Last year I went to a barbeque with some friends, taking my partner and kids. It was a warm, golden evening. We sat out on the patio sipping wine and chatting while the children milled around, shooting each other with Nerf guns and water pistols (for which it turned out my teenagers were by no means too old after all), gravitating back to the table occasionally when they wanted more burgers.
Yet the evening wasn’t a pleasant one. I was aware the couple had been having problems, but I hadn’t appreciated how bad things were. As the wine flowed, so did the increasingly barbed comments, with no regard for the fact that the children could hear every word. At one point things degenerated into the adults addressing one other through the children (“Well, if your father had fixed the trampoline, you’d be able to play on it, wouldn’t you?”). The whole evening was incredibly awkward and I felt that the people the evening allegedly focussed upon – my partner and I as guests, the children we had all agreed we should get a chance to play together while the weather held – were essentially ignored, forced into witnessing acrimony we had no desire to see. Like the children must have been, I was sad and felt torn; I considered both husband and wife to be my friends. I did not want to be forced to take sides.
This evening has come to my mind several times this week. In May last year the fifth version of Diagnostic and Statistical Manual version (DSM-5), often referred to as the “Bible” of psychiatry (in the USA, anyway; Europe tends to make greater use of the World Health Orgnaisation’s International Classification of Diseases, now in its tenth incarnation as ICD-10), was launched. At the time, this was represented in the media as psychiatry drawing a line in the sand, and an ever-encroaching line at that, taking in behaviours/experiences that had not previously been pathologised. The natural enemy of this “mission creep” was reported to be psychology, with its tendency to question the biological basis of many psychiatric conditions and challenge the scientific validity of medication as frontline treatment. Psychiatry and psychology were pitted against each other in a way that many of the clinicians I knew did not feel reflected the reality of professional working relationships.
Here’s a pretty representative article from the Guardian, headlined “Psychiatrists under fire in mental health battle” it has the byline, “British Psychological Society to launch attack on rival profession, casting doubt on biomedical model of mental illness.” I found these warfare metaphors deeply unhelpful; my concern was that it gave service users the impression that members of the multi-disciplinary teams that were meant to co-ordinate to help them were at each other’s throats. Anyone receiving both medication and talking treatments might justifiably wonder how a psychiatrist could have faith in the therapy s/he referred them to, or whether the clinical psychologist delivering the therapy was secretly sneering at their use of psychotropic medication.
At the time, therefore, I went to great lengths to talk down all this “battle” bombast by sharing my personal experiences of medically and psychologically trained staff working together for my good. I was cheered that some of the psychiatrists and psychologists I followed were similarly concerned at all this talk of a split, and pleased to be asked to take part a three-hander article for a special issue of Clinical Psychology Forum in which I was able to put the questions that concerned me as a service user to both a psychiatrist and a psychologist (a piece which the editor tells me was well-received).
Except eighteen months on, I’m beginning to feel that either I was wearing rather rose-tinted contact lenses last year, or that rather than the talk of war blowing over, a wider and wider chasm has opened between psychological theory and that of psychiatry. The Twitter conversations I witness are becoming more and more bitter and biting, particularly following this week’s publication of the British Psychological Society’s 175 page report entitled, somewhat cumbersomely, “Understanding Psychosis and Schizophrenia: Why people sometimes hear voices, believe things that others find strange, or appear out of touch with reality …and what can help.”
With my mental health as poor as it is, I’ve not been in a position to read the whole report, yet I’m already sick of it. Why? Because the instant it was published, so were psychiatric critiques, most notably this one from the Mental Elf (although it should be noted one of the authors of this particular document is a psychologist). Just as last May psychologists jumped all over the DSM-5, psychiatrists were poised to take on the BPS’s report and look for its flaws. There is nothing at all wrong in dissecting an important document, but just as last year I was left feeling that psychologists were taking rather unseemly pleasure in attempting to demolish the medical model, psychiatrists are now doing the same regarding this report. This bitterness has spilled out into vitriolic Twitter exchanges with talk of camps and parties, of critiques held sacred by some and rejected as “predictable backlashes” from others.
I am sorry to say that from the position of a humble service user, the ostensible “guest” at services’ party, I feel ignored. It is, frankly, embarrassing, watching so-called professions trying to undermine each other. I freely admit I count a number of psychologists and psychiatrists as online friends, but from where I’m sitting it looks like each profession’s desire to be “right” has now eclipsed their focus on patients. Just like at that barbeque, I want to get up and walk away from the acrimony and the awkwardness – only I can’t, because I need the services of both psychiatrists and psychologists.
I get how closely-held these principles can be. I honestly do. Were it not for my bipolar I would have been a midwife, and as a trainee I clung passionately to a desire to facilitate and support normal birth. I was a paid-up member of the Association of Radical Midwives, whose emblem was the low-tech Pinard stethoscope, symbolising philosophical objection to practices such as bed-bound continuous electronic foetal monitoring. Yet I pride myself that I never attempted to dissuade a woman from choosing the birth she wanted, be it a home water birth or planned C-section. It would have been wrong and ego-driven to insist on my preferred model of birth. Yet still I see clinicians publically stating that psych meds are harmful, or that if a person refuses drugs they will/cannot be helped.
I want nuance in my care. I want psychiatrists to care about my childhood trauma and the content of my delusions. I want psychologists to recognise that my bipolar is not just a construct, that with childhood onset I had clear symptoms for many years before I had even heard the words “bipolar” or “manic depression”, let alone met a psychiatrist. Yes, there is a strong anti-psychiatry/survivor movement among people with mental health problems. Yes, there are also plenty of true believers in the brain chemistry/biological determinism camp. But most service users are like guests at the party. We don’t want to see you fighting; it diminishes our confidence in you as caregivers. We don’t want to be made to take sides. Many of us are essentially pragmatists when it comes to our healthcare. We don’t want to sign up to a theoretical model, we just want to be able to access the things that work for us.
This is me, a service user, drawing my line in the sand. Professional debates about what is best for us are actually closing us out. You can’t insist on being right and provide flexible care. You can’t vocally and brusquely undermine another clinical group and then expect us to trust in your referral to that profession.
There are guests at the table. Behave.