Social media: the latest disruptor

“Social media is only the latest disruptor in the history of medical and scientific communication.”

– Harrison et al, The British Journal of Psychiatry 2019

Introduction

Writing in the highly-regarded British Journal of Psychiatry, Harrison St al argue that internet-based social media platforms are just the latest change in the way doctors and scientists share information. This claim has particular relevance to psychiatrists working through a global pandemic which has driven more and more of our patient and colleague communication online.

Social media refers to online forms of communication, such as Twitter, Facebook, Instagram and TikTok, which are widely available and which build networks or communities of “friends” and “followers”. A disruption is something which challenges and displaces the status quo. Medical and scientific communication refers to the way clinicians and researchers share information.

Only the latest disruption

From a historical perspective, Harrison et al are correct that social media has arisen as the latest in a long line of advances in medical and scientific communication. From Ancient Greece, where Hippocrates taught followers beneath a plane tree, to the invention of the Gutenberg printing press which made written material widely available, to modern scientific conferences, clinicians and researchers have always found ways to share their knowledge. Across history, these means have adapted to the social norms and technologies of the day. Many of these changes were initially greeted with skepticism and wariness – including fears that access to books would make people’s minds lazy – echoing some of the negative predictions about social media. Yet, in each case, the benefits of wider access to information have on the whole been positive.

Not just another disruptor

On the other hand, several features of social media set it apart from all prior inventions in medical and scientific communication. The most important of these is the way it democratises access to information. This plays out in two ways. First, anyone anywhere with a mobile phone and access to the internet can use these technologies. Unlike medical textbooks, journal subscriptions, or medical conferences which cost hundreds to thousands of dollars, the barriers to entry are low. Secondly, the extent to which people’s views are heard – whether someone achieves “likes, followers, and leading” – depends not on conventional markers of status and authority, but rather on whether they have something to say that others perceive as worth hearing.

Implications for psychiatrists

These features of social media have implications for clinical practice, professional ethics, and recovery from mental illness.

An increasing body of research shows that social media is immensely valuable for clinicians in staying up to date with latest developments, connecting with colleagues, and disseminating research findings. In addition, almost all of our patients’ lives are touched in some way by social media. A sound grasp of these platforms is needed to provide effective clinical care especially in relation to issues such as online bullying and internet use disorder (not yet a DSM 5 diagnosis, but often seen especially in adolescent populations).

From an ethical perspective, social media brings new challenges. As recognised in the RANZCP Position Statement on social media, these fall into three categories: first, concerns about the confidentiality of patients and colleagues (Principle 4 RANZCP Code of Ethics 2018); second, concerns about professional boundaries (eg looking up patient information or contacting patients online); and third, concerns about the accuracy and professionalism of information being shared. Social media guidelines, such as those promulgated by the College, are important for all psychiatrists and trainees to be aware of as we seek to fulfil our roles as communicators and advocates as well as medical experts (CanMEDS Framework).

Finally, social media has profoundly influenced the consumer-led recovery movement. For people with lived experience of mental illness, social media is not “only the latest disruptor” in medical and scientific communication; it offers a complete paradigm shift. For the first time, people with lived experience have wide access to new research findings and opinion leaders in psychiatry. And rather than being a heavily one-way channel of communication – like textbooks, journals, or conferences – social media gives patients the opportunity of an equal voice. Author Arundhati Roy says “there is no such thing as the voiceless, only the deliberately silenced and the preferably unheard”. With the advent of social media, mental health activists like Indigo Daya can no longer be silenced, as they accrue many thousands of followers and engage in meaningful dialogue with clinicians, politicians, and policy makers.

Conclusions

In the end, social media is the latest disruptor in a long line of evolutions from face-to-face clinical teaching to the printing press, journals, and conferences. However to say it is “only the latest” understates its importance. By opening up access to medical and scientific information, social media brings patients, clinicians, and researchers into conversations as active partners. We are only just beginning to see the resultant paradigm shift. Psychiatrists can choose to be late followers or to step forward as leaders: with or without our “likes” the democratisation of access to medical and scientific information through social media is happening.

Will we be better for it?

“Psychiatrists are tasked with drawing insight and uncovering hope in what are often dark situations. As psychiatry residents, we are in the heart of practicing this, day in, day out, and I think we will be better for it.” – Priya Gearin, 2020

Introduction

Writing in “Learning to do therapy” Priya Gearin argues that psychiatry residents – and by implication psychiatrists – benefit from our day to day work. In particular, Geaein suggests that our ability to draw insights and find hope in difficult circumstances makes us better people. This optimistic reflection is of particular relevance to trainees and psychiatrists practising in Australia in 2020 given the profound challenges posed by recent events, including severe bushfires, a global pandemic, and escalating mental health presentations.

Insight can be defined as awareness or enlightenment. Hope is a term that embodies a belief in a better future. The “dark situations” referred to by Geaein are the sad, confronting, distressing, and grief-laden events encountered in psychiatric practice. These may include disclosures of trauma or abuse, deaths of patients, or assaults on staff. Finally, the phrase “we will be better for it” implies a form of benefit such as new learning or greater resilience.

