Complexity-oriented psychiatrists amongst my participants bemoaned reductionism in psychiatric rationales leaving psychosis entirely lacking in meaning and entirely explainable and treatable by pharmacological models. They pointed to “stuff like extreme family backgrounds like a very violent father gets downplayed and things like genetics get emphasised”. They focussed upon the contribution of the embodied relational, social and cultural and mythological natures of the human mind to psychic life. Such psychiatrists drew attention to the lack of focus upon the psychological and social in the mainstream, pointing out that those are precisely the aspects of ‘being’ that patients with psychosis are distanced from. They emphasised the need to acknowledge the impact of carers and the environment in forming an integrated individual and pay phenomenological attention to “repeated experiences of fear and terror of the loss of mind”. Whilst some recognised the complexity of our bio-psycho-social existence, they also expressed exasperation at psychiatry’s failure to grasp the nettle.
“…but our concept of human mind is more basic than a Volkswagen motor and there a
mechanic has a more complex understanding than most psychiatrists have of the human mind. We have been stuck at the same level for a hundred years” (“Hans”)
There was obvious frustration about the mechanistic understanding of the mind and the lack of recognition of the need for a more complex model. All of those expressing such views had done psychological work upon themselves, with at least seven psychiatrists accessing personal
psychotherapy. They spoke of the need to become comfortable with the intangibles of human life, need for meaning and the impossibility of a neat, scientific psychiatry. For some the messiness of psychiatry created problems however, because they seemed to need clear causality, duality and tangible physical proofs. One spoke of moving from working with addictions to general psychiatry because he could not abide with ambiguity, preferring to work with clear medical illness instead of debating existence.
“I was much more interested in treating illness or psychopathology than with addictions… it’s hard sometimes to know…there’s even a debate in addictions….is the person ill...are they ill or is it a social thing...is it....whereas its very clear that schizophrenia is schizophrenia.” (“Keith”)
This belief that everything significant was observable and not hidden, contrasted with the majority of psychiatrists who insisted upon looking behind the surface. For two, schizophrenia was a real disease, an objective entity obviously distinguishable from a state of good health that everyone else shares. In contrast, the majority of my sample believed that psychosis lacked clear psychopathology. The complex understandings of psychosis found in the literature review did not exist for these two, with a profound diversity apparent within my sample. The lack of attention to meaning and complexity in the mainstream led to complaints about the lack of sophistication within the discipline that we encounter above. A real split existed amongst psychiatrists interviewed with regard to the function of symptoms: as problems to be eradicated or pointers to the patients‘ world-view and reasons for distress. Whilst some psychiatrists were keen to work with the psyche, others denied the existence of meaning or the patients’ search for it. In this regard, the same two psychiatrists spoke of “not looking for meaning in psychotic material” (“Doug”) and “people finding it difficult to accept themselves as bags of nerves and chemicals” (“Keith”). Another psychiatrist rejected this kind of simplification, expressing disbelief at the denial of meaning and simpler understandings of psychosis.
“that you can reduce something so complex….as somebody with a diagnosis of schizophrenia being unwell and everything that entails….and you can reduce that down to a word schizophrenia and medication…. to me...beggars belief really.” (“Dale”)
Those insisting upon complexity did not always have definite, elaborate theories but believed that more than chemicals or genetics were needed to understand people. There was a real split in understanding the individual and social aspects of psychosis: two believed it to be a biological disorder expecting clear organic pathology to emerge whilst most others cited the need for systemic, multi-dimensional models. Complex ideas about a “breakdown of common- sense understanding” or problems of “integration of the self” contrasted with a view of humans as simply “a bag of chemicals”. Some saw psychotic symptoms as patients’ “need to feel powerful through creating their own world” or “being at one with the symbolic” or “being overwhelmed due to the lack of protective armour.” For these psychiatrists, treatment required helping patients find meaning through understanding their own contexts that had made them seek protection and power in their symptoms.
