Pendientes Críticas

“I also liked the idea of spending more time with the patient….you know listening to the

patient, learning a bit more about their life history...who they were as opposed to just quickly…assessing physical problems and moving them on.” (“Keith”)

It seems that “learning who they were” means a multitude of things depending upon one’s training and ontological view. For some, understanding the patients’ psychosis meant relating to them because the illness was a product of the psyche rather than meaningless symptoms. For others, psychiatry was more attractive than the rest of medicine precisely because it allowed for relationships but they were seen as an extra, not therapeutically purposeful or essential. For these psychiatrists, knowing the person did not change the mainly technological treatment whilst others considered ‘the relationship to be the treatment’. Modelling the taking of risks for therapeutic advancement contrasted with the cloak of detachment and objectivity as essential elements of psychiatry, for the two groups. Some spoke of the sufficiency of simpler models in using pharmacology to bring patients back from psychotic worlds whilst others dwelt upon the necessity of difficult psychological work in relational bridging with the patient. Most of my sample, apart from two, recognised that not all psychiatrists understood or felt able to do such emotional journeying because of the inadequacies of ordinary psychiatric training. Some recognised these shortcomings in training and took steps to develop alternative understandings and abilities, including the need to convince patients to come back into relationships and taking risks. Whilst both groups were aware of the attraction of relationships in their practice, their understanding of its role in treatment was vastly different.

“That’s the main part in therapy that…you take certain risks and the patient has to take a

risk and that is a kind of joint adventure...that can lead to betterment, to healing and lovely experiences on both sides.” (“Hans”)

Getting closer to patients and their way of being in the world, in order to help them learn and experience more of life seemed to be the purpose of treatment for some. For others, the emotional connection and depths of psychosis remained of interest but unconnected to treatment and evoked some resistance. Some recognised that making oneself vulnerable in this way can lead to “worries about your own grip on reality slipping” but were confident of their ability to manage the risk whilst others spoke of their “need to detach from the process in myself and the patients to survive”. Such personal factors obviously affected psychiatrists’ ability and readiness to empathise with their patients, some seeing those as essential whilst others made

the same aspects incidental to the treatment. As I found earlier, some were more able than others to empathise directly with the patients.

“How do you understand the emotional depths that people get to? Literature helps so...it

sounds pretentious but in thinking about the internal lives of patients, I think about a character in a Sartre novel, someone who put a knife through their own hand to c o n v e y despair.” (“Doug”)

Risking one’s own grip on reality in order to help patients regain it feels like a radically different practice of medicine from relating to patients through a fictional character. Some seem prepared to risk their own sanity whilst others put limits on their empathy for fears of being profoundly affected. Personal awareness and philosophy of life, conscious or otherwise, seems to affect the approach psychiatrists take to their work. If one’s personal philosophy is of self-contained beings where connections with others pose risks to one’s essence, then psychiatrists focus upon diagnosis and explanation. The psychiatrist who spoke of the Sartre character, acknowledged his clinical emphasis was upon ‘doing to’ not ‘being with’. For him, understanding the patient was useful but not essential to fixing them which was his raison d’etre. For psychiatrists such as this, steeped in positivism, human process is mechanical and fixable, not about the power of fellowship or accepting limitations to the work. For others, the practice of psychiatry is intimately connected and predicated upon one’s way of being in the world and needs to build upon the initial training received. The personal becomes professional as one’s way of understanding oneself, life and others affects one’s practice of psychiatry.

“If you come in…(to psychiatry)…wanting to distance rather than relating...then...you

isolate & are isolated….due to personal & social processes and….for reasons of defence of your personality” (“Don”)

Psychiatrists may be coming into the profession for different reasons, to distance or use professional power to explain life whilst others want to relate and identify. There was a recognition that distancing from the emotional and psychological process is easier through the mainstream biological understanding of psychosis. The mainstream focus on technological

solutions to apparently structural issues and bias against relating wins out because the requisite emotional involvement is difficult. Some knew that bringing patients back into consensual reality cannot be done without developing therapeutic relationships and using them as instruments of psychic surgery.

“A bit of me thinks our operating theatre or where we do what we do is when we are in

conversation with our patients...sometimes that is seen as oh, you are only talking...or you are doing something quite passive or you are just assessing but to me what you are actually doing there is….the real work” (“Dale”)

It has to be noted however that moves towards dialogue are fraught, so only “a bit” of this psychiatrist with decades of experience acknowledged the pull. One’s place within the profession as well as links with other psychiatrists are put at risk through listening to that part and focussing upon relationships with patients. Some psychiatrists made the hard choice of challenging traditional practice and gained personally and professionally by making the decision that relating with patients was the real work. Some referred to the satisfaction derived from their movement into liminal spaces, towards relational treatment from a predominantly biomedical view. One described her experience of greater personal efficacy and fulfillment because her newly acquired capacity to relate combined with her medical knowledge and helped her feel more integrated as a professional. She gained new meaning and fulfillment from her work through her training within a psychotherapy team, something she had never experienced before. Her account suggested that her training to date had related to the patients’ brains, with their context or her own self not playing a part in the work.

“now I feel that I can use myself as a healing agent because I didn’t appreciate that just

you being there as a person listening…can make a lot of difference to them...It was always like, oh we have to put something in place…we have to refer to the crisis team…or he will have to come into hospital or must have diazepam or lorazepam.” (“Gita”)

Medical training seems to leave doctors dependent upon technology or a combination of technological and institutional interventions in the form of drugs or hospital wards. The idea of

countering the powerful effects of a neurochemical or structural fault, purely through relationship with patients had not existed in their training. Upon encountering alternative ideas, some were positively predisposed to overcoming any personal or professional resistance against emotional engagement. Others seemed to experience enormous barriers. It is impossible to comment upon the nuances of psychiatrists’ relationships to bodies, brains and dependence upon personal factors through my limited research. It is obvious however that personal factors play a crucial role in the ability to pay the necessary attention to subjectivities and relationships. Whilst some are able to use their self and surmount personal defences against exposure and vulnerability, others resist exploring their own subjectivity and those of their patients and remain within the scientific paradigm.