Psychiatrists are better off for our experience in dark situations

From a historical perspective, the concept of personal growth being tied to the practice of psychiatry is closely linked with Freudian models of psychoanalysis. Freud proposed that mental illness reflected unconscious conflicts, often arising from childhood. Given the centrality of the patient-therapist relationship, Freud emphasised the importance of therapists knowing themselves well in order to differentiate transference from the patient from the therapist’s own defences. Thus began the tradition of psychiatrists undergoing their own therapy as part of their training to “draw insights” which helped them to understand their patients and themselves.

More modern concepts of recovery from mental illness, and resilience to trauma, have hope at their heart. The ability of psychiatrists to sit with unimaginable grief and loss, while holding onto hope for recovery, is a quality that can develop during our training. By holding onto this sense of hope, both  patients and practitioners can experience what is known as post-traumatic growth, where dark situations – such as the COVID-19 pandemic – become a portal or gateway to a better world (Arundhati Roy, The Pandemic as a Portal).

Psychiatrists are worse off for our experience in dark situations

However, evidence-based research indicates that practising psychiatry is not always beneficial for the practitioner. Milner et al’s analysis of national coronial data (Milner et al, MJA) found that women in medicine die by suicide at a rate twice that of women in other occupations. Among the medical specialities, psychiatrists are reported to AHPRA for health impairments at substantially higher rates than our physician colleagues (Veness, BMJ Open). This is likely to reflect, at least in part, the emotionally taxing nature of the work that we do, day in and day out.

Unfortunately, the culture of medicine sometimes contributes to this harm. Some workplaces, and some senior clinicians, still hold the view that doctors should be able to stoically withstand long hours, demanding interactions, and over-stretched services. In my own clinical experience, onerous rosters, workforce shortages, and inadequate resources during times of crisis can lead to depersonalisation, emotional exhaustion, and reduced personal efficacy. These symptoms of burnout do not make us “better for it” but rather can impact negatively on patient care and our own wellbeing. This harm can be particularly profound when clinical challenges interact with other workplace challenges such as bullying and harassment (RACS, Operate with Respect).

Our work can both help us and harm us

The reality is that dealing with dark situations day in and day out can both harm and strengthen us. One of the differentiating factors is the nature and degree of professional support available to trainees and psychiatrists. The RANZCP Code of Ethics explicitly acknowledges the ethical responsibility we have to nurture our own wellbeing and also to care for colleagues. This can be achieved through supervision, Balint groups, peer review and supportive friendships with colleagues.

Conclusions

In the end, walking with patients through some of the most difficult days of their lives is an immense privilege. Our training as psychiatrists has the potential to equip us with profound insights into the human condition. However, it would be naïve to assume that exposure to dark situations necessarily makes us better off. Whether people experience post- traumatic stress or growth is influenced by the person themselves and the connections and support around them. As we come to the end of a year of unprecedented challenge we would all do well to reflect on what we can do to nurture conditions for growth in ourselves and in our colleagues.

The power to label is the power to destroy

Psychiatric taxonomies, always a little uncertain, are most confused and illogical when they endeavour to encompass the moral and legal aspects of human behaviour. – J Ellard

Introduction

Writing in the provocatively titled “Some Rules for Killing People”, Ellard draws attention to the fraught endeavour of classifying mental illnesses into a taxonomy. Ellard suggests that the greatest difficulties arise at the interface between illness and morality or law. This assertion has particular relevance to modern psychiatry given increasing rates of psychiatric diagnoses, and growing concern about the pathologisation of normal human behaviour (Frances, Saving Normal).

Words matter so, before we begin, a few definitions. Taxonomies are methods of classifying objects or concepts: like with like. Common examples include taxonomies for classifying plants into species or dogs into breeds. Illogical refers to something that defies reason. Morals refer to our understanding of right and wrong. In psychiatry, the two most widely used taxonomies are the Diagnostic and Statistical Manual, now in its Fifth Edition (DSM-V) and the International Classification of Diseases (ICD).

Taxonomies of human behaviour are confused and illogical

Ellard’s statement reflects a long-running debate in the history of psychiatry – exemplified by two men, both born in Europe in the year 1856. Sigmund Freud, the Viennese father of psychoanalysis, believed that every person’s state of mental health is unique and reflective of childhood experiences and unconscious conflicts between the ego, superego, and id. By contrast, Emil Kraepelin, the father of modern psychiatric classification systems, thought the Freudians were “building castles in the air” (Kraepelin). He preferred to group mental illnesses together based on observable symptom clusters and the natural history of the disease. His approach is exemplified by the distinction between the degenerative illness “dementia praecox” (close to our concept of schizophrenia) and the fluctuating course of “manic depressive insanity” (now known as bipolar affective disorder).

From an ethical perspective, the use of taxonomies to encompass moral and legal aspects of behaviour has been a source of tremendous harm. For example, homosexuality was classified as a mental illness in several editions of DSM before finally being removed under the watch of Robert Spitzer in the 1970s. The behaviour of women, subject to oppressive systems of patriarchy, has been similarly pathologised through diagnoses such as hysteria (the wandering womb). Even today, women are much more likely than men to be labelled with borderline personality disorder, a diagnosis which is often used pejoratively. Some prominent psychiatrists have expressed concern that “the power to label is the power to destroy” (Allen Frances, Saving Normal). Indeed many people with lived experience of mental illness believe that the diagnoses they were given violate Hippocrates’ injunction: primum non nocere (first, do no harm).

