© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Acta Psychiatr Scand 2015: 131: 4–14 All rights reserved
ACTA PSYCHIATRICA SCANDINAVICA
Editorial comments
To be or not to be a psychiatrist-what is the question? DOI: 10.1111/acps.12361 For centuries, psychiatrists were known as alienists and patients with psychiatric problems as aliens (1). The recent negative image of psychiatry has been confirmed by Stewart and colleagues (2). The historical negative attitudes persist and our guess is that the answers depend upon what questions are asked, who asks them and how the questions are framed and phrased? Certainly in the West, psychiatrists feel overwhelmed by continual changes in healthcare systems and increasing demands. Antipsychiatry media coverage and expansion of roles across other professions adds another dimension (3). There is no doubt that recruitment into psychiatry and medical students’ negative attitudes to psychiatry (4) also contribute to a vicious cycle leading to further negative images. However, what if we are looking at it through a different prism? To our mind, psychiatry at this point is at the cusp of major exciting changes. As a medical speciality, it is the most exciting, most intellectually stimulating and most rewarding speciality. Where else can one use social, psychological, anthropological factors in addition to biological factors? The failure as identified by poor recruitment or negative image is more common in Western Europe where psychiatric services are delivered separately and funding is separate. In addition, we believe that the problem also perhaps is not ‘selling’ the speciality or the idea of psychiatry well enough. In two recent commentaries (3, 5), it has been observed that part of the problem may be that psychiatrists feel alienated because of a number of reasons. These include external threats from the political system, other professions, reducing resources, etc but also internal threats about defensive nature of clinical practice, increased specialisation, social expectations of risk assessment and risk management. In addition as Sartorius (6) cautions us health itself has become a commodity as well as becoming political and means to buy health have become very important. In an interesting study looking at the expectations of other 4
professions, Bhugra et al. (7) observed that patients and their carers were positive about psychiatrists and trainee psychiatrists were more positive than other professions. This indicates that the universal negative images do not exist. Interestingly professional bodies were seen as the key to improving roles and images of the discipline. Emphasis on training and doing it the right way is important. Psychiatry as a discipline stands at the cusp of major discoveries and better understanding of the brain structures and functioning. There is little doubt that brain changes and understanding will determine mental functioning. Psychiatrists are the only profession working in the field of mental health services who are trained in understanding bio-psychosocial models of aetiology and management and that is a major strength and somehow within the profession, we do not emphasise that and out of the profession, we do not use it as a unique feature. In addition, Cartesian mind–body dualism has not served the profession well and it is time that we ditched it and created a new understanding of mental illness from other models. For example, Ayurvedic model takes into account genetic factors, environment, diet, taboos, relationships, etc in the causation of mental illness, so perhaps there is something there we can adapt. We need to stop the mind-body split and physical-mental health split as we know physical illnesses affect mental wellbeing and mental illnesses lead to physical problems. Psychiatrists are therefore, well-placed in delivering integrated wellbeing focusing on both physical and mental health. Where available the integration of physical, mental and social care services will lead to better services perhaps more efficacious and better outcomes. Rather than becoming too involved in dealing with negative images we must put the positive messages across. In psychiatry, for example, sexual dysfunction cases get a cure rate of over 90% but we hardly ever publicise that. The images need to be all inclusive. We know that three quarters of psychiatric disorders in adulthood start below the
Editorial comments age of 24 and half below the age of 15 so educating parents, communities and society at large and getting involved in public mental health agenda is crucial. There is no doubt that serious mental illness carries with it serious burden of disease perhaps more so than cancer or heart disease but it is only recently that policy makers are beginning to take that into account for funding. There is no doubt that psychiatry has a glittering future provided we can as a profession speak cogently and clearly and not get diverted by too much specialisms. Psychiatrists need to show leadership and clinical acumen and planning, developing and delivery of services. We must demonstrate the strength of bio-psychosocial models. Medical training and medical approach is crucial. In the end, all medicine is social (8). We need to listen to what the profession is saying (9) but also lead by example. More importantly, we must speak out loudly and clearly about what our unique selling point is basically providing holistic care including biological underpinnings or substrate, individual and social psychology and social and cultural factors which determine the world view and cognitive schema of patients as well as their healers. D. Bhugra1 (President of the World Psychiatric Association) and A. Ventriglio2
1
Mental Health and Cultural Diversity, HSPRD, London, UK and 2 Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy E-mail: [email protected]
References 1. Werner A, Campbell RJ, Frazier SH, Stone E. The American Psychiatric Association’s Psychiatric Glossary. Washington, DC: APA, 1984. 2. Stuart H, Sartorius N, Liinamaa T. Images of psychiatry and psychiatrists. Acta Psychiat Scand 2015;131:21–28. 3. Bhugra D, Moran P. Alienation of the Alienist: psychiatry on the ropes? J R Soc Med 2014;107:224–227. 4. Farooq K, Lydall G, Bhugra D. Research into recruitment: critical gaps in literature. Int Rev Psychiatry 2013;25:366–370. 5. Bhugra D. Alienated alienist. Lancet Psychiatry 2014. Published online August 13, 2014 http://dx.doi.org/10. 1016/S2215-0366(14)70283-4. 6. Sartorius N. Medicine in the era of decivilization. Rad Croatian Academy of Sciences and Arts. Med Sci 2009;33:9–28. 7. Bhugra D, Gupta S, Smyth G, Webber M. Through the prism darkly: how do others see psychiatrists? Australas Psychiatry 2010; 18: 7–11. 8. Bhugra D. All medicine is social. J R Soc Med 2014;107:183–187. 9. Bhugra D. Professionalism and psychiatry: the profession speaks. Acta Psychiatr Scand 2008;118:327–329.
