recent GUPIG (Glasgow University Psychiatry Interest Group) talk, many of them engaging impressively with the awkward nitty-gritty of first principles.  They are our future, or they could be if they look out and are met by a psychiatry in Scotland itself palpably “confident enough to handle uncertainty and ambiguity“, and which they perceive to be forward-looking, open and genuinely integrative in outlook. Karl Popper was aware that progress in science arises from a clash of opinions, but only if such robust debate and dialogue occurs within what he described as an Open Society.

 

I’m not sure we are quite there yet.  We could be, and we should be, but I do think there is a way to go.