The doctor who hears voices again
I wrote a post about this the other day before I’d actually seen it and I’ve watched it now.
For anyone who didn’t see it, ‘The Doctor Who Hears Voices‘ was a film shown during the past few days on Channel 4. It concerns a doctor called ‘Ruth’ – her identity has been changed, but we are told that the documentary is a mix of film of Dr May taken throughout the actual treatment, spliced with reenactments of Dr May’s sessions with ‘Ruth’ with Ruth being played by actress Ruth Wilson. Ruth has no wish to take psychiatric medications and is currently off work with depression; she has a diagnosis of bipolar disorder. She is sure that if she tells her work that she is ‘hearing voices’ then she will be sacked and sectioned.
I thought that I’d start this post by listing the things that I liked about the documentary. So far I’ve only been able to think of one – that it’s good that mental health issues are being given airtime by a major television channel.
There were lots of things I found objectionable about the film.
1. The subject’s suitability was questionable:
Was it really suitable to film a documentary over a seven month period of a vulnerable patient having a mental health crisis? I cannot believe that this helped in her recovery, and I suspect that it simply served to raise Dr May’s profile. Sure, she must have consented before broadcast, but by then the damage could have been done.
2. The film is misleading
Dr May is described as a doctor – whilst this is strictly true, he has a doctorate, most people would interpret this as meaning that he is a medical doctor. He is not, he is a psychologist.
The film implies that people who have voices are always sectioned, this is not the case. The film also gives the impression that were ‘Ruth’ to admit to be suffering auditory hallucinations, then she would be sacked and sectioned on the spot. In fact her dismissal would have to be sanctioned under employment law, and if she were to be sectioned, this would require two independent doctors and an appropriately qualified social worker.
No attempt is made in the film to put the treatment of this patient in context. All that one can legitimately say about this film is that Dr May’s interaction with this patient coincided with partial recovery for this patient during one of her relapses. Many people will leave this film thinking that because of Dr May’s limited ‘success’ that current mental health treatment is all wrong. This cannot be concluded on basis of one case.
3. The film is unrepresentative and unrealistic:
‘Ruth’ is not a particularly representative patient. She is above average intelligence, and I cannot help but notice, is played by a young and beautiful actress. I wonder if this film would have been made if its subject matter was a typical London inner city patient.
Whilst Ruth Wilson played the role believably, her depiction was not challenging to the viewer. The most chaotic thing she does is put her head under a stream and walk out in front of a slow moving lorry. She remains coherent and well turned-out throughout. What if she did other things less palatable to the body beautiful: neglected personal care, started to have sex with (unattractive) strangers or lived in a filthy house? Let’s consider how much publicity a conventional psychiatrist, offering medications to a patient who would go home much better the following week, would muster – not much I expect.
Early on, we are told that Dr May sees Ruth in an unofficial capacity in addition to his NHS work. Even if it worked, about which I remain dubious, there is simply not the capacity within the health service to allow all patients with serious mental health problems this sort of intensive input.
At the end of the film, we are encouraged to think that ‘Ruth’ has managed to return to work successfully, despite continuing to have auditory hallucinations. It is implied that this is because Dr May and ‘Ruth’ manage to pinpoint the identity of the voice which is troubling her; this is over simplistic. We are told nothing of the long term outcome of this case. Remember that both bipolar affective disorder and schizophrenia (the two terms are used interchangeably during the film) are chronic disorders of a relapsing and remitting nature.
4. Dr May is deeply unprofessional:
Dr May shows a total distain for other professionals working in the psychiatric field. Informed by his own experiences, he says that people who work on psychiatric wards consider their patients to be ‘degenerate’. Psychiatric wards are not nice places, but they are staffed in the main by caring people who do an extremely difficult job with very difficult patients. It is insulting to suggest that, to a person, they all consider patients with mental health problems in this way.
Dr May’s relationship with ‘Ruth’ seriously blurs the boundary between patient and professional. Ruth is seen to stay with his family and there is no mention of any other important relationships in Ruth’s life, for instance the support which might be available from parents or friends. Instead, Dr May positions himself as a svengali character and it appears that his professional zeal for alternative psychiatric treatment may be an expression of his own personal distaste for the psychiatric profession with Ruth as a unwitting pawn.
Ruth is an extremely vulnerable patient. The programme takes place over the course of seven months, during which time who, if anyone if managing the risks she poses to herself and others? At one stage Dr May admits that she has been told by the voice that she hears that she should kill her parents. He simply considers this to be ‘useful’. At another Ruth goes missing and Dr May is concerned that she may have committed suicide. When asked about why he is reluctant to talk to camera about this he admits that he is reluctant, in our risk adverse age, to implicate himself on camera, perhaps realising how far out on a limb he has gone. He is also described as using a technique which many psychiatrists think ‘irresponsible and dangerous’. Imagine if your surgeon told you he wanted to try a procedure on you that other surgeons thought ‘irresponsible and dangerous’ – you would not be impressed, and neither should we be.