Taxonomies can reduce confusion and illogical thinking

Conversely, taxonomies can be seen to have reduced confusion and illogical thinking in many areas of psychiatry. Psychologist Jeremy Sherman says “to name it is to tame it”. In my clinical experience, the use of taxonomies can aid clear communication by ensuring that diagnostic labels refer to a similar set of symptoms whether you are working in primary care, emergency medicine, or the forensic system.

Indeed, much of our research-based evidence on what does and doesn’t work in psychiatry owes thanks to psychiatric taxonomies. Without some form of classification system, it is impossible to know whether you are comparing similar groups of patients when assessing the impact of an intervention. This includes research into disorders with clear moral and legal dimensions such as conduct disorder, substance use disorder, and paraphilias.

Taxonomies flawed but necessary

F Scott Fitzgerald famously spoke of the value of having “the ability to hold two competing ideas in mind and still retain the ability to function”. And so it is with taxonomies in psychiatry: they can be confused, uncertain, and illogical, and yet – at the same time – a useful and necessary tool. The RANZCP Position Statement on classification systems emphasises that taxonomies have an important role to play in research and clinical practice, while urging psychiatrists to be mindful of their limitations and to apply them with “common sense”. Similarly, Allen Frances – former Chair of the DSM Taskforce – emphasises that psychiatrists need to understand taxonomies but not be beholden to them.

Particular caution needs to be exercised when applying standardised diagnostic tools to patients from diverse cultural backgrounds. Common human experiences including grief, pain, and depression may manifest differently in different cultures. DSM diagnostic criteria should always be supplemented with a more nuanced understanding of the person and their context. Here, the person’s own understanding of their experience, and the insights of indigenous mental health workers and cultural liaison workers have an important role to play.

Conclusion

In the end, Ellard is right that taxonomies are uncertain, and sometimes even confused and illogical, especially when applied to moral and legal aspects of behaviour. However, we cannot let the perfect be the enemy of the good.

Rather than discarding taxonomies we need a clear-eyed view of their weaknesses and strengths, a commitment to continuously seeking to improve them, and a focus on adapting taxonomies to the needs of our patients. Particular scrutiny needs to be applied when using taxonomies in ways that may further disadvantage marginalised groups, as occurred with the labelling of homosexuality and hysteria as diseases. Taxonomies are but a tool of our own creation, and a tool that must be shaped and used wisely.

On Shamans and Charlatans

“I don’t hold with shamans, witch doctors, or psychiatrists. Shakespeare, Tolstoy, or even Dickens understood more about the human condition than ever occurred to any of you. You overrated bunch of charlatans deal with the grammar of human problems, and the writers I’ve mentioned with the essence.”

― Mordecai Richler, Barney’s Version

Introduction

Writing in Barney’s Version, Richler condemns psychiatrists as “an overrated bunch of charlatans”, no better than shamans and witch doctors. Richler suggests that great authors are better able to capture the heart of the human condition than psychiatrists. Richter’s critical views present an important challenge for psychiatry as we face increasing pressure to conform to rules and standards, perhaps at the expense of understanding our patient’s unique essence.

Richter likens psychiatrists to shamans or witch doctors, two groups that are defined by promises of cure without substance. His concept of the “human condition” goes beyond illness to include those aspects of life that give connectedness, hope, identity, and meaning to our lives (CHIME, Leamy). “Grammar” refers to the technical process by which a story is formed, while “essence” refers to the meaning.

Psychiatrists who missed the essence

Looking back over the chequered history of psychiatry, there is much truth to Richler’s criticism. From Hippocrates’ theory that mental illness resulted in an imbalance of the four humours, through to biological psychiatrists high hopes for “the decade of the brain”, our profession has long sought to reduce the human experience to its component parts (“the grammar”). As a result, patients have been subjected to a range of ineffective and inhumane procedures: insulin comas, orgone therapy, and frontal lobotomies to name just a few (Lieberman 2015, Shrinks).

However, in shifting from a paternalistic world of “doctor knows best” to one in which individual rights are respected, we still carry the risk of focusing on grammar rather than essence. From an ethical and legal perspective, modern psychiatry has a heavy focus on the right of individual autonomy for every “human being of adult years and sound mind” (Justice Cardozo in Schloendorff). Yet feminist scholars like Carol Gilligan (“In a different Voice”), would argue that theories of ethics which focus on individuals are missing the essence of the human condition in which relationships are the most meaningful source of roles and responsibilities. Gilligan’s ethics of care resonates more closely with the deeply complex and interconnected worlds of Tolstoy, Shakespeare, and Dickens than technical discussions of competence and capacity.

The importance of the grammar

At the same time, the reductionist and rule-driven approach of grammar purists is not entirely without merit. The use of DSM V diagnoses to provide a shared language between psychiatrists has enabled us to compare the outcomes of different therapeutic approaches in a rigorous and robust way. Research shows that – overall – doctors who follow checklists and abide by evidence-based guidelines achieve better outcomes for their patients than those who rely solely on their own judgement (Gawande, The Checklist Manifesto).

