In a lecture he gave in October 2008 Consultant Psychiatrist Dr Pat Bracken spoke strongly in favour of engagement of psychiatrists with consumers of mental health services. He put it rather strongly actually:
‘If we say that we are working to develop user-centred services, training and research programmes then is it simply unethical to carry on as if the user movement did not exist’.
True to this insight, during my time as a psychiatric trainee I’ve had very little to do with user organisations, and they have therefore had little or no impact on my thinking or clinical practice*. Just like Bracken says, for me they have not existed. I am unable to say if this is the experience of all psychiatric trainees, or whether my training establishment is particularly indifferent, but I fear that I am not a unique case. This must be a regrettable oversight. Any sensible commercial entity (to which health services are becoming increasingly compared) listens to people who take the time to lodge a concern, knowing that if they do not, not only will their disgruntled customer brief others of their dissatisfaction, but also that they will be missing an opportunity to improve. Within psychiatry, patients can make complaints and are sometimes asked to participate, but they act predominantly as advisors and expertise still resides with professionals.
Why, you might say, does this matter, and why should we single psychiatry out on this? Perhaps we should not; I personally have seen from working in other medical specialties that psychiatry’s reluctance to engage with user groups is shared by other branches of medicine where there reside doctors who are very unwilling to engage with patients. Many people return from a stay in a hospital medical or surgical ward with reports of offhand medical staff and have been so uninvolved in their care that they are barely aware of what has happened to them. However, whilst psychiatric disorders resemble those of physical medicine in many ways, their formulation cannot easily be captured with the same lexicon and the interaction between psychiatrists and their patients is different. You can, at least in theory treat, a patient’s coronary arteries without so much as exchanging the time of day with them. A cardiologist who takes into account their patients’ community role and psychological well being may have more satisfied patients, but it is not their primary business. Psychiatry, on the other hand, deals with thoughts, feelings and behaviours and is entirely cited in the social world. Our outcomes are less mechanical and more nuanced than those of other parts of medicine. We have power to define normality, to bestow stigmatizing labels and to take freedoms where we think fit**.
Psychiatric disease is often chronic, so a beneficial relationship between doctors and patients can only be to mutual benefit. The fuller dialogue with patients and with user groups could lead us to devise services that genuinely engage people with mental health problems and inform our theories as to the nature and boundaries of psychiatric illness. Such engagement will lead to responsibilities for our patients too; they, as well as the wider public need to be will to be understanding over the particular areas of difficulty in our practice, such as the use of the mental health act. Recognition will also be needed of the fact that user groups do not speak with one voice and potentially have contradictory messages.
If you have worked with user groups in any capacity, please leave a comment below and tell of your experience.
*Criticism of psychiatry from former users is, of course, not new. In 1620 for instance the House of Lords received the ‘Petition of the Poor Distracted People in the House of Bedlam’ a complaint against the inhumane treatment of the Bedlam Asylum inmates.
** Not that I was there, but this transcript of a 2006 debate organised by the James Naylor Trust gives an idea of how upset some people are with psychiatrists.
Users’ movement and the challenge to psychiatrists – 1998 British Journal of Psychiatry
Addendum 5 July 2009
An interesting new publication by Pat Bracken and Phil Thomas on the user groups subject:
Addendum 8 February 2010
Louise Pembroke has written for Openmind magazine about the relationship between psychiatrists and user groups and this is well worth a read.