Knots

I’ve been reflecting on times when I’ve felt trapped during conversations with patients and their families.

Times when whatever I seemed to say, I tangled myself further into an endlessly looping web of discursive constriction.

I was reminded of R.D. Laing’s book Knots, which is a gleefully brusque collection of various traps of thinking.

Here are some of my own examples.

This one is from my time on the medical wards:

Patient’s family: “We don’t agree with your diagnosis. Do some more tests”

Me: “Did you have any specific alternative diagnoses or additional tests in mind?”

Patient’s family: “Don’t ask us. You’re the doctor!”

 

If I try to assert my medical opinion I get shot down, but if I try to divest it I get shot down too. An infinite regress of rejection.

A second example, this time from early in my career in psychiatry:

Patient seen in A+E: “Admit me or I’ll kill myself”

Me [after lengthy consultation]: “Ok, let’s admit you”

Patient: “No. I won’t come into hospital”

 

I had no idea what to do. The opening statement felt more like a threat than a presenting symptom. The patient appeared to have turned up in A+E specifically to pose me a choice and then categorically turn both self-imposed options down. It was checkmate, I was lost.

Both examples can be boiled down to “I want you to help, but I won’t let you help”.

So how do we untangle these knots?

As I have now learnt – from insightful senior colleagues and patients themselves – the key to escape is to recognise why you’re stuck. And talk about it.

What lies beneath the tangle? Defense? Confusion? Weaponry?

The first example is a double bind ­­– damned if you do, damned if you don’t. The fix is to either do or don’t but explain why you’re not damned for it. In the example given above, we explained the diagnosis again as a team – giving the option of disagreement but making it clear that we were firm in our convictions.

The second example, as well as being a double bind of sorts, is also a false choice ­– there were other options available, like the patient not being admitted but not killing themselves. Fostering some responsibility in the patient and getting them to work with us, not against us was the key to progress in that situation.

I don’t exactly look forward to more knots, but unbinding myself, or watching others unbind me, is an education.

Categorically Ill: My argument in favour of the diagnosis of mental illnesses

This is the viewpoint I gave at the debate on mental health diagnosis, “Categorically Ill”, at the Science Museum today.

It’s quite strange, quite sad I think, that after decades of anti-stigma campaigns, work by charities like Mind, so many confessions of mental illness and progressive government policies, that some people still doubt mental illness even exists. But I am very proud to defend it tonight. I don’t have the years of research experience that the other speakers have; all I have are years spent with patients and my own time as a patient. I hope that will be enough to convince you that I’m worth listening to tonight. I want to start by defining mental illness. Some people think that only your body can be ill, not your mind. But mind and body are two sides of the same coin- the mind is the product of the brain.

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Mental illnesses are simply illnesses which involve the brain, but show themselves in a form we think of as “the mind”, like distressing thoughts, feelings and behaviours. Some are caused by brain diseases, like dementia. Some are caused by the outside world interacting with an initially fairly healthy brain, like alcohol addiction. Some are a mix of small brain changes and outside stress, like psychotic disorders.

But despite the fact that the brain is always involved in some way, we don’t just send all our patients to neurology – because we know that the mind deserves its own speciality – one that respects psychological and social factors, not just biological. Having this concept of mental illness is helpful for the same reasons having a concept of any kind of illness is helpful. It helps patients discover that they are not alone, that their suffering is not a private, unique torment, but that it has a name, and other people have been through it before. It allows them to learn about their difficulties and help themselves. Using the word illness, not just “problems”, ensures that society treats people with mental illnesses with the respect they deserve; not just lazy, peculiar, and malingering.

Calling someone ill, or giving someone a label, doesn’t removes the unique meaning of their experiences, if you do it in the right way. If any of you have felt dehumanised by receiving a mental health diagnosis, it was the fault of the person who gave it to you, not the fault of the label. I listen to my patients, get to know them as individuals, hear their stories and their opinions on what they think might help  – that’s why I went into psychiatry not neurology – but I also say to them, hey, your symptoms also fall into a group we see quite a lot – and there’s a whole load of research on that.

By recognising that certain symptoms often occur together, like flashbacks, being on edge and feeling numb and by giving this syndrome a name, in this instance PTSD, we can do research into causes, and treatments that might work. Sometimes we even find a cure. We learn from these patterns we see in people – we don’t have to start from square one with everyone that comes through the door.