In my own clinical experience I have seen patients with the same presentation receive highly inconsistent care, based purely on where the treating psychiatrist trained or which pharmaceutical company lunch they last attended. I have also seen the harm that can result when the same words (“borderline”, “behavioural”, “non-compliant”) are used in inconsistent ways by different clinicians, resulting in profound misunderstandings. In these situations there is much to be said for the discipline of abiding by an underlying set of principles, and using a shared language, which is what “grammar” offers us.

The grammar and the essence

An alternative view is that Richler is offering us a false dichotomy. Rather than having to choose between grammar and essence, perhaps it is possible to have both. Indeed, the literature of Shakespeare, Tolstoy, and Dickens was created by authors with an outstanding command of language. When they broke grammar rules, it was not through ignorance, but a deliberate choice. Similarly, I suggest that the best psychiatrists are those who have a mastery of both the “grammar” and the “essence”: the ones who are familiar with professional norms and evidence-based guidelines yet have the clinical wisdom to see the person as a whole and to know when to depart from the rules.

This integration of structure and meaning is consistent with indigenous understandings of illness and recovery. For example, Mason Durie’s Whare Tapa Wha model of health has a sound structure and framework (“the grammar”) but is also broad enough in its incorporation of taha whanau (family), taha tinana (body), taha wairua (spirit) and taha hinengaro (mental health) to ensure that the essence of the person is seen and respected.

Conclusion

In the end, psychiatrists – like great writers – seek to understand the human condition. Unfortunately, the history of psychiatry is littered with examples of reductionist approaches, which sought to disassemble mental illness, and ultimately did more harm than good. At the same time, important gains in care have been achieved through the rigorous development of a shared language and robust evidence about what works and what doesn’t. The best psychiatrists, like the best writers, are not the ones who throw the rule book out the window. Rather, they are the ones whose mastery of grammar is such that it enhances – rather than detracts from – their ability to understand and communicate the human condition.

Climate change: the greatest threat to global health

Climate change is the greatest threat to global health in the 21st century. Health professionals have a duty of care to current and future generations.

– World Health Organisation

Introduction

The World Health Organisation (WHO) – the world’s leading international public health body – has declared our changing climate to be the largest danger to health around the world. WHO calls on health practitioners to act on this threat to protect the communities we serve, both now and in the future. This essay will explore the multifaceted relationship between climate health and mental health, and the role of psychiatrists in responding to WHO’s call for action.

Climate change refers to the steady increase in global temperatures due to human impact on the environment, and in particular rising levels of CO2 which trap heat causing a greenhouse effect and increased probability of severe weather events. A threat is a hazard or danger. Health is defined by WHO as more than the absence of illness: it is a state of complete physical, psychological, and social wellbeing.

Climate change and mental health

From a historical perspective, psychiatrists have long appreciated the interrelationship between mental health and nature. The first asylums were located in large gardens where people could reconnect with their health by reconnecting with nature. During World War I Florence Nightingale found that shell-shocked soldiers recovered faster when they had access to gardens and greenery. While modern mental health hospitals have often shrunk back to stark and unappealing buildings, some of the most effective treatment programs in the world, such as the San Patrignano drug rehabilitation program in Italy continue to make extensive use of gardens and horticulture in their therapeutic communities (Stuart-Smith, The Well-Gardened Mind). These relationships exist at the community as well as individual level, with research showing that rates of depression and violent crime are lower in neighbourhoods with ready access to green spaces. The looming climate crisis brings the relationship between mental health and our environment into stark focus at an even larger scale.

A growing body of research shows that the climate crisis threatens mental health in four profound and inter-related ways (RANZCP Position Statement on climate change and mental health). First, climate-related natural disasters such as floods and fires can have a direct impact on mental health by causing trauma through injury, death, and destruction. Second, climate-related extreme weather events such as heatwaves and storms amplify existing health disparities for those with mental illness by disproportionately affecting people who are homeless or living in inadequate housing. Third, at a global level, deforestation, drought, salination of water, and rising sea levels are likely to lead to a new generation of “climate refugees” contributing to the mental health challenges associated with displaced populations (Al Gore, An Inconvenient Truth). Finally, there is a risk of new and emerging infectious diseases as shrinking animal habitats bring novel pathogens, from bats and other animals, into closer contact with humans, and warmer temperatures allow the spread of disease-carrying mosquitos. The current COVID-19 pandemic is a clear example of the potential mental health impacts of emerging infectious diseases.

Duty of care to current generations

For psychiatrists, the WHO’s contention that we have a duty of care to current generations of patients affected by climate change is uncontentious. In current clinical practice, many Australian psychiatrists have provided care to people affected by bush fires, floods, heatwaves, and the effects of the coronavirus pandemic. Indeed, many psychiatrists have rapidly adapted models of care to reach fire and pandemic affected patients through Telehealth rather than conventional face-to-face assessments. The College of Psychiatry has supported these innovations and advocated strongly for new models of mental health support for affected communities.

