Do psychiatrists do more harm than good? Some reflections after a twenty-year relationship.
By: Jim Miller
Tags: Mental Health, Bipolar, Psychiatry, Recovery, Pharmaceutical

“Don’t ask the barber if you need a haircut”, as Warren Buffett famously quips. The barber, of course, is economically incentivised to cut hair, and the answer he gives will never be entirely objective. Is it perhaps also the case that you should “never ask a psychiatrist whether you need help with your mental health”? Is it possible that the same underlying economic incentives may sway his response? Is it possible that you may find yourself washed and cut, labelled and drugged, for the rest of your life simply because the psychiatrist is economically incentivised to do that, whether or not this is merited?

This blog is a reflection on twenty years of working with psychiatrists as a patient. I have also had a fair amount of experience working with psychiatrists as a carer. That is a story for another day.

I remember meeting a psychiatrist for the first time when I was in my early twenties, during a depression which followed on from my father’s suicide. I do not remember his name, or much about the session. I remember that he told me that the low mood I was suffering would be temporary, that I had always been successful in the past and would soon overcome my difficulties and become successful again in the present. He seemed caring, kind and supportive. He did not give me a diagnosis or prescribe any psychiatric drugs. He did not suggest any action, nor did he ask to see me again.

Looking back, after close to thirty years, I can see that I was stuck in grief, anger, sadness, denial and guilt at that point in my life. I did not have the language to describe what was occurring and I was so disassociated from myself, so numb, and still in so much shock and denial that I struggled to access my feelings, let alone communicate them. I can see that I presented as high functioning and stable; a carefully curated shell. The trauma that I carried was hidden deep inside of me. However much I needed to share it with someone, there just was not enough trust for me to even start to contemplate doing that.

This first doctor was not willing to engage with me in a way that would help me uncover these issues, to help me process my grief. I can see now how much support I was going to need to come to terms with my father’s suicide; with all of the related psychological, existential and emotional trauma, and the even deeper and more complex inter-personal and inter-generational issues. It makes me sad to think that I was not even given a referral to a therapist at that stage of my life, which could have helped. Still, this first psychiatrist at least complied with the advice attributed to Hippocrates, to do no harm. He did none, and as such the experience was at least not a negative one.

The second psychiatrist to enter my life was at the Priory in Roehampton in 2000, about six or seven years later. He labelled me with a diagnosis of “bipolar affective disorder” and treated me with lithium and the standard package of individual and group therapy provided at the time. After discharge I would meet with him on an ad hoc basis, whenever my mood was affected. He was meticulous about describing the side effects of lithium and ensuring that I did regular blood tests. We got on well and I considered him a support, and a father figure of sorts. He treated me for eleven years. I was stable during the whole period, although going sideways in my life, and operating within a reduced range of experience as a result of being so heavily drugged.

This doctor was disbarred in 2011, and I was no longer able to see him. This occurred as my marriage was souring, at a time when I needed a lot of support. I felt let down. There were echoes of the shocking way in which my father’s suicide removed him abruptly from my life, at a time when I needed him and in a manner that I had no say over.

I was introduced to my third psychiatrist by my GP in the wake of this disbarment and was initially suspicious. I remember not knowing whether to refer to him as ‘doctor’, or by his first name. ‘Doctor’ conferred some degree of respect for his knowledge and experience. Bruised by the experience with the last doctor I was acutely sensitive as to whether that respect was merited. Calling him by his first name, on the other hand, felt too informal. We discussed this, and he said that I could call decide what I wanted to call him.

I remember clearly the first session we had together. I interviewed him carefully, going over his academic and professional qualifications. I liked the fact that he was both a consultant psychiatrist and also a cognitive behavioural therapist. He appeared to have integrity and a spiritual side, and said he had experience of dealing with issues relating to complex families. I liked the way that he paraphrased points that I made, and how he seemed to have a better understanding than me of the power and control issues in the family that I was exiting.

This doctor explained in our first session that his style of working is to listen, write, consider and interject as needed. Over the subsequent ten years I had appointments once a quarter, and he did just that. He made occasional book recommendations, made suggestions and gave advice that he believed to be in my best interests. When he spoke, it was with authority and palpable integrity.