Overcoming stigmatizing attitudes towards psychiatrists and psychiatry DOI: 10.1111/acps.12362 The study by Stuart et al. (1) addresses an important issue for psychiatry and psychiatrists: the negative attitudes among medical teaching faculty members towards psychiatry, psychiatrists and psychiatric patients. Much is to be done here, with the ultimate goal of revising stigmatizing attitudes by academic teachers from other medical specialties, which are not only problematic for psychiatry as a medical specialty, but also for patients with mental disorders. ‘Badmouthing’ by medical faculty members, residents and fellow students has negative effects on medical student’s career choices including psychiatry (2), but – as a study by Holmes et al. (3) in U.S. medical students showed – medical students perceive specialty bashing as unprofessional and unwanted. This indicates that
bashing may redound upon those who bash others – indicating that medical students may have more mature academic attitudes than some of their peers or teachers. And this is where psychiatry as a specialty has its opportunity. By demonstrating positive academic attitudes, empathetic patient care and scientific approaches towards the existing conceptual, diagnostic and therapeutic challenges of mental disorders, there are practical means at hand to overcome stigma, discrimination, badmouthing and irrational concerns. Several issues need to be addressed in order to become efficient in counter-acting psychiatry bashing. First, while it is true that there is a considerable degree of stigma affecting psychiatry as a specialty, it is also true that psychiatrists can teach efficient ways of fighting against and coping with stigmatisation – a recent study sponsored by the 5
Acta Psychiatr Scand 2015: 131: 4–14 All rights reserved
ACTA PSYCHIATRICA SCANDINAVICA
Editorial comments
To be or not to be a psychiatrist-what is the question? DOI: 10.1111/acps.12361 For centuries, psychiatrists were known as alienists and patients with psychiatric problems as aliens (1). The recent negative image of psychiatry has been confirmed by Stewart and colleagues (2). The historical negative attitudes persist and our guess is that the answers depend upon what questions are asked, who asks them and how the questions are framed and phrased? Certainly in the West, psychiatrists feel overwhelmed by continual changes in healthcare systems and increasing demands. Antipsychiatry media coverage and expansion of roles across other professions adds another dimension (3). There is no doubt that recruitment into psychiatry and medical students’ negative attitudes to psychiatry (4) also contribute to a vicious cycle leading to further negative images. However, what if we are looking at it through a different prism? To our mind, psychiatry at this point is at the cusp of major exciting changes. As a medical speciality, it is the most exciting, most intellectually stimulating and most rewarding speciality. Where else can one use social, psychological, anthropological factors in addition to biological factors? The failure as identified by poor recruitment or negative image is more common in Western Europe where psychiatric services are delivered separately and funding is separate. In addition, we believe that the problem also perhaps is not ‘selling’ the speciality or the idea of psychiatry well enough. In two recent commentaries (3, 5), it has been observed that part of the problem may be that psychiatrists feel alienated because of a number of reasons. These include external threats from the political system, other professions, reducing resources, etc but also internal threats about defensive nature of clinical practice, increased specialisation, social expectations of risk assessment and risk management. In addition as Sartorius (6) cautions us health itself has become a commodity as well as becoming political and means to buy health have become very important. In an interesting study looking at the expectations of other 4
professions, Bhugra et al. (7) observed that patients and their carers were positive about psychiatrists and trainee psychiatrists were more positive than other professions. This indicates that the universal negative images do not exist. Interestingly professional bodies were seen as the key to improving roles and images of the discipline. Emphasis on training and doing it the right way is important. Psychiatry as a discipline stands at the cusp of major discoveries and better understanding of the brain structures and functioning. There is little doubt that brain changes and understanding will determine mental functioning. Psychiatrists are the only profession working in the field of mental health services who are trained in understanding bio-psychosocial models of aetiology and management and that is a major strength and somehow within the profession, we do not emphasise that and out of the profession, we do not use it as a unique feature. In addition, Cartesian mind–body dualism has not served the profession well and it is time that we ditched it and created a new understanding of mental illness from other models. For example, Ayurvedic model takes into account genetic