The Secret Art of Psychiatry
Mental health is now mentioned on a daily basis — in the press and media, within industry and employers, health and social care, charities, the armed forces, parliament and with reference to schools and parents. Mental health is also promoted by sports, arts, creative industries, cultural and social activities.
There is now so much attention to mental health, to the wider determinants, and to the collective response that we require to combat stigma and support each other, yet psychiatry seems to be less visible. Not only as a speciality branch of medicine, but also as a force in leading the mental health sector in the new proposed reforms and investment in England enshrined in the long term plan and the recommendations from the review of the mental health act (announced in the Queen’s speech on 14th October 2019). Psychiatrists can lead the sector in similar developments in the devolved nations and globally.
It occurs to me that we, as psychiatrists, have not explained well what we do, with our multiple specialities, including, for example, medical psychotherapy or community psychiatry, the two areas of practice that have dominated my work over the last 30 years.
There are so many varieties of psychiatry. They include perinatal psychiatry, child and adolescent, rehabilitation, addictions, intellectual disabilities, eating disorder, liaison and hospital-based psychiatry, older adults, adult psychiatry, the latter including further specialist teams like early intervention, crisis and home treatment teams, and assertive outreach, and inpatient, intensive care, and psychotherapies.
And then, psychiatrists can be consultants, training and non-training grades, affiliates, possibly physician associates in the future, specialising in mental health. There are also clinical academics among us, with various research pathways to become future principal investigators.
The public, and other professionals are rightly and modestly muddled. So, how do we summarise what we do in the clinical space?
What is our clinical task?
The ultimate objective of psychiatry is to promote the health and wellbeing of the population, families, carers, and to improve the care and treatment of people with complex needs around mental illness. All research, clinical activity and professional regulation seeks to deliver these aims.
I recently attended a seminar at the Royal Society of Medicine on professionalism that included a variety of ‘performance’ lessons, from long distance running, martial arts, film and the cultural industries, as well as evidence on what professionalism entails from former Deans and Presidents.
Following this, it occurred to me that psychiatry is in fact like a secret martial art or endurance sport, hidden and kept away from the masses.
It is practised within guidance and professional boundaries that vary from country to country, and that in the UK are largely driven by the Royal College of Psychiatrists’ curricula.
Here is my attempt to condense the components of what all psychiatrists do:
Artists who notice and see and hear
Being human and able to establish good communication and interpersonal relationships that are therapeutic. This applies to the patient, carer, and all team members, and the wider stakeholders. Every conversation embodies key messages about what we do and how we talk and relate.
Listening to deep biographies of patients and families, as if learning from art and so connecting the past with the present and destinies.
Noticing the multiple interlocking influences in a person’s life that are relevant to how they make meaning, and how they experience the world, including illness and misfortune, so as to propose therapeutic options in a way that makes sense and is helpful.
The number of influences is rarely charted, or articulated explicitly in a formal history, or in guidelines and algorithms for care, as the relevance and importance of these varies so much from patient to patient and family to family.
So, the role includes suspending preconceptions and letting the person’s world emerge and surround the psychiatrist, to see the world from the person’s perspective. Some trainings, like in psychotherapy, emphasise this way of being even more, placing importance on noticing and understanding feelings and histories being played out in the present.
Providing evidence-based interventions, weighing up risks and benefits, and sharing these openly with patients and families — which means knowing the evidence and how to appraise it.
This also means knowing how to approach a care opportunity where the evidence is uncertain and to establish a good shared plan for what might help, and empowering patients and families to make decisions of what they would like to try and what they would not.
Advocates seeking fairness and social justice
Being a psychiatrist also means advocating for patient and families and the sector in policy and commissioning, within health and social care systems, and also reaching the wider public and government with anti-stigma and anti-discriminatory perspectives, as well as emphasising the importance of effective mental health care for society.
From this follows the ability to work with people in systems that are and always will be constantly in flux, and, by doing so, providing the best care possible irrespective of the wider systems changes which seek to streamline, improve, ration or rationalise NHS care.
Here is the biggest secret: psychiatrists are systems leaders, and have negotiated complex systems of care from the minute they step into the NHS or wider sector of care.
They are constantly showing system behaviours and leadership to improve the coordination of care and harmony across sectors, placing the person and the family at the heart of their toil.
You may agree or not with my take on this, but I’d welcome discussion and debate.
As a profession, we need to share with the world what we do, and not keep it a secret.
NOTE FROM THE EDITORS: We are so pleased that Professor Kamaldeep Bhui CBE has written a piece for InSPIre the Mind! Professor Bhui has an impressive record of accreditations including being Professor of Cultural Psychiatry & Epidemiology, Consultant Psychiatrist, Psychotherapist, Editor of the British Journal of Psychiatry and a Careif Trustee, to name a few of his current roles.
We would like to say a big thank you to him for writing this very interesting and much needed piece!
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