He noticed things. He would invariably comment on my attire, whether I had had a shave, or a haircut as I entered his room, or my posture as I sat and waited in his waiting room. It was my sense that these comments or questions were intended to catch me off guard, and to give him material to work with. He was remarkably bright and articulate, as well as deep and wise.

There was a moment a few years back, after he had some press from working with celebrity clients, when he changed his attire from shirts and jackets to waistcoats and handkerchiefs. I worried at the time that the attention may have been going to his head. However, in our subsequent sessions he seemed every bit as integrous and supportive, and I relaxed back into the relationship, albeit with him wearing a new costume.

It took me some years to become comfortable with calling him “doctor”, and to feeling a sense of authentic trust and respect in the relationship. I do believe that he had my best interests at heart. He listened carefully, and challenged me at appropriate times. He was cautious about de-prescribing me from lithium, but respected my wish to come off it, and was prepared to work with me on that. He was also supportive of my recovery in twelve step groups.

The dynamics of the relationship changed over time. When I first started working with him I considered him a higher power of sorts, with the power to save me, and hung on his every word as if it was scripture. There followed a period, after I discovered twelve step recovery and survivor groups, when I realised that I had to do my own work, and so started to run my own recovery, in partnership with him. I have now reached a level of confidence and wellbeing whereby I am taking over the process. The partnership with him continues to the extent that he still prescribes me lithium which I need while I de-prescribe. Beyond that I run my own recovery.

In a recent appointment he suggested that I write a book about recovery from bipolar disorder, saying that it could give hope to others who still struggle. I thought about this for a little while, and then later asked him if he would make his notes on our sessions available to me as the foundation of such a project. He agreed, subject to a £50 fee for scanning. A few weeks later I received 200 pages of scanned notes from over forty sessions. These notes form the basis for a book, which is currently work in progress.

Over the years that we worked together I developed a much greater sense of agency for my own life. I respected his knowledge and experience, and I trusted him, while also wanting to verify what he said, and not take anything at face value. I also became more realistic around the limitations of his support and his own vested interests. I can see that he is risking his own professional standing and emotional wellbeing in supporting me to reduce the dose of psychiatric drugs that I take. I can see that it is a risk for him to depart from the language and structures of his professional, however wide the discrepancies between this and reality may be. I can see that it is safer to keep me on lithium, living a comfortable half-life, than to risk a relapse by coming off it.

These are not the only points of difference. He believes bipolar is a disease with a chemical, biological or genetic constitution. I believe it is a label. He believes it is a chronic condition. I believe that the symptoms ameliorate over time and are curable. He believes drugs are necessary in perpetuity. I do not agree. In short, he is determined that I am mentally defective and need to be medicated for life. I am determined to make a full recovery. I cannot be certain that my beliefs are true. I have asked on numerous occasions how he can be so certain of his and have yet to receive a satisfactory response.

The points of difference cause a tension in the relationship which is unhelpful. With other holistic and functional medicine providers available who are supportive of my point of view it is only a matter of time before I change doctor. It is a notable quirk of the world of mental health that the psychotherapists that I have seen over the years also disagree with the doctor, and agree with me.

Ironically, the next stage of my recovery is from the harms caused by the cure. After twenty years of taking lithium I experience issues with my memory and cognitive function, as well as my kidneys. Who knows what further damage has been caused. It is only as I reduce the dosage that I come to terms with the adverse affects of so many years of usage.

I do believe that a good doctor, at the right time, can be an effective partner in the recovery process. I have appreciated the therapeutic support that I have received from my current psychiatrist, who has been a supporter, an observer and a trusted confident. When I was first given a diagnosis twenty years ago it seemed like a relief. The continuing insistence that I have an incurable brain disease, however, has seemed less and less realistic as my recovery has progressed. I have, in fact, come to see the diagnosis as unnecessary, perhaps even abusive. The lifetime prescription of lithium that goes hand in hand with the diagnosis of this chronic condition also seems to have caused more harm than good. And then, I remember “don’t ask the barber if you need a haircut”.