Presidential Address
The Psychiatrist and the Clinical Practice of Psychiatry in an Uncertain Environment: Looking Ahead
Le psychiatre et la pratique clinique de la psychiatrie dans un environnement incertain : penser à l’avenir
Chers, Chères collègues,
Dear colleagues, Mesdames, Messieurs,
I wanted to honour and show recognition to the psychiatrists and the future
psychiatrists in clinical practice who are le sel de la terre, the salt
of the earth, of Canadian psychiatry.
The CPA wanted also to invite psychiatrists to pause and allow themselves
a period of recollection on what they are in an era of changing conceptual,
organizational, and philosophical issues on the shape of psychiatry—a revolutionary
period driven by technological advance. By its nature, a period of revolution
is a period of uncertainty. Added to the fact that our health system is
experiencing economic pressures and is being reexamined (commissions and
committees over commissions and committees), the mix of new diagnostic
and treatment possibilities and the lack of appropriate resources to support
them is very much evident and adds to the uncertainty.
The paradox of contemporary psychiatry is the extraordinary mismatch between
the realities of clinical practice and the impressive advances in research
that inform psychiatry.
Definition of a Psychiatrist
Who Are We?
Etymologically, the word “psychiatrist” comes from the Greek word psukhê,
or “psyche” (soul), and iatros (physician): physician of the soul.
Le Petit Larousse définit psychiatre: médecin spécialiste de psychiatrie
(a physician specialized in psychiatry). Psychiatry, according to Merriam-Webster’s
Collegiate Dictionary, is “a branch of medicine that deals with mental,
emotional or behavioural disorders.”
The CPA core services in psychiatry discussion paper notes that psychiatrists
are physicians who “enhance the person’s quality of life by providing psychiatric
assessment, treatment, and rehabilitation to people with psychiatric disorders
in order to prevent, reduce, and eliminate the symptoms and subsequent
disabilities resulting from mental illness or disorder” (1).
The Royal College of Psychiatrists observes that “psychiatrists are informed
and uniquely skilled in the integration of medicine, psychiatry, neuroscience
and the psychosocial sciences” (2).
In “Human Resource Planning for Psychiatry in Canada: A Background Paper,”
the principle author, G Hnatko, states:
The psychiatrist is trained as a clinician. Psychiatrists are primary,
secondary and tertiary care physicians who consult on many levels, to many
individuals and on a variety of treatment locations. They provide their
services across the age range. Within the scope of practice are numerous
subspecialty groups defined by separate and distinct knowledge and skill
sets (3).
The background paper goes on to say:
Although granted privileges to practice by regional authorities, it is
within the clinical role that the psychiatrist by reason of his(her) training
and qualifications undertakes full responsibility for the clinical care
of his(her) patients, without supervision in clinical matters by any other
person.
The Royal College of Physicians and Surgeons of Canada has prescribed what
specialists must now be, as set out in the CanMeds 2000 Project (4). These
skills can be restated for psychiatrists as follows: in addition to providing
medical expertise to prevent, diagnose, and treat mental disorders, a psychiatrist
must be a humanist professional, a communicator, an independent contributor
who is also a team player, a manager with decision-making responsibilities,
a learner-teacher, and a champion of the mentally sick.
The Psychiatrist as a Medical Expert in Psychiatry
What Do Psychiatrists Study?
The simple answer: “Psychiatrists focus on troubles that appear in people’s
thoughts, moods and behaviours rather than in their skin, bones and viscera”
(5).
Psychiatrists study the mind. The locus of the mind, according to the scientific
evidence we have to this day, is the brain.
The question merits an expanded answer as well, which was summarized by
Paul McHugh and Philipp Slavney:
Psychiatrists study the mind—a distinct system of capacities and functions
expressed in human consciousness as thoughts, moods and decisions. Just
like other doctors, psychiatrists study this life system for evidence of
disorders that can be treated or prevented. The components of the mind
can be individually disordered (as with memory loss), the functional interrelationships
of the components can be troubled (as unmet hopes can generate distress
and fear), or the mind’s customary goal-achieving capacities may be thwarted
(as habitual decisions go awry). By systematic assessment of the life story
and mental state of the person psychiatrists discern disorders and launch
efforts to treat them (5).
To master the discipline of psychiatry :
Psychiatrists have two tasks to accomplish. On the one hand, they must
become familiar with the features of mental disorders and their treatments
and on the other hand and simultaneously, they must grasp the implications
embedded in the several methods of explaining mental disorders that, when
unacknowledged and unordered, give psychiatry a denominationalist and factionalist
disarray inimical to progress (5).