Duty of care to future generations

The more controversial aspect of the WHO’s call to action lies in its assertion that we have a duty of care to future generations. This requires a wider understanding of psychiatrists role in society, as not just medical experts, but also as advocates, collaborators, and scholars (CanMEDS). Through participation in organisations such as Ora Taiao, the New Zealand Climate and Health Council, psychiatrists can contribute to wider efforts to advocate for strong climate action. This action can begin with a commitment to environmental sustainability our own workplaces, with hospitals being a major contributor to carbon emissions, and expand to wider social advocacy on issues such as the carbon tax and use of renewable energy.

From an ethical perspective, Don Berwick – the former head of the Institute for Healthcare Improvement – has argued that doctors have ethical duty to address the “moral determinants of health” (JAMA). These moral determinants include humanity’s relationship with the natural world, and the social inequalities which allow the top 1% to profit at the expense of the environment and the health of those at the bottom of the social-economic ladder. Similarly, British psychiatrist Sue Stuart-Smith (The Well-Gardened Mind) makes a compelling case for those who care about mental health to also care about humanity’s relationship with our natural world.  

Conclusion

In the end, the health of humans and the health of our environment are inextricably intertwined. Climate change poses an unprecedented threat to mental health. While psychiatrists will always have a role in responding to the mental health needs of individual patients in the here and now, the scale and urgency of the climate crisis demands a larger response from us. Our duty of care to future generations calls on us to advocate for meaningful climate reform in our own workplaces, our communities, and in our government’s response to the greatest mental health threat of our lifetimes.

Inventing hope

“Where there is no hope it is incumbent on us to invent it”.

• Albert Camus, The Stranger

Introduction

Writing in his classic novel “The Stranger” author Albert Camus speaks of the primacy of hope in the human experience. He calls on the reader to generate hope in apparently hopeless situations. Working in a medical specialty where our patients may at times be considered “hopeless” (by society, by clinicians, or by themselves) this call has special relevance to psychiatrists.

We can define “hope” as a belief in something better, a sense of optimism that the future can be better than the present. “Incumbent” carries a sense of duty or obligation: something that must be done. The word “invent” refers to creating something that did not exist before.

Incumbent on psychiatrists to invent hope

From a historical perspective, mental illness has often been seen as a “hopeless” disease. From ancient times, people with serious mental illnesses have been shunned or pushed to the margins of society. Some of the most significant breakthroughs in mental health care came from clinicians who dared to hope for a better future for their patients. Notable examples include French psychiatrist Phileppe Pinel and American psychologist Marsha Linehan. Working in France at the turn of the 19^th century, Pinel – supported by his colleague and former patient – Jean-Baptiste Pussin – freed “hopeless” patients from their chains at the Salpetriere asylum in favour of a more moral treatment. More recently Linehan devoted her life to showing that there is hope for patients with borderline personality disorder to recover from what was previously seen as an untreatable personality disorder. Their commitment to inventing hope changed the lives of countless patients.

In my clinical experience, working with profoundly suicidal patients, I have observed skilled senior clinicians telling patients that they will “hold onto hope” until the patient can feel hope for themselves. Reading the memoirs of patients like Prof Elyn Saks (“The Centre Cannot Hold”) these moments, where a clinician created hope when the patient felt none, can be life-saving.

Not incumbent on psychiatrists to invent hope

On the other hand, psychiatrists have an ethical obligation of truth-telling. Virtue ethics holds honesty as an important virtue. Philosopher Dame Onora O’Neill – in her Reith Lectures – speaks of honesty as an integral component of being worthy of trust. These ethical obligations are echoed in the legal concept of informed consent. Informed consent is only possible if a patient receives honest and balanced information about their illness, the effectiveness of treatment options, and their likely prognosis (Rogers v Whitaker 1992). Presenting a falsely hopeful picture – such as guaranteeing recovery after ECT with no memory loss – would be both unethical and illegal.

Despite significant advances in psychiatric research, the reality is that we still don’t have assured methods of treating all patients, and profound disparities exist for Maori and Aboriginal patients. For example, at an individual level some patients have what is termed treatment-resistant schizophrenia which does not even respond to clozapine. At a population level, people with a serious mental illness have a life expectancy around 20 years less than that of people without a mental illness (NZ Inquiry into Mental Health and Addiction). Rather than inventing hope, perhaps what we need is more raw honesty about which patients and sectors of society are being failed by our current treatments and systems of care.

Create but don’t invent

Perhaps the best way to resolve these tensions is through a focus on building “honest hope”. Hope is a central element of the CHIME recovery framework (Leamy 2011). However, in the recovery context advocates like Indigo Daya do not want false platitudes from the mental health profession. Rather “honest hope” arises from a commitment to working with every individual to help them find, create, and keep a personally meaningful life. It also means being truthful about the benefits and limitations of what psychiatry can offer so that patients are empowered to make choices that support their own recovery goals.

Conclusions

In the end, hope lies at the core of the human experience. It is what enables people to keep going through the most difficult of times. In situations where a patient is despondent of their depression ever lifting, or where a society is ready to write off a group of people as “hopeless”, it is incumbent on psychiatrists to create hope where none exists. However, this hope must be honest and not hollow. Rather than offering empty platitudes, the hope we give must be grounded in reality and accompanied by a commitment to bringing about a better world by walking with patients through their hardest times and shining a light for a path to a fairer and more inclusive society.

