A guest at an awkward party: a service user observes the acrimony between psychologists and psychiatrists

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.

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About purplepersuasion

40 something service user, activist, writer and mother living with bipolar disorder. Proud winner of the Mark Hanson Prize for Digital Media at the Mind Media Awards #VMGMindAwards 2013. Winner of the World in Mentalists Mood Disorder blog 2012. Regular guest blogger for the International Bipolar Foundation http://www.internationalbipolarfoundation.org/ Expert by Experience working with Mind training department. Working on The Incoming Tide, a bipolar memoir. Find me on Twitter @BipolarBlogger or at my Facebook page http://www.facebook.com/BipolarBlogger
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12 Responses to A guest at an awkward party: a service user observes the acrimony between psychologists and psychiatrists

  1. This brings to mind an experience with psych liaison in A&E earlier this year. When asked what helps me, I responded with distraction in many forms, but added that I was being encouraged to distract less and learn to tolerate myself a bit more. The psych nurse rolled his eyes and muttered ‘that would be the psychologists advice then…’

  2. Excellent post. You managed to express so eloquently all the unease I was feeling myself about this debate. People who suffer from mental illness so often have no voice at all. Mental illnesses often affect a person’s core sense of self, identity and sense of meaning; they should not be treated as a sort of intellectual blood sport.

  3. The lived experience of a service user teaches another great lesson. I am also often complaining about the ‘medical model’ of care. If that difference is there we should be including the service user. Great reminder that treatment is not “one size fits all.” Treatment is not based on “we” want, it is what the service user needs.

  4. eindt says:

    I disagree with much of this post.

    For too long bad ideas and misrepresentations of the evidence have been allowed to fester within mental health care because professionals have not been willing to openly condemn the quackery coming from their colleagues. Given the current state of mental health research and care I think that we probably need more of a tolerance for open conflict and acrimony to drive out some of the serious and ongoing problems. There have been problems with both sides of the med vs therapy debate exaggerating the efficacy of their particular treatments, and this is harmful to patients. My hope is that the more this is thrashed out publicly, the more this should become clear to all, and pressure for change will continue to grow.

    Professionals on both sides are likely to have biases and incentives which lead them to provide patients with a distorted view of the evidence, and the more willing people are to attack this the better.

    While this might be unsettling for those who want to justbe able to trust those mental health professionals who are working with them, the sad state of affairs is that currently mental health professional cannot be trusted to be basing the claims they make on good evidence – many of them clearly do not. Better to be aware of this than lulled in to a false sense of security.

    • I’m not saying “don’t debate, don’t criticise, don’t challenge” – if that’s what you think, then go back, read the piece again, you’ve misunderstood but leapt in to comment. I’m saying the opposite! Debate. We NEED debate. We NEED to question the efficacy of drugs, and how robust the studies are, and who funded them. We NEED to question the efficacy of talking therapies and not just prescribe CBT for everything. Just don’t want to see practitioners “debate” like a pack of ridiculous schoolboys trying to score points off each other. Professionals? Then act like it. Don’t make service users watch you squabble over what are to them life or death matters. It’s frankly insulting to see professional ego trump service user focus. Now please stop inferring things that simply aren’t in my post.

      • eindt says:

        Sorry if I gave the impression of having misrepresented you, but having re-read your post, I still think that most of my response stands. I had started my reply by quoting you say: “It is, frankly, embarrassing, watching so-called professions trying to undermine each other,” and I think it would have been better to have left that in place, instead of changing it to “I disagree with much of this post”. Much of your post is you describing how you feel about things and it is not my place to judge that.

        I’m relieved to see professionals openly trying to undermine one another, and think that we need more of this. Also, I think it is good that the debates are taking place in public so that service users can see what is going on, and gain a greater awareness of the evidence, controversies and uncertainties that swirl around much of the advice they are given by professionals.

      • Again, I have never said I want debates to happen where we can’t see them. I just feel my trust in professionals in frankly undermined when the “debate” is a bunch willy-waving. If you want to be treated by people who act like children in trying to take down each others’ position, rather than seeing how both professions can work to have a service user focus, then BINGO! Your luck is in.

      • eindt says:

        When you say things like “Don’t make service users watch you squabble over what are to them life or death matters” I take this to mean that you thought people should restrict what they said publicly in order to present an image of professionalism. I think that approach has been and would be harmful as it encourages unwarranted faith in professionals and allows those in positions of authority to make unfounded claims with less risk of being publicly taken to task for it. British notions as to what is ‘proper’ in a social situation seem to encourage the sort of courtesy and deference which allows those with power to avoid obligations to justify their actions and claims.

        To me, the clearest current example of ‘professional ego trumping service user focus’ comes from those professionals who try to present the current debates as being undignified, or something which should take place within academic journals. It is they who seem to be most concerned about their image, rather than a pursuit of truth. I think it’s good for everyone to realise that mental health professionals are not that different to any other group of people in the way that they behave.

        I want to be treated by professionals who know that they have a responsibility to restrict the claims they make to patients to those which are supported by good evidence. It seems that we have a long way to go, but I am hopeful that the current ‘willy-waving’ will help move things forward or at least increase awareness of the problems in this area.

  5. Sarah says:

    Fantastic piece Charlotte you have a wonderful way of putting what a lot of us service users feel into words. I agree with you totally keep it up!

  6. This is brilliant, absolutely brilliant.
    I’m a Canadian patient, and I was at CAMH, a large institution. Occasionally I have felt this problem, and other times I’ve been impressed at how varied their approaches are. My psychiatrist had the confidence in his work to say: ‘I’m responsible for your pharmacological treatments, but you should try some other things, such as CBT. If you get suggestions from other practitioners, I will help you connect with them.’ He was so straightforward and great, but his attitude is all too rare.
    Dogmatic adherence is always problematic, and when service users get caught in the middle, it’s damaging. I feel like I’m just poorly summing up what you said, though. Brilliant piece.

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