Brief (radical)Top Tips for Being a Better Psychiatrist
1. You will always become institutionalised in your own way: the question is how, not whether.
Don’t deny or worry about it – just learn to recognise it.
2. Don’t mistake what is said for what is true
If a patient tells you his father was absent and his mother was cold, all you know for a fact is that he has told you this. It isn’t that you should disbelieve him but automatically believing him runs the risk that you consolidate unhelpful archetypes or internal objects he carries round with him. [NB not believing is not the same as disbelieving]
3. Don’t tell someone what they already know
This is an occupational bad habit. Patients know far more about themselves (and probably life as well) than you do. If you tell them something about them or about life in general that they already know, this runs the risk that they will feel you don’t understand them and will make it harder for them to develop the faith and trust in you which is essential for clinical progress.
4. Your focus should be on asking the right questions not providing answers
Patients generally know the answers but don’t know they know the answers. Work on framing the right questions so that these answers emerge into the light.
5. Always be an ally of the normal not an enemy of the sick
First link yourself with what is “normal” in or about the patient so that you can then form an alliance to look at what is abnormal or sick. There will be far more things which are normal about the patient and his life than there are aspects which are pathological .
6. Remember mental health services in the NHS are anti-family and this is institutionalised
Relatives will be around far longer than you or your particular service will be. Assume that they will be marginalised – then consider effective ways to mitigate this.
7. Beware the post hoc ergo propter hoc fallacy: that because depression or breakdown comes after a trauma or event it has been caused by it
They may have been but equally they may be independent of each other. Assuming that the relationship is causal may lead to a failure of understanding and the wrong or ineffective treatment.
8. Never increase medication if you are not certain that the patient is actually taking it at a lower dose
An easy and common mistake.
8a Establish clearly whether a patient is taking anti-depressant medication just as carefully as you would with anti-psychotic medication
Another common failing
9. Pay more attention to when a patient was doing well than to when a patient has been doing badly
Look in detail at the circumstances in a phase when the patient was stable and doing well. Often this is over a number of years since they first became unwell. It will teach you much more about what works and is more productive (and maybe interesting as well) than a focus on what happened when the patient was ill (apart from risk events – see below)
10. There are tricyclic patients just as there are SSRI patients, and haloperidol patients just as there are risperidone patients
This is what is called pharmacogenetics. This means that changing medication until there is the right response is good, scientific practice but changing medication where a patient has evidentially done well on a particular medication in the past (see above) often owes more to magical than rational thinking.
11. Disregard risk from years ago because circumstances at the time no longer apply not because it was years ago
Another area where unhelpful assumptions creep in. For example, if the patient was using alcohol or drugs heavily when he committed offences or acted dangerously in the past but he has been free of both for some time, risk may now be minimal. But in general people will revert, sometimes after many years, to the same behaviour when they become unwell again – just as golfers will revert to the same past errors if their form declines for any reason. The mere age of risk events should never be a reason for discounting them.
12. Where risk is concerned, the patient is not your only client
In other words, the patient’s partner, parent, neighbour, rival (e.g. in morbid jealousy) or members of the public will be the object of your duty of care just as much as the risky patient will be.
13. You will often find serious attempts at suicide early on in a psychotic illness but much less so later on
This demonstrates the risks of what tends to be called “insight”. The first emergence of psychosis is a time when identity feels most under threat and despair is at its most acute.
14. Refer the person, not the problem
Referring the problem before understanding the person with the problem leads to premature or inappropriate referring and over-referring. All of these risk increasing despair, perhaps the most common triggerfor suicide, because they lead to feelings of untreatability.
15. Suicide is [often] the echo of a death that has already happened
Ask the patient if it is as though something had already died. Re-enactment of past trauma – and also of past but dormant pathological behaviours – is a common but often overlooked phenomenon.
16. It is as dangerous to treat biological depression with psychological therapy as it would be type 1 diabetes
CBT, for example,may help with managing illness but not with the illness itself
17. Helpful therapy may carry as much risk as unhelpful therapy
Despair is almost always the platform for suicide. When helpful therapy and a good therapeutic experience are ended (or removed) this may actually create more despair than when unhelpful treatment is (yet again) ended.
18. Your interest, enthusiasm and optimism are as much part of the treatment as medication is
These are clinical essentials. Without them, best to go into research or management.