Selling alcohol like milk and bread

Alcohol delivery services are allowed to operate like cowboys in Victoria – it’s causing harm and it’s time to rein them in. Alcohol causes memory loss and fuels injury and violence – and that’s not even taking into account the long-term health impacts like cancer and stroke. We need to stop treating the alcohol industry like they’re selling benign products like milk and bread.
– VicHealth CEO Dr Sandro Demaio May 2020

Introduction

The Chief Executive of Victorian public health agency, VicHealth, is a vocal critic of industries that harm public health. Earlier this year he called for the “cowboys” delivering alcohol to homes to be reined in. The extent to which individual choice should trump population wellbeing in the area of alcohol sales is a question of relevance to all psychiatrists, given the detrimental impact of alcohol on mental health.

Alcohol delivery services – similar to takeaway food delivery services – allow individuals to purchase alcohol online and have it brought to their home for a small additional delivery fee. These services often offer delivery within the same day, or even within the hour. The phrase “cowboys” brings up an image of “the Wild West” – a land without rules, although the sale of alcohol – including home deliveries – is in fact subject to detailed laws and regulations.

Alcohol delivery is a consumer product

The tension between social order and individual pleasure is as old as human history. The Ancient Greeks worshipped both Hygeia – the goddess of health and hygiene – and Dionysus – the god of wine and ecstasy. In some cultures (e.g. modern Iran) and periods in history (e.g. prohibition of the 1920s) alcohol has been banned from sale. However, in modern society, alcohol is normalised as a social lubricant, with a ubiquitous presence at work functions, restaurants, weddings, and funerals. Many people use alcohol recreationally, as a consumer product, without significant harm.

From an ethical perspective, libertarians (like John Stuart Mill) would argue that – as long as an individual is not harming anyone else – their decision about what, when, and where to drink should not be restricted by the state. Our current alcohol delivery laws certainly lean towards privileging individual autonomy over broader questions of social justice. This is consistent with laws permitting the sale of cigarettes (a product that kills half of its customers when used as directed) but in marked contrast to the criminalisation of cannabis.

Alcohol delivery needs to be reined in

On the other hand, decades of research unequivocally demonstrate the harm caused by alcohol. Using a biopsychosocial model (Engel), these harms can be conceptualised as biological (e.g. risk of liver failure, oesophageal varices, cancer, and stroke), psychological (e.g. increased rates of depression, dementia, and suicide), and social (e.g. association with assault, motor vehicle accidents, and intimate partner violence). Research by Professor David Nutt has shown that the harms associated with alcohol are greater than those for cannabis, heroin, and many other drugs. Ease of access to alcohol has been shown to increase the probability of harm, with home delivery of alcohol providing perhaps the easiest access of all.

In the clinical context, psychiatrists encounter alcohol-related harms on a regular basis. Unfortunately, our services are poorly designed to care for people with dual-diagnoses and it remains much more difficult to impose involuntary treatment on someone who is close to killing themselves with alcohol than someone who is close to killing themselves with paracetamol. Sadly, these harms disproportionately fall on the most vulnerable groups in society, with people who are unemployed, who have mental illnesses, or who come from indigenous backgrounds having higher rates of alcohol dependence and harm.

One of the key challenges for our profession, is whether we should confine ourselves to treating individual patients, or whether we should join Dr Demaio in publicly advocating for stricter regulatory controls. Under the CanMEDS framework, being a scholar, collaborator, and advocate is just as much a part of being a psychiatrist as our more traditional role as medical experts. As trusted health experts, doctors have a crucial role to play in drawing the attention of the public and policymakers to the harm of liberal alcohol laws, including the availability of home delivery services.

Conclusions

The debate about the appropriate balance between individual freedom and safe and healthy communities has been with us for millennia and is unlikely to be resolved soon. A socially liberal approach would argue that individuals have the right to purchase services, such as alcohol delivery. However, research and clinical practice clearly indicate that the harms associated with alcohol are severe and far-reaching. Psychiatrists can play an important role in promoting robust and evidence-informed decision-making around alcohol policy settings. Stronger regulation of alcohol laws in general, and home delivery in particular, would help to reduce these harms with consequent benefits for some of the most vulnerable members of society.

The goodness of the physician

“As long ago as 400BC, Hippocrates wrote of how “the patient, though conscious that his condition is perilous, may recover his health simply through his contentment with the goodness of the physician”

Di Blasi et al (2001). – Influence of context effects on health outcomes: a systematic review. The Lancet

Introduction

Writing in The Lancet – one of the world’s leading peer-reviewed medical journals – Di Blasi recalls the words of Hippocrates, the Ancient Greek father of medical ethics. Hippocrates’ emphasised the healing power of trust in the patient-practitioner relationship: a concept of renewed relevance to psychiatry in an era of guidelines, pills, electronic records, where “contentment with the goodness of the physician” can easily be relegated to the side-lines.

In thinking about what it means to recover health, we can define health as more than the absence of illness, involving a state of physical, psychological and social well-being (World Health Organisation). Contentment is a state of happiness or satisfaction. The “goodness of the physician” can be understood as referring to the personal and ethical qualities of a doctor rather than their technical skill.

