The effect of history in UK psychiatry

by TheEditor

Categories: Medicine, Mental Health

I feel a sense of despair as I observe many younger doctors rushing headlong into UK psychiatry, and I wonder, “Do they know what they’re in for?” But then I have to remind myself that for a sizeable proportion, this is driven by forced choices based on economic survival.

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Recruitment

About 10 years ago I was persona non-grata in a debate about the RCPsych’s revamped at the time, recruitment drive. I lost – as is usually the case because the majority were brainwashed to their perspectives, unknowingly to themselves. In essence the College had the usual bumf about how great it is – yuh know ‘thuh challenge’ and ‘rewards’ of becoming a consultant psychiatrist. There were lovely photos and video about it. My argument was that they did not put up the true picture of what ‘the challenges’ were. I had suggested that anyone even vaguely considering entering psychiatry be offered to shadow a consultant psychiatrist for full working days over 4 weeks (for everything except time in the toilet). Well, you could imagine how a ton of bricks landed on that one – mercilessly crushed I was. How dare I suggest that full reality be presented?

The point is that med students and young doctors (back then and today) float in and out of their brief stints. They may see a few ‘challenges’ but they do not get the full monty. Many are left, “Yes – I wanna do that.” or others “No way – not for me.” But our masters only need a small percentage to jump on the treadmill, and they’re trapped.

Well hang on a sec, if you’re on a recruitment drive – do you really want to present the worst sides of a profession squarely alongside the best parts. If you think so, then you’re a fair and reasonable person but not everybody in recruitment circles is like you.

History forgotten

History is a thing that is naturally forgotten with each passing generation, but history remains to shape the future. – I can just hear some (in my imagination) thinking, ‘What are you on about, now?’

How many are around today, to recall Paul Boeteng (around 1998) video streaming in (state-of-the-art stuff at the time) from the Home Office to a packed audience of psychiatrists somewhere down in Cardiff. With arms akimbo and pointing fingers at a crowd of psychiatrists, they were told words to the effect ‘get on board – get on the field – or we go our own way‘. [I was there, so I know what I saw and heard].

And you may be thinking that I’m ‘sexing this up’. Well, also in history forgotten – was the Michael Stone homicide (1996) – when psychiatrists were squarely blamed about two years before Boeteng. Jack Straw, the Home Secretary at the time of the Michael Stone case, was highly critical of psychiatrists and their approach to managing dangerous offenders with personality disorders. Here’s a summary of his key criticisms:

  • Straw believed that psychiatrists had adopted a narrow interpretation of the Mental Health Act 1983, refusing to detain individuals labelled as “untreatable,” even if they were considered dangerous. He implied they should take a more practical approach in assessing the risk to the public rather than being bound by strict definitions of treatability.
  • Straw felt that some psychiatrists’ hesitation to detain high-risk offenders prioritised medical definitions over protecting the public. He stated, “…it’s time, frankly, that the psychiatric profession seriously examined their own practices and tried to modernise them in a way that they have so far failed to do.
  • Straw suggested that there was a disconnect between the priorities of psychiatrists and public expectations of managing dangerous individuals. He felt that a lack of willingness to detain potentially dangerous people demonstrated a failure to understand the fear and concerns of the public.

Central to the dispute was the RCPsych’s alleged narrow definition of “treatability” within the Mental Health Act (as it was at the time). The College argued that psychiatric illness needed to be amenable to treatment for someone to be legally detained, excluding some patients with personality disorders who would not necessarily respond to available interventions. That was actually the law, but Straw disagreed, believing this approach put the public at unnecessary risk.

This discord became quite public, with Straw accusing the RCPsych of being part of the problem instead of part of the solution. In turn, the RCPsych, under then-president Professor Robert Kendell [a man of moral and ethical backbone], strongly rebuked Straw’s accusations. The College rightly asserted their stance was driven by legal and ethical obligations, not negligence regarding public safety. It was the whole truth because it was written in law available to everybody.

Consequences:

  1. Strained relationship: The confrontation severely damaged the relationship between the Home Office and the RCPsych for a period.
  2. Increased scrutiny: Straw’s criticism contributed to heightening public scrutiny of psychiatric professionals and mental health management in cases of serious violence.
  3. Policy changes: The conflict eventually played a role in policy shifts favouring broader interpretations of “treatability” within the Mental Health Act, increasing psychiatrists’ powers to detain high-risk patients with personality disorders.

In the fallout, Stone’s consultant psychiatrist, the late Dr Philip Sugarman, was pilloried in the media. He successfully sued for defamation. Snippets remaining in history state to substantiate the issue, “Stone had asked to be admitted to the unit, but was refused a bed. We now understand, and accept, that both statements were incorrect. In fact. Stone did not even see Dr Sugarman at that particular time. We apologise unreservedly to Dr Sugarman for any implication that he had failed” [Not to point to any particular organisation]. I was trained under Dr Sugarman. He was one of the last greats – a man of immense intelligence and moral fibre.

Relevance

If you got here – you’ll be forgiven for wondering, “What’s this long lah dee dah story got to do with anything 25 years later?” – especially if you were not part of an unfolding history over the last 25 years.

You will have missed

  1. how noticeable it was at each 5-year interval, psychiatry had become more and more dumbed down, flooded with quasi-experts, and ‘therapists’.
  2. the meteoric rise of psychology with an obsession in the last 5 years for formulations based on trauma. [Caution: I do not imply that trauma is irrelevant]
  3. how the law dripping into policy changes slowly to emasculate psychiatrists.
  4. how almost ‘anybody’ can now take the consultant role – of course it is not called that anymore – as it has been redefined by law.

Focus

Yes – one tragic situation in history with a ‘PD’ patient, significantly change the way government and services would view psychiatrists and psychiatry. Of course, you’d find that written on a placard somewhere. It is called politics – or politricks if you prefer.

Today in my bias – by experience and perceptions of working in all the wrong places – I observe that consultant psychiatrists are put in clinical leadership positions in teams but:

  1. Have no real control over the performance of those teams or individual members.
  2. Have become largely paper pushers – correspondence is desirably a 30-second read, lacking depth, and there are tons of those to generate, so don’t get excited.
  3. Have become largely prescription rewriters.
  4. Are overwhelmed to the eyeballs with work, and responsibilities outside of their locus of control.
  5. Will risk creating a rod for their own backs if they hold anyone to account.

In the last 30 years, I have seen and heard of:

  1. Several of my colleagues succumb to mental health, and terminal physical health problems, at an earlier than expected age.
  2. Many colleagues suffering demoralisation and burnout.
  3. Too many toeing the line and not speaking up for the ethics of the profession. [You wouldn’t speak up when you see so many whistleblowers being hung out to dry, in what the BMA once referred to as a “Stalinist culture” (check it – it is on the net)].
  4. Increasing callous and insensitive behaviours.
  5. More misdiagnoses and inappropriate treatments, the scale of which is missed by regulatory bodies.

I’ll stop there abruptly else risk throwing in another 2000 words easily.

Wrapping up

Some will be asking me or thinking, “So is your mission to discourage people from becoming psychiatrists?” Totally not! My mission in this post is to provide, in limited time and space, a historical context of a key set of events which I think has led to psychiatry being shaped the wrong way over the last 25 years. I expect to fail.

I encourage trainees and med students to join psychiatry with the fullest understanding of what the job of a consultant involves and an appreciation of how historical context has unfolded to this day. I say – weigh up the pros and cons with real knowledge – and then decide about a career path for the next 20-30 years.


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