What do psychiatrists actually do? Our perceptions are shaped, if not by direct personal experience, largely by popular culture. And that is often expressed in newspaper and magazine cartoons as well as on movie and television screens.
In newspapers, a common editorial cartoon features a balding, bespectacled, vaguely mittel-Europa male psychiatrist sitting behind a couch, with a patient recumbent on it. One of the two of them is saying something ridiculous to make a political or social comment; it matters not which of the dyad is speaking. It perpetuates the idea that psychoanalysis remains the dominant approach in psychiatry rather than a more vestigial one, and often suggests either the psychiatrist or the patient is a buffoon. Or both.
In film, thanks to Irving Schneider’s 1987 scholarly paper on the theory and practice of movie psychiatry, we have a typology of three recurring depictions of psychiatrists since 1906 – labeled Dr. Dippy, Dr. Evil, and Dr. Wonderful. The first is crazier than any patient he sees (think Peter Sellers in What’s New, Pussycat?). The second abuses his power and privilege for malign intent (think Michael Caine in Dressed to Kill). The third is all-knowing, omni-available, and more empathic than anyone else in the patient’s life (think Judd Hirsch in Ordinary People). These reflect our extreme fears as well as our deepest wishes about psychiatrists.
Similarly, depictions of treatment modalities like electroconvulsive therapy (think One Flew Over the Cuckoo’s Nest), psychotherapy, and medication bear little resemblance to the real world of evidence-based help.
But these caricatures play into our fears about our mental health and, by extension, the people who treat mental illness. There is no greater threat to our personal identity than mental illness. If your leg is broken, you are still you. If your mind is not working, if your brain is broken, are you still you in how you see yourself and others see you? Separating the illness from the person and appreciating how the two interact is the art and challenge of psychiatry; treating the illness and the person is the science and the goal of psychiatry.
So more than a decade ago, I decided to “write what I know” about what it is like to be a psychiatrist. I did so in collaboration with my friend and colleague Dr. Pier Bryden, who forced me to confront aspects of our work that is the most challenging and also provided historical context to our shared profession. She is also an alumna of Oxford, having completed an MPhil in Politics prior to medical school.
I took a momentous week in my professional and personal life to show what a hospital-based psychiatrist does and how it affects him – how his personal and professional lives intersect.
When my friends and medical colleagues said to me as a medical student, “I can’t believe you’re going into psychiatry”, it was at best a compliment that I seemed like a regular person – and at worst a denigration of the field and a disdain for its patients. When in psychiatric training one of my friends said this to me, she added, “I could never do what you do. I would find it so depressing”. She was training in oncology at that time in the 1980s, when outcomes were far worse than now (and more of her patients died of their diseases than mine did).
How do psychiatrists deal with the pain to which they bear witness? How do they maintain necessary therapeutic optimism? That’s also part of this book. Spoiler alert: over a 40-year career, I had ample opportunity to see people get better, both in terms of symptoms as well as quality of life. But, like all physicians, I also lost patients to their illnesses.
We wrote this book a decade ago, while I was still in active practice as an academic clinician. It took several years to write (and five long days in a recording studio to narrate it for the Audible version). It has found audiences among patients, families, students, colleagues and in the one-in-one members of the general public who have experienced mental illness or witnessed it at close range in someone they care about. If it broadens understanding of the real worlds of the experience of mental illnesses and roles of psychiatrists, then it meets its goal.