Wednesday, January 11, 2012

Our Guest Blogger Writes About Psychiatrists, Are They Devil Incarnate?

We just listened to our entire interview with Last Podcaster Standing (links here and we definitely don't feel like writing, (we feel like there was so much more we could have clearer about in the interview, also...a whole lot of other issues [with each other]) so it's a good thing we have a piece from Kerry in our inbox.

Kerry Stott is our guest blogger, a mental health nurse, writer, and friend. (if you don't follow her on Twitter you should give her a chance). Today she's writing about psychiatrists. We've had plenty of dealing with them, some liked to prescribe medications and use us as a guinea pig (severe depression, social anxiety and bipolar disorder diagnoses make one a great testing bed for medication blending), others psychiatrists we remember...but we don't. The psychiatrist who gave us the schizophrenia diagnoses, years after the initial diagnoses, while wrong, was the best therapist we ever had. Even though we stopped seeing her for a couple of months before our car accident, she made a house visit to make sure we were okay.

So, just like real people (as Kerry says), some are the devil, and some are an angel.
Are Psychiatrists the Devil Incarnate?

I hear lots of people talking about psychiatrists, hardly surprising given my job.  Some say that they are wonderful people; others hate them with a passion that you can only dream of.  Which one is the truth? Is there one definitive truth?

Like a lot of people when I was little I was told that ‘doctor knows best’ and I wasn’t to question anything a doctor said.  Because I was told that by my parent’s I didn’t question it.  As I grew older and became a surly teenager, I felt that every time I went to see the doctor, that I wasn’t being listened to and that they didn’t understand me.  Now I am an adult I am aware that some doctors worked better with me than others.

Now, as mental health nurse I come into contact with more doctors than most of the average population, or at least I should hope that I do.  I get to see behind the scenes.  I am aware that my North American [Twitter] followers could easily poke holes in this blog as I only know about UK doctors, never having been to that fine continent.  So this is like a sneaky behind the scenes peek at the UK system and UK psychiatrists.

Psychiatry is a branch of being a medical doctor. I know that this sounds obvious but what this means is that they have to go to medical school and then specialise in psychiatry, in just the same way as you would to become surgeon, or an oncologist, or a GP.  They must have this training as a grounding in wider medicine and medical practice.  Therefore psychiatrists can, although I wouldn’t recommend it, work in Accident and Emergency.  Medical students spend 5 years training at medical school.  Generally by 3rd or 4th year they are allowed somewhere near patients in the hope that they won’t kill them but they can’t call themselves doctors until that have qualified after 5 years.  Then they become Foundation level 1 doctors.  This means that they are officially everyone’s dog’s body, even student nurses can boss them about!  At this stage in their training, it is my experience that they are allowed to take patient histories with some degree of competence but that’s about all.  They then, to hand around in gangs for safety, with pocket medical dictionaries squirreled somewhere about their persons; for fear of being questioned by consultants.  During this part of their training they are moved from clinical area to clinical area to expand their range of knowledge and experience.  This is extended on in level 2 a year later, then they can boss about level 1 doctors but no one else.

The next stage is where they can specialise in a clinical area, if they know what they want to do, or carry on training. 

So now our not so wet behind the ears doctor gets to spend 6 months at a time in different clinical areas of mental health and there are many areas! CAMHS (child and adolescent mental health services), adult (18-65) affective disorders (mood disorders), adult psychosis, early intervention, assertive outreach.  The list goes on and on.  Each specialist area contains it’s own standard type of medication and how that medication is used.  The only way for anyone to be able to understand how these medications are used is by doing it in real life.  Learning from books if ok but it just does not compare to having a patient in front of you.  Nothing makes you remember to be on your toes more than a patient who is shouting in your face.  You never forget your first mistake and you certainly never forget your first death.  There is no better learning environment than real life, but they are still supervised by a consultant psychiatrist throughout all of this training.  However, in addition to all of this new training, hands on experience, and learning; they still need to take exams at the same time.  This means working full time and studying between shifts, at evenings and weekends.  It is a lifestyle choice.  I know this because they get paid less than me, after training for 7 years.  The will eventually get paid a lot more than me but it does seem an awful lot of hard work just to get to there.

After a period of time, they can step off the training treadmill and become a staff grade psychiatrist.  This means a pay rise but it also means that they cannot progress any further.  Of course, progression to consultant level is not always what is wanted and all of the consultants that I know work so hard.  I have not seen another profession like it.  On the other hand, perhaps I only hang out with ‘nice’ consultant psychiatrists.