factors, environment, diet, taboos, relationships, etc in the causation of mental illness, so perhaps there is something there we can adapt. We need to stop the mind-body split and physical-mental health split as we know physical illnesses affect mental wellbeing and mental illnesses lead to physical problems. Psychiatrists are therefore, well-placed in delivering integrated wellbeing focusing on both physical and mental health. Where available the integration of physical, mental and social care services will lead to better services perhaps more efficacious and better outcomes. Rather than becoming too involved in dealing with negative images we must put the positive messages across. In psychiatry, for example, sexual dysfunction cases get a cure rate of over 90% but we hardly ever publicise that. The images need to be all inclusive. We know that three quarters of psychiatric disorders in adulthood start below the
Editorial comments age of 24 and half below the age of 15 so educating parents, communities and society at large and getting involved in public mental health agenda is crucial. There is no doubt that serious mental illness carries with it serious burden of disease perhaps more so than cancer or heart disease but it is only recently that policy makers are beginning to take that into account for funding. There is no doubt that psychiatry has a glittering future provided we can as a profession speak cogently and clearly and not get diverted by too much specialisms. Psychiatrists need to show leadership and clinical acumen and planning, developing and delivery of services. We must demonstrate the strength of bio-psychosocial models. Medical training and medical approach is crucial. In the end, all medicine is social (8). We need to listen to what the profession is saying (9) but also lead by example. More importantly, we must speak out loudly and clearly about what our unique selling point is basically providing holistic care including biological underpinnings or substrate, individual and social psychology and social and cultural factors which determine the world view and cognitive schema of patients as well as their healers. D. Bhugra1 (President of the World Psychiatric Association) and A. Ventriglio2
1
Mental Health and Cultural Diversity, HSPRD, London, UK and 2 Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy E-mail: [email protected]
References 1. Werner A, Campbell RJ, Frazier SH, Stone E. The American Psychiatric Association’s Psychiatric Glossary. Washington, DC: APA, 1984. 2. Stuart H, Sartorius N, Liinamaa T. Images of psychiatry and psychiatrists. Acta Psychiat Scand 2015;131:21–28. 3. Bhugra D, Moran P. Alienation of the Alienist: psychiatry on the ropes? J R Soc Med 2014;107:224–227. 4. Farooq K, Lydall G, Bhugra D. Research into recruitment: critical gaps in literature. Int Rev Psychiatry 2013;25:366–370. 5. Bhugra D. Alienated alienist. Lancet Psychiatry 2014. Published online August 13, 2014 http://dx.doi.org/10. 1016/S2215-0366(14)70283-4. 6. Sartorius N. Medicine in the era of decivilization. Rad Croatian Academy of Sciences and Arts. Med Sci 2009;33:9–28. 7. Bhugra D, Gupta S, Smyth G, Webber M. Through the prism darkly: how do others see psychiatrists? Australas Psychiatry 2010; 18: 7–11. 8. Bhugra D. All medicine is social. J R Soc Med 2014;107:183–187. 9. Bhugra D. Professionalism and psychiatry: the profession speaks. Acta Psychiatr Scand 2008;118:327–329.
Overcoming stigmatizing attitudes towards psychiatrists and psychiatry DOI: 10.1111/acps.12362 The study by Stuart et al. (1) addresses an important issue for psychiatry and psychiatrists: the negative attitudes among medical teaching faculty members towards psychiatry, psychiatrists and psychiatric patients. Much is to be done here, with the ultimate goal of revising stigmatizing attitudes by academic teachers from other medical specialties, which are not only problematic for psychiatry as a medical specialty, but also for patients with mental disorders. ‘Badmouthing’ by medical faculty members, residents and fellow students has negative effects on medical student’s career choices including psychiatry (2), but – as a study by Holmes et al. (3) in U.S. medical students showed – medical students perceive specialty bashing as unprofessional and unwanted. This indicates that
bashing may redound upon those who bash others – indicating that medical students may have more mature academic attitudes than some of their peers or teachers. And this is where psychiatry as a specialty has its opportunity. By demonstrating positive academic attitudes, empathetic patient care and scientific approaches towards the existing conceptual, diagnostic and therapeutic challenges of mental disorders, there are practical means at hand to overcome stigma, discrimination, badmouthing and irrational concerns. Several issues need to be addressed in order to become efficient in counter-acting psychiatry bashing. First, while it is true that there is a considerable degree of stigma affecting psychiatry as a specialty, it is also true that psychiatrists can teach efficient ways of fighting against and coping with stigmatisation – a recent study sponsored by the 5