“In non-psychotic disorders people suffer from reality....in psychotic disorders people
change reality... to avoid the suffering even though the change might not be very effective.” (“John”)
Other psychiatrists saw these changes in reality as symptoms or deviations from the norm and simple signs of illness in patients, without inherent meaning. In contrast to the multi-dimensional models of psychosis used by others, a couple used single system models decried by “Dale” above, where biological dysfunction required permanent pharmacological treatment. Whilst some considered psychological work as essential to fan the fires of life and address the turning away from others, with drugs useful only in managing extreme distress, a minority saw drug treatment as the sole and necessary aspect. For some, constitutional vulnerabilities derived from both psychic and physical aspects making it difficult to establish a single cause. For some, psychosis was a simple biological dysfunction in need of attention, with psychological aspects mere epiphenomena. Whilst some could combine a biomedical understanding of psychosis with the breakdown of complex psychological scaffold of reality, a minority insisted upon the treatment for psychosis being no different, for example from that for tuberculosis (TB). Just as the typical symptoms of TB (chronic cough, haemoptysis, unexplained weight loss and physical
decline) are treated with antibiotics, nutrition and rest, the chemical imbalance in psychosis is treated without considering the psychological impact of the breakdown of the self.
“It’s a simple biological dysfunction in brain chemistry and although I can’t explain the
physiology of schizophrenia...the simple medical model fits with an organic explanation.”
(“Doug”)
In contrast, other psychiatrists focussed upon patients’ need to rediscover meaning in life. They sought meaning in illness through attending to history and using their own subjectivity and minds to understand their patients’ withdrawal from reality. They placed a great deal of emphasis upon recovering motivation and inspiration in patients, with the loss of those aspects critical to the psychosis. There was a staggering diversity in the understanding of psychosis and its treatment within my small sample, with the majority of my sample feeling like a minority within the profession.
“I feel responsible to uncover the motivation….the fire in the belly...necessary for t h e
patients to recover. The voices or delusions become the patients’ reality as they withdraw from social life and habituate to their psychotic experiences. In the process, particular neural circuits are recruited with those connections getting stronger, the longer the psychosis goes on.” (“Don”)
4.2.2.1 Cultural diversity and meaning amongst psychiatrists
Within my sample of psychiatrists, I felt that cultural and social values may impact upon meaning in psychiatric practice. “Gita” and “Raj” were both recent migrants from India who had done their basic medical training in India but specialised in England. They were the least experienced amongst the consultants and had experienced a strongly psychotherapeutic end to their mainly biological training. The ending had not been an active choice for either, but both spoke of having developed a very different attitude to treatment as a result of exposure to such relational training. They felt much more integrated as professionals through bringing the scientific training together with their personal philosophies and meaning structures.
“Giving them time, your ears, listening to what they have to say,...ummmm and seeing them feeling a little better at the end of that conversation....just gives you a satisfaction in yourself....just meaning in life I would say” (“Gita”)
Subjectively speaking, these too were more similar to the psychiatrists with significant personal experience of psychotherapy, in their ability to identify with patients and focus upon the human bond. The Indian psychiatrists in my sample seemed more focussed upon meaning and relationships than those without significant experience of therapeutic relationships. Doubts about the adequacy of the biomedical paradigm in attending to crucial human needs such as meaning were clearly expressed by these two. The attention paid to ontology in these two seems significant although I am unable to draw any firm conclusions. Cultural differences may explain some of their ability to question their previous learning within the biological paradigm. The concepts of “use of self” and “meaning” were used by these two and those who were consultants in psychotherapy but did not feature at all with “Keith” and “Doug”. Perhaps their openness to different conceptions of ontology derives from a complex mix of valuing depth and emotional connections, identity and a possible interaction with my own Indian background.
“I have felt the same thing, if I am bothered about something, I ... want someone just to
listen, for me to just vent it…. to tell how I am feeling” (“Raj”)
I have evidence for radically different accounts of understanding psychotic patients and conceptions of ‘being’, with major implications for treatment. Psychiatrists with professional experience of exploring their emotions and sense of self seemed more open to seeking common ground and meaning with patients. They mostly shared a conviction that both patients and psychiatrists lose out through emphasising the objective and ignoring the subjective.