I Am a Critical Psychiatrist

PORTRAIT OF A PSYCHIATRIST

-Series Editor, H. Steven Moffic, MD

In most respects, my career as a psychiatrist working in community mental health has been ordinary. I have a long-standing and deep curiosity about the phenomenon of psychosis. Although I worked in academic settings early in my career, my interests in clinical work along with my desire to work part-time when my children were young, led me to community mental health. I have worked for the same community agency for over 25 years and I am currently serving as its Chief Medical Officer. I feel fortunate that my interest in my patients and work has not waned. What is most surprising to me is that, nearing the end of my career in psychiatry, I have come to define myself as a critical psychiatrist.¹

Although I did not enter medical school intending to be a psychiatrist. I became enamored of the field-specifically psychoanalysis-early in medical school. However, after several years of intense study, I became disenchanted. Psychoanalysis seemed like a closed loop that was resistant to critical inspection. Objections to the field could always be framed as a reflection of the objector’s internal conflicts. That seemed to me highly problematic for a discipline that purported to be a branch of medicine. The authority given to the psychoanalytic perspective worried me.

At the time I veered away from psychoanalysis in the mid-1980s, the so-called biomedical model was in its ascendancy. DSM-III was a well-established guide to diagnosis and there was much enthusiasm about the drugs available to treat a host of problems. In that light, I decide to pursue an area that seemed more fitting to a branch of medicine-psychosis. I was not sure that the many problems that fell under psychiatric purview fit comfortably into a medical conceptualization. But psychosis seemed to me to conform to the notion of a “brain disease.”

The narrative of modern psychiatry is that it has undergone a remarkable evolution in the past 30 years. We have shuttered most of our large mental hospitals-the common wisdom being that this was a reflection of the power and effectiveness of drugs prescribed by psychiatrists. These drugs helped not only those who, in another era, might have been institutionalized but also those who were functioning-in some cases quite well-but suffering with sadness, worry, distraction.

When new drugs were introduced in the late 1980s and 1990s, I was optimistic. I had worked for about a decade with the older drugs and I knew that there was room for improvement. But I quickly saw that, in the clinic, these drugs did not live up to their hype. Of even more concern was that their rosy promotion did not match what was documented in the studies of their safety and effectiveness, which had been undertaken to gain FDA approval. What bothered me most was that the institutions that should have countered the commercial interests-our academic centers-seemed to be doing most of the promoting.

At this point I might begin to sound like one of my patients-someone who has beliefs that are not shared by others. But my observation is that medical academia has been captured by commercial interests. While most physicians seem to believe that their scientific training protects them from bias-that they see what’s behind the promotion-this is not what I observe. I see arrogance and a lack of humility at our limitations in overcoming bias. When challenged, many seem to agree generally with this observation but see it more in others than in themselves. So non-psychiatrists might recognize the problem in psychiatry but not in their fields or they see it among other doctors but not in themselves.

My concerns go beyond medicine. For example, industrial agriculture is an environmental disaster. The pharmaceutical industry sells drugs to farmers, allowing them to raise livestock in horrific conditions so that they can produce more food that makes people sick, bolstering the market for still more drugs. And while this might not have been a conspiracy hatched in some back room, once in place the obstacles to change appear insurmountable.

My views of psychiatry and its limitations are reflected in how I have come to think about my own life. Like many of us, I was drawn to psychiatry-psychoanalysis in particular-because I thought it might help me understand myself and some of the personal challenges I faced. I was often angry and sad for reasons that did not make sense, given how fortunate my life had been.

My story is not an uncommon one. My grandparents were all immigrants and I come from one of those hard-working, striving families who benefited enormously from the American promise. I had an older brother and older male cousins. They were all strongly encouraged to go to medical or law school and, from an early age, I was determined to follow them. While I was loved by my family, I also felt that my ambition was suspect, and I absorbed a message that this was not an attractive female quality.

The search for personal understanding in psychiatry led me to two conceptualizations of my struggles: one defined my anger and sadness as a reflection of an internal conflict, the other as a manifestation of an illness or disorder. Neither of those seemed to fit. In recent years, as I have deconstructed my ideas about my profession and learned ways of understanding that are less pathologizing, I have wondered if my feelings were understandable reactions to a culture that did not have room for an ambitious girl, in which my temperament did not comport with societal expectations. It might have helped if someone had validated my perception that my striving was unattractive and/or had helped me to figure out how to navigate my way through this. I eventually figured it out on my own, but it took years and that support and confirmation would have been welcome.

I am heartened by those who are working for change. I have been fortunate to connect to a larger network of people-professionals as well as people with lived experience of extreme distress-who are working hard to change the paradigm of care. They are pushing back against the pathologizing discourse that is so dominant-where almost every uncomfortable human experience is conceived as representing a medical condition. They understand that many experiences labeled as “disorders” are understandable reactions to life experiences rather than evidence of dysfunctions within the people having them. Framing our experiences in such a way might be more helpful to people than conceptualizing them as illnesses. It is an uphill struggle, but their work inspires me to be a better doctor and a better person. These days, many of the people who are teaching me are not psychiatrists. In fact, those who have taught me the most in the past few years are the one who have lived experience-who have been the subjects of psychiatric care but have found their recovery elsewhere.

My personal view of psychiatry is that we need to acknowledge and embrace humility. We need to become as curious about how to stop the drugs we prescribe as we are in how to start them.² As a profession, we have done harm, often with the best of intentions. This is a hard narrative when we live in a culture that values spin over content. Messages of humility can be viewed as indications of incompetence or weakness. It takes strength to acknowledge uncertainty and to remain humble and transparent about the limitations of our profession. There is so much we do not know about the struggles of those who consult us.

While I feel some dismay, I know that it is important to express gratitude, so I end on a positive note. I am a member and serve on the board of the American Association of Community Psychiatrists and, through that organization, have met many wonderful colleagues. I am especially awed by the younger generation. I worry about their futures, but these strong, courageous people provide me much comfort and, more importantly, I am heartened by what they are doing not only for our profession but for the communities in which they work.

On a final note, I know how deeply fortunate I have been. I remain fascinated and moved by my patients’ stories. I admire them and the many decent people who work so hard each day to be of service. I am truly grateful to be surrounded by such remarkable people.

Disclosures:

Dr Steingard is Chief Medical Officer, Howard Center, and Clinical Associate Professor of Psychiatry, University of Vermont Larner College of Medicine, Burlinton, VT. She is chair of the Board of the Foundation for Excellence in Mental Health Care and a member of the board of Mad In America Continuing Education.

References:

1. Steingard S, Ed. Critical Psychiatry: Controversies and Clinical Implications. Switzerland: Springer; 2019.

2. Steingard S. Five year outcomes of tapering antipsychotic drug doses in a community mental health center. Comm Mental Health J. 2018;54:1097-1100.