20 JANUARY 1967, Page 12

How to Choose Your Psychiatrist



WHEN I was a medical student, psychiatrists, like whisky, came in three main flavours— Scotch, Irish and imported. It wasn't a fashion- able speciality and the English, snobbish as always, turned up their noses at it. The Scots took it on as they have always taken on all the dirty jobs for the British and the custody of lunatics was only another step in this tradi- tional martyrdom. The Irishman, by contrast, tended to drift into psychiatry in the same way as he drifted into the armed services. The imported psychiatrist took it very seri- ously indeed. He was usually an analyst of the Freudian school and the great contribution he made was that he forced the medical profession to think of psychiatry as a live, dynamic sub- ject, with a part to play in relation to the com- munity as a whole, rather than just as a method of management of the mentally deranged.

There are still three main approaches to psy- chiatry, but nowadays they are rather different. The analysts are still with us, but their influence varies greatly from country to country. In the United States the analytic method is still enor- mously popular. Various reasons have been ad- vanced to explain this preference on the part of the Americans. The most recent, suggested by the celebrated neurologist, Dr Henry Miller, is that ordinary American medicine has now become so obsessed with laboratory tests that the analyst is the only person left who is pre- pared to listen to what the patient has to say. In England, and in most of Europe, psycho- analysis has waned in popularity. One of the main reasons for this is the amount of time the doctor has to spend with the patient. A full analysis involves about three interviews a week for several years. The treatment, naturally enough, is extremely expensive and is in any case only really suitable for intelligent patients. At the end of the course of treatment the symp- toms may be improved. However, such a long time has passed that the patient's circumstances have inevitably changed to some degree or another in the meantime. It is argued by oppo- nents of the method that the improvements claimed by analysts may well be due to the passage of time, or changing circumstances, or simply the degree of personal attention given to the patient.

At the opposite pole to the analysts are those psychiatrists who place almost their entire faith in physical methods. They regard analysis as little better than mumbo-jumbo. They rely largely on drug treatment, in particular the new drugs which have been developed during the last ten to fifteen years. They do not spend much time trying to find the inner cause of the patient's disturbance; they prefer to deal with his symptoms as they arise, treating agitation with tranquillisers and depression with anti-depressant drugs. They claim that this empirical method gives the disturbed individual what he is really looking for, which is not self-knowledge but relief of the symptoms that are troubling him. It is also quick, relatively cheap, and constitutes a practical approach to the mass of mentally ill people who are entitled to treatment under the Health Service.

The majority of practising psychiatrists fall somewhere between these two extremes. They use drugs when they feel they may be useful, but they also use what is known as psycho- therapy. Psychotherapy may be defined as an effort to get to grips with a patient's emotional problems by questioning and discussion, without attempting the depth of exploration which is demanded by full psychoanalysis. By means of this technique the doctor hopes to deal with the problems, either by explanation or by sug- gesting modifications in the patient's way of life. To help him in his latter task he uses the psy- chiatric social worker, who can visit the patient at home and make a study of his environment.

The patient has, therefore, a choice. The analyst, the empiricist, or the eclectic psychiatrist who is prepared to take what he can use from either school. Any judgment as to the relative value of these groups can only be a matter of opinion, since in the present state of our knowledge there is very little in psychiatry which is susceptible to exacting standards of scientific proof. However, it is fair to say that medical opinion in this country definitely favours the last group in preference to- the other two.

So far as the individual psychiatrist is con- cerned, it is presumably just as legitimate for the patient to assess him as it is for him to assess the patient. There are various bad reasons for taking up this speciality which are likely to pro- duce an unsatisfactory practitioner of the art. It isn't, for instance, a particularly good sign if a doctor has specialised in psychiatry simply because it was a sedentary occupation, or because he found it difficult to make his way in general medicine. Another type to watch out for is the man who took it up in an attempt to solve his own psychological problems. The therapist should have his mind on the patient, not on himself, and should possess the necessary human touch which enables him to identify with

the problems of others. He shouldn't therefore be too eccentric. He needs balance and a sense of humour. And he should be prepared to listen patiently to long and rambling stories.

The vital thing to remember is that psychiatry is not a religion or a form of witchcraft. There is nothing very special about its practitioners. They don't spend their time probing the mind in some subtle, mysterious way, but in classifying patients according to certain accepted diagnoses and then applying standard treatments as skil- fully as they can. A psychiatrist is just a physician who happens to be working in an area where scientific understanding is rather less advanced than in most others. If that's the im- pression he manages to convey to you, he's probably a pretty good one.