Parity of esteem within the biopsychosocial model: is psychiatry still a psychological profession?

[Hutan]

I have seen some reports on the forum of psychiatrists being helpful, and we do have some psychiatrists as members.

I think though, that while there may have been a valid role for psychiatrists, that role is rapidly shrinking.

Biological: As knowledge of the diseases that cause problems with behaviour and thinking and their treatment increases, those diseases become the domain of neurologists, immunologists and others.

Psychological: Dealing with difficult life circumstances, even things like addictions, generally aren't primarily medical issues. Expensively trained specialist doctors are usually not the most cost-effective or even the most suitable people to provide most of the needed support.

Social: Social factors are a really important for health, but they are primarily the domain of public health and community health services (and welfare services and government and economists). I'm not sure that social issues were ever a focus of psychiatry.

 

[Joan Crawford]

I don't think psychotherapy has been on the training for psychiatrists since the 1980's? Most manage patients with pills after incredibly brief assessments. Few have the clinic time (in NHS) to assess and review patients as whole people and endeavor to figure out what has happened to them, how they have responded and how in the wider sense they could be supported. When they do have more time, in for example, medico-legal settings, they often plump for the first obvious diagnosis and leave it at that - and suggest a pill for it. Missing often key issues for patients and their history and therefore failing to suggest/encourage wider support and so forth. And also missing biomedical reasons for people's mood/mental health issues too.

I have no idea what models of human behaviour and so forth psychiatrists are taught. And how they use them. In NHS they usually manage severe addictions, psychosis and so forth where medical prescribing can be part of care, along with interventions such as ECT and so forth. There are a few psychiatrists specialising in psychotherapy - but they are few and far between. I suspect this would be training they would complete after training as a psychiatrist - not integral to all psychiatrists way of working.

 

[SNT Gatchaman]

Biological: As knowledge of the diseases that cause problems with behaviour and thinking and their treatment increases, those diseases become the domain of neurologists, immunologists and others.

I'm not sure about this. There is excellent and (actually) promising work in molecular/immuno- psychiatry. Fast forward, I imagine if that all came to fruition and we were able to effectively treat or cure the major mental disorders, then that would still be looked after by psychiatrists. They're the group that know how to take a history and mentally examine a patient, in the same way that a rheumatologist might do the physical equivalent for a joint or muscle problem. Wouldn't neurologists be lost trying to evaluate disordered thinking and mood disorders and immunologists even further out to sea?

Although maybe it comes down to semantics, as psychiatry evolves into sub-specialty neurology, alongside those who deal predominantly with eg MS.

 

[Solstice]

I'm not sure about this. There is excellent and (actually) promising work in molecular/immuno- psychiatry. Fast forward, I imagine if that all came to fruition and we were able to effectively treat or cure the major mental disorders, then that would still be looked after by psychiatrists. They're the group that know how to take a history and mentally examine a patient, in the same way that a rheumatologist might do the physical equivalent for a joint or muscle problem. Wouldn't neurologists be lost trying to evaluate disordered thinking and mood disorders and immunologists even further out to sea?

Although maybe it comes down to semantics, as psychiatry evolves into sub-specialty neurology, alongside those who deal predominantly with eg MS.

They might be able to slap diagnoses on people, but I'm assuming that if there turns out to be some deficiency in peoples bodies this is by definition not really in the psychologists wheelhouse. There'd be biomarkers to indicate what is wrong in the body which then would require medicine to sort it out I'd imagine. I may be way of base here.

 

[Trish]

They might be able to slap diagnoses on people, but I'm assuming that if there turns out to be some deficiency in peoples bodies this is by definition not really in the psychologists wheelhouse. There'd be biomarkers to indicate what is wrong in the body which then would require medicine to sort it out I'd imagine. I may be way of base here.

Psychiatrists are doctors who can order biomedical tests and prescribe medications etc, so they should be able to diagnose and treat biochemical deficiencies like any other doctor.

Psychologists are not medical doctors, so can't do the above, all they can do is talk to people, ie do talking therapy.

 

[Arnie Pye]

They might be able to slap diagnoses on people, but I'm assuming that if there turns out to be some deficiency in peoples bodies this is by definition not really in the psychologists wheelhouse. There'd be biomarkers to indicate what is wrong in the body which then would require medicine to sort it out I'd imagine. I may be way of base here.

Once a psychiatric diagnosis has been slapped on to a patient, even if the patient has a fixable physical problem that just hasn't been found, they (the patient) will find it very, very difficult to get anyone to do any further testing, provide prescriptions, or refer for surgery. What they are most likely to get is advice to lose weight and do some exercise.

