Your Psychiatrist might be wrong


Don’t dismiss modern medicine – educate yourself about it

When you can’t see it or touch it, the probability of misunderstanding it is raised many folds; especially as an external examiner.

During my time as a house officer in the department of psychiatry, I was responsible for the treatment of a 38-year old gentleman who had been admitted for severe depression. Upon learning that this patient had not been performing namaz for several weeks, our senior psychiatrist prescribed the patient a five-times-a-day prayer schedule in addition to the usual treatment plan, and even asked me to make sure he follows it.

If you are a Muslim reader, you may rightly consider this a useful if not absolutely necessary, piece of advice. But consider, for a moment, if a Hindu psychiatrist prescribed you a bhajan – and implied that your health problems are being caused by your lack of devotion to one Hindu deity or another. You would probably be incensed by such a suggestion and wonder why the psychiatrist whom you’ve approached specifically for a prescription in the light of medical science, is offering you spiritual advice instead.

In another office, a psychiatrist is being visited by a patient who meekly confesses to his homosexual orientation and inquires about a cure. Irrespective of your religious or cultural opinion of this matter, you must note that psychiatric medicine has not regarded homosexuality as a disease since 1973. And if it’s not a disease, then it most certainly cannot be ‘cured’. The psychiatrist, instead of delicately conveying this piece of scientific information to the confused patient, makes a series of culturally biased statements aimed at provoking guilt and self-loathing.

The mind sciences – psychology or psychiatry – have always been tricky fields to tread. The human heart works essentially the same way in every human being, with some well-documented anomalies or variations. The mind, on the other hand, is extremely adaptable. Your mind is the product of everything that has happened to it since it first flickered to life, just like everyone else’s. One can imagine our predicament in attempting to devise a universal procedure that fixes a particular ailment, say schizophrenia.

In Pakistan, it is difficult to find a doctor who treats psychiatric illnesses specifically by the textbook. Frankly, there is no fixed ‘textbook’. The Diagnostic and Statistical Manual of Mental Disorders, or DSM for short, provides a list of mental illnesses and the criteria for diagnosing them. It’s comprehensive and has gotten to where it is today after decades of research and correction. But when it comes to management – particularly what we call the ‘psychodynamic’ approach – each clinician’s or therapist’s approach may vary markedly.

When visiting a psychiatrist, your doctor will meticulously collect information regarding the symptoms you or your attendants have reported; and take note of any clinical signs that you haven’t noticed. This is true for all clinicians, in the department of psychiatry or otherwise.

But when psychiatrists discuss a patient among themselves, there is often a preoccupation – an obsession even – with categorisation and labelling. The discussion, at times, never proceeds beyond that. The emphasis is always on the “what’s” and the “why’s” of the matter. “What is this behaviour called?” and “Why is he behaving this way?” The primary objective is to put to label on it, and produce some explanation of why this label is there.

The question of “How do we fix this?” almost seems like a foolish one to ask. Psychiatry barely ‘fixes’ anything. You cannot cut into the human brain with a scalpel and scoop out the bug of depression. You roll the pharmacological dice, and cross your fingers, as mind-drugs are often notorious for hit-or-miss therapeutic responses and troubling side effects.

The aim here is not to peddle anti-science paranoia to the public. The drugs do work, particularly the newer ones, and this is backed by plenty of research. They just don’t work as effectively as most other kinds of medication. If I may digress briefly, I ought to point out that the one treatment in psychiatry that does work quite well is also the one for which psychiatrists have been thoroughly reviled – the “electric shock”. Electro-convulsive therapy (ECT), however, is not what you recall seeing in the film ‘Manto’; it is a minimally painful and entirely non-dramatic medical procedure carried out on a sedated patient, which often yields encouraging results.

The problem with management of mental health problems, ultimately, is that each doctor feels like he’s sailing into uncharted territory when a new patient comes into his office. It doesn’t matter if medical science has studied depression. Medical science has not studied your depression yet, and your mind is unlike the mind of every other test subject that we’ve treated with SSRIs. There are going to be some common features – like tearfulness, fatigue, or poor appetite – but we may never encounter a true ‘textbook’ case of depression through our entire careers.

These huge variations create room for as-you-go experimentation, and the absence of reliable universal protocol allows room for some of the psychiatrist’s own formulations. This, unfortunately, leaves the door wide open for the clinician’s own religious or cultural biases to come into play; and makes your experience with psychiatrist X markedly different from your experience with psychiatrist Y. Both may prescribe the same drugs, because the psycho-pharmacological methods have bestowed some objective structure to psychiatry. But what Dr. X says to you, might be very different from what you hear from Dr. Y.

You have to place a certain amount of faith in the medical expert you’re seeing, because he knows many things that you don’t. And the purpose of this article is certainly not to dissuade those with mental health problems, from seeking expert care.

But at the same time, it is advisable to seek more than one opinion, and possibly do your own research. This is especially true for controversial matters pertaining to gender, sexuality, or other politicised psychosocial issues.

Trust your psychiatrist. But also – buyer beware.