In discouraging Ruth from seeking any professional advice but his own, Dr May steers her away from evidence based (but I grant, imperfect) methods of treating mental illness, towards his own paradigm. In the film she is portrayed as manic for in excess of six months, and would have been unlikely to have been so were she on appropriate medication. In addition to not seeing a psychiatrist, in isolating her, Ruth would also not be helped by the array of other professionals who work in community mental health. We see her at the end, apparently recovered, but where on earth is her follow-up?
Dr May has a professional case to answer in his attitude to the panel that is to decide whether Ruth is safe to be practicing as a doctor. This panel is not there simply to get in Ruth’s way, but to make sure that vulnerable patients are to be treated safely by competent doctors. Whilst being aware that Ruth has symptoms of serious mental illness, Dr May encourages Ruth to lie to the panel and also coaches her to do so.
This is in direct contradiction to the GMC good practice guidelines which state:
‘If you know that you have, or think that you might have, a serious condition that you could pass on to patients, or if your judgement or performance could be affected by a condition or its treatment, you must consult a suitably qualified colleague. You must ask for and follow their advice about investigations, treatment and changes to your practice that they consider necessary. You must not rely on your own assessment of the risk you pose to patients.’ (my italics)
I don’t doubt that a lot of patients are not keen on taking antipsychotic medications. It’s widely known that people with mental health problems have trouble finding and keeping employment. If Dr May’s work aims to help people with their mental health problems get back into employment and deal more effectively with their illness, they we’re on the same side. And perhaps there’s a four hour version of this film which would clear up all of the above concerns. But this film is unbalanced and unhelpful.
Here’s a guardian review of the TV show and some interesting comments.
Kathryn Flett in the Observer didn’t like it much either
Addendum: Dr May has kindly commented on this piece below. There’s a BMJ review of TDWHV available on his website, which raises some interesting points.
If you enjoyed this post you can buy me a coffee!
April 25th, 2008 at 5:21 pm
I agree with your post
April 28th, 2008 at 9:55 pm
I’m glad I didn’t watch it!
April 29th, 2008 at 7:16 am
The film has recieved strong reactions in both directions. Mind commend it (see their home page http://www.mind.org.uk/); many commentators have said it was powerful and inspirational. Others more attached to a medical view of madness have spent a lot of time and energy criticising it and seeking to dismiss it.
Many people like Ruth from all kinds of backgrounds find it empowering to be given a choice about how to see and approach their mental health problems. This film took a story of empowerment and self determination to a national audience. Most psychiatrists tell people lots of facts that actually have very dubious evidence bases. For example the reliability and validity of psychiatric diagnosis is contested in many academic analyses. The biochemical imbalance explanation also lacks an evidence base. Yet many psychiatrists tell the people they see they have lifelong disorders, (do not talk about recovery) and tell them the cause is a biological imbalance. On my view psychiatry is misleading the people they are supposed to be helping. They are offering one way of seeing distress as if it is the only way.
Ruth did not want to take medication because of the adverse effects. Many clinicians would see this as non-compliance and take actions to change the situation as Trevor Turner outlines in the film. The coercive pressure to take medication is very strong in mental health services. I think a more moral approach is to try to support the person to manage their emotions in the way they want to. And yes that is very difficult when the whole system is set up to administer to suppressing medication. This is what needs to change. Resources need to be spent less on administering medication and more on providing alternatives.
Their are huge repercussions if you report experiences of distress to Occupational health and or the GMC If you need a practical example of this that is not from your own practice look at the Rapid Responses to the Wounded Healers Review by Professor Phil Thomas in the BMJ (you can also read his review at http://www.rufusmay.com). This is why even Trevor Turner former vice chair of the Royal College of Psychiatry in the film, talked about encouraging people to be very careful what they tell their employers.
Why are psychiatrists so reluctant to talk about recovery and look at the social and cultural meanings of people’s experiences of distress. Why are they so keen to focus on the form of people’s distress rather than the content? Why are they so keen on a drug based model that temporarily suppresses emotional difficulties (and in the process creates lots of health problems) rather than holistically working through them? Hopefully we will see increasing debate and discussion about this area of our lives.