Apart from the hours that they work, they have a lot of responsibility.  Medication is not given out willy nilly.  All medications have desired effects and non desired effects (side effects).  Each person is different and reacts differently to different drugs.  Therefore, if a person is only on one drug, there is a range in which we could expect that drug to work, a bit like a (very well) educated guess.  If a person needs to see a psychiatrist, the likelihood is that they will be in need of more than one type of medication.  More medication, the greater risk of side effects, and the more uncharted the territory it is for the individual.  It is not dissimilar to making a cake; the right ingredients, it tastes lovely; too much cinnamon and it is a bit wrong; too much butter and it’s stodgy.  There must be a balance and that, I’m afraid, comes with practice.  In a future blog post I will write about medication in more detail.

So what else do psychiatrists do?

They diagnose.  It sounds so simple, just telling people what is wrong with them but it can have a devastating effect on their lives.  I met someone today who has recently had a diagnosis of borderline personality disorder and because it was not handled well, they are very angry, fuming.  Sometimes a diagnosis is what a person wants, it is something to hang their hat on, a place to start, or a name to their symptoms.  Some people don’t want that at all, they want to be well and having someone say that they are ill can be shattering or even destructive to them in many different ways. Such serious diagnosis need to be made with care, and in my experience doctors generally do make them with care.  It is others who are not trained in making diagnosis who jump the gun, I include mental health nurses in that too.  I have recently had some extra training around making a diagnosis for people with personality disorder, and it made me feel very nervous about labelling anyone and more respectful for the job that psychiatrists do.  A useful insight I think.

Keeping someone in hospital is usually the decision of the doctor.  Admitting someone to a psychiatric hospital need not be, it is the domain of the crisis team who gate keep admissions.  However, keeping them there when they want to leave, also known as detaining them under the Mental Health Act, has to be done my a psychiatrist, a general practitioner and an approved mental health professional (usually a social worker).  Once someone is detained (sectioned) they can forcibly be kept on the ward.  It is not a nice thing to happen but people are only detained if their life is at risk, there is no other reason to do it.  This role of judge and jailer is not one that sits well with everyone.  Some people think that psychiatrists should not have this power, others are very grateful that they do.  There is no pleasing everyone so it comes down to ethical principles of ‘for the greater good’, to ensure that the majority of people are kept safe.  Sometimes that means going expressly against the will of the individual.  This deprivation of liberty is covered by several acts of law, of which I will not go into detail in this post, and decisions made can be challenged.  In fact, any psychiatrist worth their salt will recommend that their decision be challenged.  The reason for this is that it ensures that these legal decisions to detain are challenged by an independent body.  It means that the law is applied in a fair and consistent manner.

All of this requires a certain application of mind, over and above the norm.  To be fair the majority of doctors who are attracted to psychiatry tend to be the ones with better interpersonal skills.  I can hear some people spitting at that comment so let me qualify it.  Since the amount of study required to just become a doctor is immense, let alone the extra work needed to become a psychiatrist, it is unsurprising that sometimes their ‘people’ skills can be wanting somewhat.  It is not unlike gaming fanatics (I would say freaks but I have a few of them following me on twitter).  They are so obsessional about gaming to the extent that they cannot communicate well with people outside that sphere and they become what I affectionately call cellar dwellers.  I put doctors in the same category.

So after all that geeking and grafting, what are they really like?  I recall a consultant psychiatrist from when I was a first year nursing student.  She was tall and cold and scared the shit out of me!  After I finished that placement I was speaking to a lecturer about her.  It was then that I was informed that that particular consultant was afraid of students and would withdraw into herself when confronted with them.  It occurred to me then that possibly they were human and not the gods that we/society/the system has lead me to believe.  The more contact I have with psychiatrists, the more I realise that they are earning money to pay the bills.  That they have families whom they love, and who worry about them.  That they get embarrassed and confused and make mistakes like just the rest of us. 

Due to this familiarity I treat them like regular people, this generally means me taking the piss out of them on a regular basis but I am aware that people who come into contact with them may not feel so confident.  I would always advice people to take someone that they know and trust in with them to a consultation with a psychiatrist if they are feeling nervous.  I would also advise them to write down questions before they go and ask at the meeting.  That way when you feel that the pressure is on then you will be able to remember what it was you wanted to ask.  I have not come into contact with any psychiatrist who disagrees with writing down questions or having an advocate in supporting the patient.

To conclude, do I think that psychiatrist are the devil incarnate?  I think that they have a lot of power, and a lot of responsibility.  Some of them manage to balance this better than the others and they tend to have better working relationships with their patients than the others do.  Ultimately they are human, so I treat them as such and would advise you to do the same.  If you don’t like one, ask for a change of doctor.  If you do like one, then tell them.  They are definitely no more the devil incarnate than I am…but perhaps this is not the best comparison to make.
 Kerry x

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