Models of the discipline of psychiatry based on ideological points of view
periodically dominate psychiatric thinking. Factionalism in psychiatry
has divided psychiatrist practitioners into party blocs or camps according
to their beliefs. As Paul McHugh points out, “psychiatry is the only discipline
in which one practitioner asks another ‘What is your philosophy or is your
orientation?’ shortly after they have been introduced” (6).
Goldbloom and Garfinkel have noted, “The rapprochement between biological
and psychodynamic conceptual and therapeutic schools is recent and tentative,
sharing scientific vocabulary and techniques to validate each other in
public while remaining sceptical in private” (7).
How Does the Brain Generate the Mind?
The brief answer: we do not know how the brain generates the mind.
Psychiatry remains a medical discipline long on disorders and short on
explanations :
Psychiatrists, primarily because of the nature of their subject matter,
really know little about how the disorders they can identify derive from
the basic elements of life—physical or psychological. Despite impressive
advances in neuroscience, something needed to explain how consciousness
springs from the brain tissue is missing from its contribution. How does
the material brain produce such a thing as the self, I, and how does the
brain relate to it ? As yet, no scientist can connect this perception of
the I and its controlling capabilities totally to what is known of brain
structure and function. A disjunctive gap interrupts the path of explanation
from physical to psychological states (5).
At this time, the brain–mind discontinuity has to be bypassed in our everyday
clinical work.
Psychiatrists, to make sense of some mental disorders, certainly do use
the progress in neuroscience. However, the way we work with this information
is a means of circumventing the brain–mind discontinuity, not eliminating
it. Psychiatrists need several methods of explanations.
In fact, the fundamental question for psychiatric practice is What is the
nature of the problem that a proposed therapy aims to mend?
McHugh and Slavney in their book The Perspectives of Psychiatry (5) identify
4 standard methods for explaining mental disorders implicit in contemporary
psychiatric thought. The methods, which these authors call perspectives,
offer a visual metaphor intended to emphasize that each method can illuminate
some aspects of psychiatric responsibilities but will be blended with other
concepts. They are as follows:
-
the disease perspective
-
the dimensional perspective
-
the behaviour perspective
-
the life story perspective
Whether we agree or not with what these authors propose, psychiatrists
must be familiar with several different modes of explanations to comprehend
both the diversity of mental disorders among their patients and the pitfalls
of their treatment.
Gnothiseauton (Connais-toi toi-même. Know thyself.)
This inscription on the temple of Apollo in Delphi was chosen by Socrates
as his motto. What do psychiatrists in clinical practice know, or what
should they know, about their medical-expert selves?
That they exercise their trade, their art and science, in an era of changing
conceptual, organizational, and philosophical issues on the shape of psychiatry—a
period of explosive growth of knowledge in neurobiology and progress in
psychosocial sciences—an era in which scientific advances frequently make
the most recent scientific or medical journal obsolete by the time of publication
or shortly thereafter.
But psychiatrists also know that, while extraordinary progress has taken
place in the diagnoses and treatment of mental disorders in the last half
of the 20th century, and while the efficacy of short-term treatments is
also proven and sustains the comparison with other specialities of medicine
(80% short-term remission for bipolar disorders and panic disorders; 65%
short-term remission for major depression; 60% short-term remission for
obsessive–compulsive disorders and schizophrenia [NIMH 1993]), the fact
remains that, in the long term, several mental disorders show an evolution
marked by relapses and chronicity.
It is worth remembering that 2002 marks the 50th anniversary of the clinical
trials of chlorpromazine (Largactil ) in psychiatry by Jean Delay and Pierre
Deniker, in Paris, France. Their discovery opened the way to treatment
of patients suffering from severe psychotic disorders and the development
of psychopharmacology. The neuroleptic drugs—a term coined and proposed
by Professor Delay—transformed psychiatric treatment radically and contributed
largely to revolutionizing the psychosocial organization of psychiatric
care and psychiatry. The neuroleptic medication confirmed and ratified
the psychiatrist dans son rôle de médecin soignant (in his role of physician)
as a treater of severe mental disorders. The door was opened to ambulatory
treatments and the transformation of mental institutions. Psychopharmacology
is not the only instance responsible for this revolution, but it had much
to do. “Psychopharmacology” and “neuroleptic” rapidly became household
words in psychiatry and in medicine in general.
“But still we have no cures. Indeed we have no illnesses. We have syndromes
and clusters but as yet no definitive tests for our diagnosis (8).” The
psychiatrist in clinical practice knows that.
With the developments in genetics, in neurotransmitters understanding,
in neuroimaging technology, we may have begun to address the need for diagnostic
tools but nevertheless the tests are not available (8).
1 | 2
| 3
|
