Psychiatry is fascinating because it deals with consciousness, choice, motivation, free will, relationships – indeed everything that makes us human. While it is often cloaked in forbidding jargon (‘affect’ instead of mood, ‘anxiety’ instead of worry, ‘phobia’ rather than fear, ‘cognition’ instead of thinking) the conditions described are still instantly recognizable.
However, it may be best to start by deﬁning what psychiatry is (and what it is not) before returning to the philosophical and political controversies that attend it.
All the ‘psychs’:
psychology, psychotherapy, psychoanalysis, and psychiatry
‘Psyche’ is the Greek word for mind. All these four terms describe different approaches to understanding and helping individuals with psychological and emotional (mental) problems.
Psychology is the study of human thought and behaviour.
It originated just over a century ago from a tradition of introspective philosophy (trying to understand the minds of others by understanding our own) and is now a ﬁrmly established science. Psychology is studied at school and as an undergraduate course at university. It encompasses the study and understanding of mental processes in all their aspects and it has many branches.
Experimental psychologists conduct experiments to explore the very basics of mental functioning (perception, memory, arousal, risk-taking, etc.). Indeed experimental psychologists do not restrict themselves exclusively to humans but study animals both in their own right and as models to understand human behaviour. Experimental psychology is generally considered a ‘hard science’ which follows the same scientiﬁc principles of investigation as physics or chemistry.
There are several professions stemming from psychology e.g.
- educational psychologists,
- industrial psychologists,
- forensic psychologists.
- clinical psychologists
The Clinical psychologists have postgraduate training in abnormal psychology and use this understanding to help people deal with their problems. The most obvious early example of this approach was the application of learning theory (i.e. consistent rewards and punishments to shape behaviour) in behaviour therapy.
Behaviour therapy has been particularly successful in helping disturbed children or those with learning difﬁculties to modify their behaviour. It works without requiring a detailed understanding of the issues by the patient. Psychological treatments have, of course, become much more sophisticated and currently one of the most successful and widely practised psychotherapies (cognitive behaviour therapy) has been developed by clinical psychologists and is provided mainly by them.
Clinical psychologists are essential members of all modern mental health (‘psychiatric’) services.
Psychoanalysis is the method of treating neurotic disorders developed by Sigmund Freud towards the end of the 19th century in Vienna. In psychoanalysis the patient is encouraged to relax and say the ﬁrst thing that comes into their mind (‘free association’) and to pay attention to their dreams and to the irrational aspects of their thinking. Freud was convinced that his patients suffered because they tried to keep unconscious (repress) thoughts and feelings that were unacceptable to them and that doing so caused their neurotic symptoms. The analyst listens carefully to what is said and over time begins to detect patterns and clues to these ‘conﬂicts’. By sharing these insights he helps the patient confront and resolve them. Psychoanalysis is intensive and very long with patients traditionally coming for an hour a day up to ﬁve times a week for several years. Psychoanalysis is the origin of the cartoon image of the bearded psychiatrist sitting behind the patient lying on the couch.
It soon became clear that there was more to psychoanalysis than Freud’s original remote and neutral exploration of the unconscious. The relationships formed in this intense treatment were themselves
found to be inﬂuential. Analysts began to explore these relationships and experimented with more active approaches and with different types of therapy (time-limited therapies, more structured therapies, therapies in groups and in families, etc.).
These psychological approaches, in which the relationship was used actively through talking to promote self-awareness and change, are broadly understood as ‘psychotherapy’. Most of the early psychotherapies leant heavily on Freud’s theories (often called ‘psychodynamic psychotherapy’ to emphasize the impact of thoughts and feelings over time) but several of the newer ones do
not. These (e.g. non-directive counselling, existential psychotherapy, transactional analysis, cognitive analytical and cognitive behaviour therapy) draw on a range of theoretical backgrounds.
What is psychiatry?
So if it is not psychology and not psychoanalysis or psychotherapy, what is psychiatry? There are overlaps with the other ‘psychs’ but there are some fundamental differences.
First and foremost psychiatry is a branch of medicine – you can’t become a psychiatrist without ﬁrst qualifying as a doctor.
Having qualiﬁed, the future psychiatrist spends several years in further training. He or she works with, and learns about, mental illnesses in exactly the same way that a dermatologist would train by treating patients with skin disorders or an obstetrician by delivering babies.
Within medicine, psychiatry is simply deﬁned as that branch which deals with ‘mental illnesses’ (nowadays often called ‘psychiatric disorders’)
What is a mental illness?
There is a marked circularity about this (‘a psychiatrist is someone who diagnoses and treats psychiatric disorders’, ‘psychiatric disorders are those conditions which are diagnosed and treated by psychiatrists’). There has been endless controversy about the reliability of psychiatric diagnoses and even whether or not mental illnesses exist at all . It is worth spending a little time on why psychiatric diagnoses are so controversial both because it keeps cropping up and also because the same issues are fundamental to all
medicine although rarely as striking.
The subjectivity of diagnosis
The hallmark of the psychiatrist’s trade is the interview. We make our diagnoses (and still conduct much of our treatment) in face-to-face discussions with patients. We take a careful history (as do all doctors) but then, instead of, or sometimes in addition to, conducting a physical examination (feeling the abdomen, taking the pulse, listening through a stethoscope) we conduct what is called a ‘mental state exam’.
In this we probe deeper into what is worrying the patient, their mood, way of thinking, etc. Some of this involves simply noting what the patient reports (that they are hearing strange sounds or that they panic every time they think of going out) but some involves us in constructing an understanding of what they are going through using ‘directed empathy’.
Directed empathy means actively putting ourselves in their shoes, understanding what they are feeling and thinking, even if they have difﬁculty in expressing it. For instance we may come to the conclusion that a patient who recounts a series of vindictive acts carried out against them by strangers and friends alike is, in fact, excessively suspicious (paranoid) leading to misinterpretation of common events.
Diagnoses based on a patient’s mental state contain no concrete evidence for the diagnosis – there are no blood tests or x-ray pictures. A written list of what is said or a detailed description of the behaviour (e.g. the diagnostic criteria for depression) are only part of the process. Psychiatric diagnoses rely on making a judgement about why someone is doing something, not just the observation of what they are doing.