So mental illness is a useful concept. But is it a valid one – are mental illnesses real? Of course they are. Some mental illness or disorders are quite plainly real. Dementia, addiction, severe autism and learning difficulties are all expressed through the mind, and therefore listed in those evil “psychiatric bibles” – but no one would argue that they didn’t exist.

But as soon as something is found to have a solid cause in the brain, it tends to get called “neurology”, so the heat can be kept focussed on psychiatry, on disorders for which a biological focus is less clear cut.

Some say, well, you’ve had years to find a simple cause or test for these disorders, things like depression, and you haven’t done it. So depression can’t be a real illness! But medicine doesn’t work like that. We don’t suddenly decide that the symptoms don’t add up to an illness just because we haven’t found a cause or a test yet – because the symptoms are still there. We don’t even have a good idea what causes migraines yet, we certainly don’t have a test, but no one will be telling people with headaches that sorry, no clear cause yet and no test, so no illness. So we won’t stop calling things like OCD and bipolar disorder illnesses. Our patients deserve better than that.

A lot of people think that no two psychiatrists will agree on a diagnosis, that there is no reliability, but the reality in very different. Here are some correlation co-efficients – the closer to 1.0 the number is, the more psychiatrists agree on the diagnosis. Anywhere near 0.7 is pretty damn good. Mostly ok.

Autistic Spectrum Disorder 0.69
PTSD 0.67
ADHD 0.61
Bipolar Disorder 0.56
Borderline Personality Disorder 0.54
Schizophrenia 0.46

Surely physical health problems all score 1 though? I’m afraid not. Here are the scores for a few physical conditions.

Atherosclerotic stroke 0.60
Lung cancer under a microscope 0.57
Osteoarthritis on X ray 0.51-0.68
Reflux using endoscopy 0.56
Heart attack using blood test and ECG 0.52
Smaller stroke 0.20

You see, people think that physical health is perfectly scientific, that patients fall into neat, valid little boxes, that there are tests that give yes/no answers for every condition. Anyone who tells you these things has not worked in general medicine. Sure, some patients fall easily into boxes; big heart attacks, massive strokes, overwhelming chest infections…but most patients have a collection of small problems, all in the ill/not ill grey area, which add up. This is why when our elderly relatives are admitted to hospital, the doctors tell us things like “maybe a small stroke” or “a small heart attack but we’ll treat him for an infection just in case”. It’s nonsense to say that big hearts attacks aren’t real because lots of people have small ones…we just have to be wary that illness isn’t a precise concept anywhere in medicine – psychiatry is not alone in this.

Every speciality changes its classification of illnesses every few years, as we learn more about illnesses, but only psychiatry gets abuse for doing so. How high your blood pressure has to be to be high changes every 5 minutes, we used to have bronchitis and emphysema but now we have COPD, the stages and groups of cancers changes every few years. Making categories more accurate is important and I look forward to seeing them improve with time.

Let’s be clear on another thing – psychiatry is not “growing out of control”, “medicalising normal emotions” – you only need to read the headlines about the shameful ways our services are being cut to see that. Mental health is being suffocated, and our patients with it, because it is seen as less deserving because some people are still willing to get up on stage and tell you that they don’t believe mental illness even exists.

Tonight, you have to vote whichever way you believe is best for the people who suffer from mental illness. The choice is your own, but you have to understand what voting against mental illness would mean. It would mean saying to the young woman with a BMI of 12, who thinks she is fat, that she doesn’t have a condition ­– anorexia has a 10% death rate, by the way. It would mean saying to the man who has scrubbed the skin off his hands to try to get rid of intrusive, plaguing thoughts, that he doesn’t have a disorder, just a problem with living. It would mean saying to a man whose muscles are rigid, who hasn’t eaten or drunk in days and who is mentally unconnected with the outside world, who soils himself and would die of dehydration without intensive nursing – a state I might call catatonia – you aren’t ill. It would mean telling Stephen Fry, and other public figures who have revealed their histories, that they might think they have bipolar disorder but actually it doesn’t exist; it would mean looking all your friends and family who’ve had a mental illness in the eye and telling them that their diagnoses were nonsense and they weren’t really ill, they shouldn’t have seen their doctor for that, they shouldn’t have been allowed health insurance or sick leave or medication or treatment for that, that they were just sad, obsessed, stressed or weak.  

One short step away from get over it. I thought we’d moved past all that.

Thank you.

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