The patient-practitioner relationship supports recovery

For much of human history, the mainstay of psychiatric treatments was the human relationship. From ancient shamans, to mediaeval priests, to Freud’s talking cure, treatments for mental illness were vested in the patient’s trust in their chosen healer. Indeed, before the development of chlorpromazine in the 1950s (Charpentier / Laborit) a trusting relationship with a good doctor was one of the few effective treatments available to patients with a serious mental illness.

Years of robust research show how powerful a patient’s belief in (or “contentment with”) treatment can be. For example, double-blind placebo­-controlled studies of antidepressants consistently show that around a third of depressed patients improve with placebo treatment. There are two main explanations for this. The first is that the natural course of many illnesses is self-limiting (or at least episodic) with symptoms naturally resolving over time. The second is that our beliefs have a powerful influence on our biology. Contrary to the mind-body dualism proposed by Descartes, there are profound connections between mind and body, and a doctor who engenders trust and hope can have a powerful healing influence.

Recovery can occur without contentment in one’s doctor

On the other hand, in modern psychiatric practice it would be unethical for a psychiatrist to seek to treat a patient with “contentment” alone, without at least considering the role of other modalities of care. The legal and ethical principle of informed consent requires us to discuss the nature, risks and benefits of treatment, including a discussion of reasonable alternatives (Rogers v Whittaker, Principle 5 Code of Ethics). While some patients may choose therapy alone (relying on the “goodness” of their doctor for their cure) others will prefer to place their trust in biological therapies such as medication or transcranial magnetic stimulation.

Indeed, in the clinical context, we can all recall situations where a patient recovered – not because of their positive relationship with their doctor but rather in spite of it. This is particularly true in inpatient psychiatric wards, where a patient may be subject to involuntary treatment under a Mental Health Act. In my own clinical experience I have seen patients with persecutory delusions that their treating team was trying poison, destroy, or kill them, nevertheless achieve full resolution of their psychotic symptoms with the use of antipsychotic medications and time.

The patient-practitioner relationship is not always sufficient for recovery

For many patients, the best hope of recovery will come from a therapeutic engagement with a trusted clinician, complemented by judicious use of medicines, support from loved ones, and engagement in personally meaningful activities. Writing about her recovery from schizophrenia, Professor Elyn Saks (The Centre Cannot Hold) reflects on the crucial role of her beloved therapist Mrs Jones: “While medication kept me alive, psychoanalysis helped me find a life worth living.”

Conclusions

After 2000 years, the words of Hippocrates still carry a deep wisdom. As the title of Di Blasio’s article suggests, context affects health outcomes. The powerful effect of talking therapies and placebo pills indicates that trust in one’s doctor can facilitate healing. Yet for some patients, the therapeutic relationship will be neither necessary nor sufficient for their recovery. The challenge for psychiatry is to incorporate the best of our biopsychosocial treatments, with the power of the patient-physician relationship, to help people achieve and maintain a personally meaningful life.

Blind to the world we live in

“However, the truth was that my own preconceptions had made me blind to the influence of the social environment”

– Robin Murray. Mistakes I have made in my research career. Schizophrenia Bulletin

Introduction

Writing in Schizophrenia Bulletin, Robin Murray reflects on mistakes he has made in his research career. Among these mistakes was allowing his own beliefs to blind him to the role of the social context. Murray’s reflections should give all psychiatrists pause for thought, as our preconceptions can impact on the way in which mental health is understood and the actions taken to alleviate the burden of mental illness.

We can define preconceptions as the personal knowledge and attitudes with which we enter a given situation. Social environment is a broad term which is analogous with social determinants, meaning the environments in which we are born, grow, work, live, and age (World Health Organisation).

Preconceptions blind us to social influences

The history of psychiatry has been characterised by individual, rather than social, explanations for mental illness. From pre-enlightenment theories of moral sinfulness, to Freud’s model of unconscious motivation, to modern research on neurotransmitters, the locus of explanation has been at the individual rather than the social level. And indeed, genetic studies show that individual biology does contribute to the onset of some mental illnesses. For example, among identical twins, if one twin has schizophrenia there is about a 33% chance of the other twin also having the illness (Hilker et al). This is much higher than the rate among the general population, but still leaves a significant amount of variation which cannot be explained by genes alone.

Despite efforts to promote a biopsychosocial model of care, the reality is that health research and delivery in Australia is still predominantly oriented around a medical model. In my clinical experience, the day-to-day focus of care is on assessment, diagnosis, medication, and therapy. Yet an individualistic, medical model fails to explain patterns that exist at a broader population level: Why are 90% of patients with eating disorders women? Why do people with schizophrenia die, on average, 20 years earlier than people without a serious mental illness? (RANZCP) Why do Maori and Aborginal men have some of the highest suicide rates in the world?

Answering these questions, as both clinicians and researchers, requires us to discard our preconceptions and open our eyes to the influence of the social environment.