Throughout my life I have been absolutely amazed by the belief that many members of the medical profession appear to have that mental illness diagnosed just once can automatically exclude physical illness, either for many years, or for ever.

And another thing that can happen is that any surgery that has been done is always assumed to be perfect, and cures all ills the patient may have complained of. Insisting that something is still wrong after surgery or treatment of almost any kind is often treated as yet more evidence of yet more mental illness.

 

[Hutan]

Although maybe it comes down to semantics, as psychiatry evolves into sub-specialty neurology, alongside those who deal predominantly with eg MS.

I think this is right. If doctors who specialise diseases of the brain/central nervous system are neurologists, then a lot of illnesses with psychiatric symptoms should be managed by them. Perhaps, as there is more knowledge, the subspecialties will be divided up less by the outward symptoms, e.g. Parkinsons patients can experience psychosis as well as motor problems, and more about the underlying processes.

 

[Jonathan Edwards]

I think there is a major confusion in many people's minds. Psychiatry will continue to be an essential discipline and probably grow. Its proper role is to deal with biological illness that primarily presents as disordered thinking. This is not neurology because there are no local neurological signs or imaging changes on most cases. Psychiatry saves lives - including my wife's.

Psychotherapy and psychoanalysis are completely different things, just as physiotherapy is different from rheumatology. Please don't confuse the two. This piece is an attempt to conflate quack psychodynamic therapy with mental health care. A psychiatric diagnosis is not in most cases a matter of esteem or stigma. If it is known someone has bipolar disorder or dementia it helps to relate to them optimally.

It is salutary to visit a psychiatric ward on a daily basis. There are large numbers of people totally disabled by psychiatric disease much in the way that PWME are. Nobody treats them with contempt - they are too obviously ill for that. some never speak. Some need drip feeding.

The problem is not that ME is treated as a psychiatric illness but that it is treated as if there was neither psychiatric nor any other sort of illness. So the drip feed is denied.

What the paper seems to be highlighting is that psychiatry may be ready to shed its quack other half, just as rheumatology got rid of wax baths and mineral water cures when we began to understand arthritis. And the quacks are getting peevish.

 

[Hutan]

Psychiatry will continue to be an essential discipline and probably grow. Its proper role is to deal with biological illness that primarily presents as disordered thinking. This is not neurology because there are no local neurological signs or imaging changes on most cases. Psychiatry saves lives - including my wife's.

Disordered thinking is a symptom, and can be caused by a range of things, in the same way that fatigue or headache are symptoms that can be caused by many things. It makes sense to have some doctors who are really good at diagnosing conditions from a main symptom, or from a range of symptoms. But, if I was designing a medical system, I'd then want those people with diagnosed serious illnesses treated by people with expertise in the specific illnesses and underlying biological processes.

I think having all people suffering from disordered thinking managed by one speciality makes as much sense as having all people who suffer from fatigue being managed by one speciality.

 

[Solstice]

Thanks for the information everyone. I didn't mean to imply mental illness isn't real btw, I know it's very real. My thinking was more along the lines of @Hutan's last post.

 

[Jonathan Edwards]

I think having all people suffering from disordered thinking managed by one speciality makes as much sense as having all people who suffer from fatigue being managed by one speciality.

I don't see any problem with all people suffering from fatigue, without any other organ specific issues, being managed by one speciality. After all there is a desperate need for such a speciality for ME.

Most psychiatric disease has no other organ specific issues and not even any specific neurological features - beyond the thinking problems. We need people with high level expertise in diagnosing thinking problems and there is absolutely no reason why they should not then organise the treatment because it does not depend on specialised knowledge of kidneys or even nerve connections. It requires specialist knowledge about does titration and modality choice for disordered thinking. The quality of service varies a lot but the guy who eventually sorted my wife out was one of the most impressive physicians I have ever met. Young, modest, diligent, always available and always ready to explain everything in detail.

As a rheumatologist I dealt with people with joint and muscle problems of a huge variety of causes - immunologic, metabolic, mechanical, infective, neurological - you name it. Where there was overlap I co-managed patients with other specialists, at least in the days when that was allowed.

But I would have been totally incompetent faced with someone with disordered thinking. Psychiatrists get about ten years training in the complexity of the different patterns and causes. There is a huge amount not understood but that applies at some level in all specialities.

 

[rvallee]

Aside from the absurd idea of fatigue being psychiatric, looking back at the last few years, with a few exceptions like the usual PACE gang, neurology is actually far more misguided regarding post-infectious illnesses like ours than psychiatry is. Very little comes out of psychiatry that has anything to do with us, aside from psychosomatic medicine, which in my opinion ranks about as low as astrology and homeopathy.