You will be able to find out more about such thinking at http://www.rufusmay.com
April 29th, 2008 at 12:54 pm
Thanks for your comment. I actually think that examining the context of someone’s delusion is not a terrible idea, and I can fully appreciate that psychiatric medications are not pleasant to take. However the method of approach in the film in question was very unsafe and, if Ruth is work as a doctor, anyone involved in the case has a duty of care to make sure that patient care is not compromised. I can’t see that this was done.
April 29th, 2008 at 6:02 pm
Thankyou for your reply Can I firstly submit a tidier version of the comment I sent early this morning here it is:The film has received strong reactions in both directions. Mind has commended it saying; “This is an eye-opening documentary that challenges traditional perspectives about the treatment of mental health problems. Rufus’ pioneering approach gets remarkable results and shows that people can recover to lead a full life”; many commentators have said it was powerful and inspirational. Others more attached to a medical view of madness have spent a lot of time and energy criticising it and seeking to dismiss it.
Many people like Ruth from all kinds of backgrounds find it empowering to be given a choice about how to see and approach their mental health problems. This film took a story of empowerment and self-determination to a national audience. Most psychiatrists tell people lots of facts that actually have very dubious evidence bases. For example the reliability and validity of psychiatric diagnosis is contested in many academic analyses. The biochemical imbalance explanation also lacks an evidence base. Yet many psychiatrists tell the people they see they have lifelong disorders, (do not talk about recovery) and tell them the cause is a biological imbalance. On my view psychiatry is misleading the people they are supposed to be helping. They are offering one way of seeing distress as if it is the only way.
Ruth did not want to take medication because of the adverse effects. Many clinicians would see this as non-compliance and take actions to change the situation as Trevor Turner outlines in the film. The coercive pressure to take medication is very strong in mental health services. I think a more moral approach is to try to support the person to manage their emotions in the way they want to. And yes that is very difficult when the whole system is set up to administer mind-suppressing medication. This is what needs to change. Resources need to be spent less on administering medication and more on providing alternatives.
Their are huge repercussions if you report experiences of distress to Occupational health and or the GMC If Frontier Psychiatrist needs a practical example of this that is not from his own practice I would suggest looking at the Rapid Responses to the Wounded Healers Review by Professor Phil Thomas in the BMJ (you can also read his review at http://www.rufusmay.com). This is why even Trevor Turner former vice chair of the Royal College of Psychiatry in the film, talked about encouraging people to be very careful what they tell their employers.
Why are psychiatrists so reluctant to talk about recovery and look at the social and cultural meanings of people’s experiences of distress? Why are they so keen to focus on the form of people’s distress rather than the content? Why are they so keen on a drug based model that temporarily suppresses emotional difficulties (and in the process creates lots of health problems) rather than holistically working through them? Hopefully we will see increasing debate and discussion about this area of our lives.
You will be able to find out more about such thinking at http://www.rufusmay.com
April 29th, 2008 at 6:18 pm
I guess my point is that I think psychiatric intervention has high risks and is often carried out in ways that damage the person psychologically. The work carried out with Ruth was while she was not at work she was on 6 months suspension (as is documented in the film). Her fear that she might lose her carreer, which was ‘her life’ was the major cause of her distress, in my view. She only started to hear a voice after the suspension (I think the film could have been clearer on this). The film shows that I clearly trusted her and never thought she would be a risk to others. Because someone hears a voice saying destructive things does not equate to that person being a risk to others. People can easily resist the promptings of a voice like they can an intrusive thought. Ruth was and is one of the most caring people and competent clinicians I know. You have to be able to separate levels of distress from competency.
Once Ruth had worked through her pain she was ready to go back to work much fitter and stronger than before when she was getting bog-standard psychiatric treatment. I believe psychiatric intervention for Ruth’s voice hearing (and other distressing exsperience) would indirectly have deprived society of an excellent clinician.
April 30th, 2008 at 9:11 am
Unfortunately I’ve a feeling the film falls foul of the reductionism Psychiatry is often misrepresented as doing.
Let me be clear, Psychiatry is not defined as one treatment modality, namely locking people up and forcibley drugging them. Those options are available for particular patients, and I might add particularly disturbed patients.
Yet there are patients for whom discussion and reason are not accessible at particular moments in their condition (illness? - that’s another debate), it’s simply not fair to brand psychiatrists as spotting hallucinations, slapping a big schizophrenia label on you, pumping you full of tranquilising drugs and turning the key. Empathy and communication, and attempting to formulate the problem always come first. It seemed that though Ruth was undoubtably suffering from her symptoms, there did appear to be some level of insight - she was actively seeking help and prepared to engage with the support Rufus offered.
Not everyone does.
But why should that matter - if you don’t want help, why force it?
