Psychiatry and ethics Book

This is a brief but excellent overview of psychiatry. It starts by defining psychiatry, explaining how it is influenced by the illnesses it treats and the treatments available, and explaining the main mental psychoses, neuroses and personality disorders. It then outlines the history of psychiatry, from its origins in the first public madhouses to the first asylums, which started well but got overcrowded, to the shift to smaller psychiatric units in larger hospitals and community care. All these changes were influenced not only by discoveries of effective treatments but also by social attitudes. The fourth chapter describes the types, effectiveness and criticisms of psychoanalysis and psychotherapy. The book then goes on to criticisms of psychiatry, including ethical issues like whether it infringes the human right to be different, its impact on the legal system, and its expansion to questionable diagnoses like oppositional defiant disorder. Finally, the last chapter makes predictions for psychiatry in the 21st century.

As a medical student I expect to receive training on the practical aspects of psychiatry in the near future, so I was delighted that this book covered the history of the profession, providing the background for my future education and practice. I've never realised how much the current definition and scope of psychiatry is moulded by its past, which in turn was influenced by changing cultures and societal attitudes. In fact psychiatry is defined by culture, as what is considered abnormal can only be understood in the context of what is culturally normal. As Tom Burns tells us, this raises the ethical issue of whether normal healthy people are forced to think they are abnormal, or even forced into treatment, just because they are not like the rest of society.

Another ethical issue that I found interesting was what psychiatry should treat. Burns explains that psychiatrists are partly influenced by patients. Patients seek help when they find their symptoms unacceptable. As the stigma of being diagnosed with a psychiatric illness decreases and stoic perseverance is appreciated less, psychiatrists are being called to treat people in circumstances where previously alternative forms of coping would have sufficed. Hw do we decide who needs psychiatric help? The Introduction says that mental illnesses involve experiences familiar to all of us such as depression or disinhibition, with the additional criteria that an important threshold has been crossed. How do we define this threshold? Do we even bother to identify it? And if we don't, are we undermining the value of personal resilience? Or do we just ignore the ethical debate, and say argue that as long as people are helped, it doesn't matter who helps them?

As someone who is interested in a career in psychiatry, I found it interesting that nurses and medical social workers are increasingly able to handle psychiatric illnesses. Even as more patients seek out psychiatric help, the doctor's role may evolve or even diminish in the future, and that is definitely something to consider for career planning.

I also found the following passage helpful.

The qualities of a good therapist transcend the different schools of thought. The essential ingredients are accurate empathy (the therapist must really understand what the patient is going through, it is not enough just to feel sorry for them), unconditional regard (the therapist has to like and respect the patient, you can’t do therapy with someone you really dislike), and non-possessive warmth (the therapist must be able to show warmth without making the patient feel beholden to them). These insights are particularly useful in psychiatric practice. Matching patients and therapists really does matter – not all of us can get on with everyone. To work with violent or sexual offenders, for instance, requires a particularly tolerant and forgiving individual.

Accurate empathy, unconditional regard, and non-possessive warmth. I couldn't have put it clearer myself. However much the face of Psychiatry changes, the qualities that make one not just a good doctor, but a good psychiatrist, never change.