The problem indeed seems to be more the fact that psychiatry doesn't actually deal with us, it's mostly generalists or other specialists who think they should. But psychiatry has nothing for us, doesn't understand anything about our illness. Even the concept of functional disorders is mostly taking place in neurology, who don't know anything about it either.

The issue really mostly is over a missing entire specialty. Psychiatry is not the place for us. Neither is neurology, for the most part. Although they really are completely missing the boat over dysautonomia, but they deal with structural issues, broken nerves, they don't really know how to deal with things related to us, and seem far more stuck with Freud's very bad ideas than psychiatry.

Regardless, the main issue is the very existence of the biopsychosocial model, which is simply an unscientific jumble of vague, generic ideas that are used as a dumping ground for every problem that doesn't have easy answers for generalists, or specialists. Psychiatry really does not to grow big boy pants and rein in their quacks, but some of those quacks are beloved and influential, and medicine is the last profession where people will speak truth to power. Compliance is everything.

I really don't think anything moves forward until the discipline of infectious-triggered illnesses exists. But ending the atrocious biopsychosocial model is something we can pretty much all agree on here. Unfortunately, it is a very popular trash can that MDs have gotten too used to using. But no one is responsible for it.

 

[rvallee]

Although one big issue psychiatry does have, is that most psychiatrists would probably agree that we are actually suffering from depression, or maybe somatization, and frankly this proves that even if those things actually exist, as a single entity, they can't even tell the difference. So they do have a lot of work to do, but it's unrelated to us. It's work they have to do on themselves. I'm just not sure they're up for it, their methodologies aren't especially scientific.

 

[Sly Saint]

I think though, that while there may have been a valid role for psychiatrists, that role is rapidly shrinking.

no pun intended?

 

[Hubris]

But I would have been totally incompetent faced with someone with disordered thinking. Psychiatrists get about ten years training in the complexity of the different patterns and causes. There is a huge amount not understood but that applies at some level in all specialities.

While we are talking about this, I want to ask you something.

As you have implied in your post, the most capable, science oriented psychiatrists do not think ME or fatigue is a mental illness. This is obvious, otherwise we would have phase 3 trials with psych drugs all over the place. The only psychs that think of ME as a mental illness are the low quality ones, who have no concept of science and are happy to prescribe things like hypnosis that have no evidence behind them.

Despite psych illness not having organ specific problems, or even Neuro issues, there is still a large effort to study the neuroscience there and try to apply cutting edge treatments (like for example the brain implants they use in treatment resistant depression, OCD, etc).

So my question is this:

There is this misconception among non psych doctors that fatigue (if you don't have obvious biological abnormalities) is a mental illness and it's treated effectively with psychotherapy. This belief is encouraged and propagated by both the low quality psychs I mentioned, and the ignorance of non psych doctors about mental illness. Why do the serious psychiatrists not speak up against this? Why have they abandoned us, knowing that nobody will help us? Ok, we are not mentally ill so our illness is not part of their expertise but since everybody else mistakenly thinks we actually do have a mental illness, and get referred to psychs all the time, don't they at least a moral and ethical obligation to set the record straight, or at least make a statement?

 

[Hutan]

while there may have been a valid role for psychiatrists, that role is rapidly shrinking.

no pun intended?

I was quite happy with that, glad you noticed.

 

[Jonathan Edwards]

Why do the serious psychiatrists not speak up against this?

I think largely because they are too busy trying to deal with real mental illness. When I was a rheumatologist and saw large numbers of people being sent to physiotherapy for no good reason I didn't make a great fuss about it because I was concentrating on trying to find a better solution.

 

[Hubris]

I think largely because they are too busy trying to deal with real mental illness. When I was a rheumatologist and saw large numbers of people being sent to physiotherapy for no good reason I didn't make a great fuss about it because I was concentrating on trying to find a better solution.

So we literally can't even get their attention? How disappointing...

 

[Sly Saint]

article in Guardian from 2016
Therapy wars: the revenge of Freud

Cheap and effective, CBT became the dominant form of therapy, consigning Freud to psychology’s dingy basement. But new studies have cast doubt on its supremacy – and shown dramatic results for psychoanalysis. Is it time to get back on the couch?

https://www.theguardian.com/science...evenge-of-freud-cognitive-behavioural-therapy

 

[duncan]

Mental illnesses are problems with the brain. I use brain cancer as my rubric. Would I go to a psychiatrist to treat my brain cancer if I developed it? That's just silly.

Nor would I go to one if my brain were infected by a pathogen - even if I evidenced mental problems.

If psychiatry is invoked when we don't understand the etiology or nature or cause of brain diseases/disorders, then that is a sad and dangerous placeholder.