In my mind there’s two reasons.
If by the nature of an illness/psychotic experience/thinking style - whatever you want to call it, you are prevented from seeking help (eg. delusion that key people, including hospital staff have been replaced by aliens who are out to experiment on anyone who walks through the door) does that person not deserve a chance to be treated? If the delusion tortures them to such a degree that they later kill themselves rather than be subjected to alien domination, should we pat ourselves on the back and say, well at least we respected their autonomy?
And what if they didn’t kill themselves, but decided they could identify the aliens for all to see by carrying a knife, because aliens bleed green not red.
So immediate risks to self and others have to be considered - though, Ruth did seem to have command hallucinations saying destructive things about herself and Rufus, which DOES equate to risk.
In Schizophrenia (I’m not saying that’s what Ruth had - only a clinician meeting her could properly formulate her distress.) there is some evidence shows voices reduce risk of suicide, and that affective (mood) symptoms are the single biggest risk factor, however with homicide, command hallucinations are a different kettle of fish - risky.
Then there’s the second point - very briefly glossed over in one of the Trevor Turner moments. What happens long term?
The advocates of the recovery model like Rufus often make an excellent point about seeing relapses as a moment of adversity in a persons life from which a recovery can be made.
I understand and sympathise with this strategy, to reduce stigma and empower patients. However I do think it’s quite dishonest i that it misses completely the nature of the condition, focussing only on the th here and now of the experience.
Schizophrenia - for one example (whilst I realise the term itself sparks a debate about categorical diagnosis - which clearly has limitations) may relapse and remit, but untreated (by psychotropic medication) does lead to a cognitive deficit, and profound negative symptoms. You only have to read about schizophrenia patients prior to 1953 (invention of Chlorpromazine.) to see what is meant.
So to use a contentious medical model analogy - you can live with diabetes and not take your insulin. You’ll get ill from time to time, go to hospital and get your infections and ketoacidosis managed, but eventually you’ll go blind.
The thing is diabetes doesn’t change your capacity for decision making - you could chose not to medicate, but what if you didn’t believe you had diabetes and would go blind?
What if you don’t believe in mental illness?
Now I’m not saying Ruth should have been detained under the Mental Health Act and forcibley treated (as I’ve mentioned it would take a clinician who met with her to properly formulate her problems and risk.)
By Rufus’ intervention the NHS may have gained an excellent clinician - I really hope he’s right. Maybe Ruth will recover, and never relapse, but maybe things aren’t as simple as the snapshot of her life the film portrayed, and maybe there won’t be a happy ending.
April 30th, 2008 at 1:57 pm
Can I also mention that doctors of any grade or specialty suffering from any mental health difficulties in London can self refer to the MedNet service, which is staffed by 3 Consultant Psychiatrists in Psychotherapy, and maybe a less maverick way of doctors in mental distress seeking help:
Mrs Chris Loizou (Administrator)
MedNet
Tavistock Centre
120 Belsize Lane
London NW3 5BA
Tel : 020 8938 2411
Fax: 020 7447 3745
May 10th, 2008 at 2:06 pm
I watched this with a pretty open mind, having been through the system as a teen right through till I was 30.
I see psychiatry and all areas of mental health as the most individual illness anyone can have. There are no exact right or wrong’s - the medical, social and holistic model all have their benefits and negative’s. We can’t even claim to know how each person will react to any of these models and while many do well with each or combined intervention, there are just as many who remain chronically unwell for the rest of their lives despite everything that has been tried.
Rufus May reminded me of the work of Ron Coleman, Marius Romme, Sandra Escher etc who look at voice hearing and other psychotic phenomena in a different way from the medical model.
I don’t particularly engage with any as having an advantage over the other. I personally have used everything out there, including medication to help myself. ALL have played a part, but I would never try to influence somebody else specifically with those methods that have helped me. The brain is far too complex for that.
Re: employment - with discrimination legislation you cannot be prevented from working. I have now been in employment as a mental health support worker for around 4 years now and have not hidden the fact that I have had mental health issues. My declaration always states “I have suffered from……. but this in no way impairs my ability to do this job effectively”
I disagree with the comment about bipolar and schizophrenia being chronic, remitting etc. There are a minority who are so badly affected that they never live independently, but the majority go on to either recover, or manage their illness very well, working, hobbies etc and have a good quality of life.
Lastly, as far as psych hospitals go, they are always last to have money ploughed into them, under-staffed, full of temporary posts whereby there is no consistency of care and insanely boring and dilapidated. I visit my local one as a worker (visiting clients) and it sends shivers down my spine and is disheartening when so many have to access advocates to address errors, incompetences and lack of care.