Opening our eyes to social influences

Pressing threats to mental health – including homelessness, violence against women, climate change, and the current pandemic – all raise profound ethical questions about the just distribution of benefits and burdens in society. As psychiatrists, we have an ethical obligation to consider not just the individual before us, but these broader questions regarding the just distribution of resources both within healthcare systems, and within society. (Beauchamp and Childress)

Our professional roles as psychiatrists go well beyond the role of medical expert to encompass leadership, advocacy, and scholarship. (CanMEDS). Writing in JAMA (2020) Donald Berwick urges all health practitioners to move beyond their traditional role of “curing illness” to “demand and support social reform”. Such efforts may include addressing social determinants at the individual level (eg by assisting a patient to find secure housing), the research level (eg by considering the relationship between occupation and suicide rates (Milner, Bismark et al)), the political level (eg by calling for a strong response to the climate crisis), or at the social level (eg by campaigning for improved rural healthcare as psychiatry trainee Skye Kinder does).

From a recovery perspective, healing often comes from the social environment rather than from the healthcare system. Prominent consumer advocates, including Dr Sarah Gordon at the University of Otago, have spoken of the importance of friendships, family, and work in their own recovery from mental illness. While medical treatment has an important role to play in reducing symptoms and preventing relapse, deeper elements of recovery – including connectedness, hope, identity, meaning, and empowerment (Leamy 2011) – are not found in a hopsital bed or a pill.

Conclusions

In the end, the power of societal factors to influence health is enormous compared with the power of health care to counteract them. As clinicians and researchers, we should learn from Robin Murray’s mistakes and ensure our own eyes are open to the influence of social determinants of health. This requires lifting our gaze from the individual to the context in which people are born, grow, work, live, and age. Through our roles as advocates, scholars, and collaborators, we can – and should – move our efforts upstream to improve not just the health of individuals but the health of the societies in which we all live.

Models and Metaphors

“The choice of model and metaphor has profound consequences in practice. The metaphor and model of a specific disease/specific treatment … has been especially powerful in medicine but has exhausted its usefulness in psychiatry.”

– Rosenman S Australian & New Zealand Journal of Psychiatry 2016

Introduction

Writing in the Australian and NZ Journal of Psychiatry, Rosenman urges us to be mindful of the metaphors and models we use in psychiatry. In particular, he cautions that the medical model of “one treatment for one disease” is no longer apt in psychiatry. This is an issue of profound importance for psychiatrists because – whether we are aware of them or not – our internal representations of health, illness, and cure influence every aspect of our work.

A model can be defined as a representation of something else, often simplified for the purposes of understanding. A metaphor is a figure of speech whereby something is compared to something else. For example, Beck’s concept of distorted thinking is one model for understanding depression, whereas “depression is a black cloud” is a metaphor.

Medical model overstepped its usefulness

The history of psychiatry illustrates the extent to which mental models and metaphors shape our knowledge, attitudes, and behaviour. During Ancient Greek times, when mental illness was understood as an imbalance in the four humours, the solution was purging, vomiting, bleeding, or sweating. When Freud developed the metaphor of the unconscious mind as the base of an iceberg, therapists focused on bringing what was hidden to the surface. The preferred solution is inextricably linked to our perception of the problem.

In clinical medicine, the most prevalent model for understanding disease is one of cause and effect. In simplified terms, X causes Y which should therefore be treated with Z. For example, insufficient insulin causes diabetes so insulin is the treatment for diabetes. Psychiatry has tried to adapt this model to mental illness, as evidenced by the assertion that an imbalance of chemicals in the brain causes mental illness so chemicals are the treatment. The reality is far more complex.  

From a recovery perspective, the medical model of mental illness is an impoverished concept. As explained by Melbourne-based “mad activist” Indigo Daya, it grossly simplifies the complexity, diversity and meaningfulness of so many important human experiences. It hides underlying social causes, like poverty,  abuse & hate, making their real impact unseen, unchecked, ongoing. When we apply too narrow a lens, we miss seeing the bigger picture.

Medical model still has some use

However, to use another metaphor, we must be careful not to throw the baby out with the bath water. The medical model has undoubtedly contributed to major breakthroughs in the treatment of mental illness. Where NMDA encephalitis was once a poorly understood form of madness, the medical model of illness helped to elucidate its aetiology and treatment. Without this mental model, Susannah Cahalan – author of Brain on Fire – could still be suffering years of ineffective therapy rather than fully recovered from a treatable illness.

In my clinical experience, the medical model can also be helpful for some patients and carers in destigmatising mental illness. For patients who need long-term treatment with neuroleptic medication to remain well, I have found that drawing an analogy with the long-term use of inhalers for severe asthma can be helpful in normalising the need for ongoing treatment. Using a medical model when speaking with families can also be helpful for reducing the shame and blame that is still associated with mental illness in some cultures. Of course this should not occur at the expense of deeper biopsychosocial and cultural formulations of their experience.

Conclusion

In the end, the purpose of models and metaphors is to help us understand the world around us. Models that are too rigid – or inaccurate – can cause more harm than good as shown by historical abuses in psychiatry. Modern concepts of recovery embrace models which are more holistic and person-centred than medicine’s narrow linkage of one treatment for one disease. At the same time, medical models of illness still have a role to play – particularly in research and drug development. Used wisely, they may also be helpful in addressing stigma by reminding patients, practitioners, and communities that patients with mental illness are as deserving of effective care and treatment as patients with a pneumonia or diabetes.

The challenge for the future is not to discard the medical model entirely, but rather to widen the mental models and metaphors available to us. This will give us the agility to view a situation from multiple perspectives, ultimately giving a clearer view of our patient and how best we can support their healing.