Thursday, May 23, 2013

Protestors at the APA

Every year that I can, I attend the American Psychiatric Association annual meeting in order to obtain CME (continuing medical education) and connect with old friends. And pretty much every year that I’ve attended there have been people outside the meeting protesting. Some years there are more, some years there are less, but there always seems to be someone outside accusing psychiatrists of being dangerous, harmful, greedy individuals. This year, I finally got up my nerve to go speak to some of them. I wanted to know why they were there and what their concerns were in a more detailed way than I could work out from reading their signs. So I walked over to where one protestor was manning a large truck showing a looping video of how awful psychiatry is and introduced myself and asked “Why?” Why is this important to you? What are your concerns?

He was very nice and offered to walk me over to their main protest area, where they had literature and an exhibit set up. He let me know he belonged to a group called the Citizens Commission for Human Rights (CCHR). On the way over I asked him my questions about his specific concerns and why this is important to him. He noted that he is just “the most curious guy in the world” and claimed that once you start reading the abuses are obvious. I asked him if he had personal experiences with psychiatry for himself or his family members and he shrugged a little and commented that he knew a few people. He then kindly pointed me in the right direction and said goodbye.

I walked over to where the CCHR had their exhibit set up in Yerba Buena Gardens, across the street from the convention center where the meeting was being held. They had a long narrow white tent, the type you might see at an outdoor reception, and they had arranged a walk through exhibit that presented their argument that psychiatry is harmful. I walked through and read their displays and watched some of their videos, and I found several major problems with the statements that were being presented. The first problem is that many of the displays talked about events in the 1800’s, in Nazi Germany, and in the Soviet Union. I am not arguing that terrible things were done by psychiatrists (and many other people, including other medical doctors) in the past. But those events do not represent psychiatry as it is practiced today nor does it represent the psychiatrists who practice it. I’m not saying there aren’t bad or unethical psychiatrists, but as a group and a profession we repudiate past abusers and strive for high ethical and humanistic standards in caring for our patients.

The second problem was the persistent statement that psychiatry has no scientific basis. That statement is just wrong. There are hundreds of research papers documenting changes in the brain that occur with multiple psychiatric illnesses. There are hundreds more that document specific genetic abnormalities linked to different illnesses. There are even papers showing reversal of brain changes with treatment of depression. Is the science of psychiatry where it needs to be? No, absolutely not. It would be fantastic to have a blood or imaging test that could tell us in a simple, clear and specific fashion if someone had a mental illness, what illness they had and what treatment would be optimal. We don’t have any such testing yet, which is incredibly frustrating to psychiatrists as well as our patients. But it also isn’t surprising because the brain is the most complex organ in the human body. It has 100 billion neurons that connect to each other in over 100 trillion synapses. No offense to my cardiology or pulmonology colleagues, but the brain is just a lot more complicated than a heart or a lung. And we haven’t had the tools to study that complexity for very long. So the science of psychiatry is new, and growing, but it is absolutely there and psychiatrists are working hard to improve it. At my own hospital we are taking part in a study to see if EEG’s can give us guidance as to whether (and which) medication might be helpful for an individual. The DSM (Diagnostic and Statistical Manual, of which version 5 was just released) is not a perfect tool, and people are already talking about revisions for DSM-6. I would suggest, however, that our imperfect diagnostic and treatment systems are better than no care at all.

The third major problem I found was the repeated accusation that psychiatrists were greedy and power hungry. Quotes were taken out of context and plastered on billboards to convey the idea that psychiatrists want to infiltrate education and government and mind control the entire population. Other statements were made that psychiatrists make up illnesses and drug people to keep themselves in business. I am sure some psychiatrists have made extreme statements and that some psychiatrists are greedy. After all, we are a group of human beings and that means that we will have a range of intentions and goals. However no one goes into medicine to get rich (try business instead if wealth is your goal) and psychiatrists are on the low end of the physician pay scale. We do our work for other reasons than money. Do you know the best attended, most crowded sessions I found at the APA this year? Sessions on mindfulness and sessions on cognitive behavioral therapy were so tightly packed people were standing in the back. Neither of these sessions were about topics that are going to make anyone any money. They were about topics with profound potential to reach out and touch our patients and improve their lives.

The last major problem was the implication that psychiatrists go out looking for patients and harm them. I can’t speak for all psychiatrists, of course, but I’ve never gone out looking for patients in my life. People come to me, asking for help. It often feels like a flood of people beating down my door. People tell me they are suffering and I try to work with them to figure out what to do about that. I can’t speak for all psychiatrists, but I was taught and I continue to practice a collaborative model of psychiatric care. I attempt to think with my patients about what is going on in their brains and in their lives. I talk about a range of various interventions we could try and I speak honestly about the risks and potential benefits of medication, therapy, or even doing nothing. I’ve had many, many patients tell me I’ve helped them. I’ve even had a few where I think I saved their lives. I’ve had patients return months or years later to let me know they are doing well now and to thank me again for my help. Obviously that’s just my personal perspective and experience, but it just doesn’t match with the material the CCHR was presenting on the damage they feel my profession is causing.

At the end of the exhibit I talked to another protestor. She was also very pleasant and courteous, even after I told her I was a psychiatrist. She shared her concerns that doctors use their authority to coerce people into treatment. She also mentioned that she hasn’t had a personal experience with psychiatry, but that her beliefs grew out of her religion of Scientology. She informed me that the Citizens Commission for Human Rights is Scientology group. She was open to hearing from me that one of the reasons I went into psychiatry is that a dear, much loved family member had ECT treatment after years of depression and suicide attempts and that it worked incredibly, amazingly well. We smiled and shook hands and I left, fairly certain I had not convinced her of anything but hoping I had given her something to think about.

Here’s what I wish CCHR understood. Being a psychiatrist is one of the hardest medical professions. Our science is new and underdeveloped. We struggle against the ongoing fear our culture has of mental illness and the mentally ill, and that stigma reaches out to brush us as professionals. Working as a psychiatrist can be painful and exhausting as we work with patients who have been deeply traumatized by either their biology or their environment or both. And we keep doing this work because we care. Most psychiatrists go into mental health because of a deep wish to connect with and heal others. Ours is the most philosophical branch of medicine, the branch that deals directly with the human experience in this world. Psychiatry touches on ethics, religion, science, art, sociology and medicine. As psychiatrists, we tap into the length and breadth of our lives to reach out a build a bridge to our patients, to help them walk back across the abyss into health. We do a difficult and necessary job, and we strive to do it well.