(note I do not call it a medical speciality per se, for such would be counter to the thesis that psychiatry is historically and conceptually something of a secular priesthood masquerading as medicine, science and art). The psychiatrist is well aware of this heterogeneity. When challenged, rather than feel anxious they will psycho-defensively reframe their castles built on shifting sand as a badge of honour, saying if one is too “linear and “black and white” one ought to become a surgeon. To properly do justice to just how internally heterogeneous would easily occupy several hundred pages. Herein will be two examples, with a preface to the first.
Unlike every other speciality there is a vast gulf between how public and private psychiatric practitioners diagnose and treat. This is even if the same practitioner works in both sectors, being public hospital one day and private practitioner the other. The differences within psychiatry dwarfs the closest other point of comparison, that of obstetrics wherein private (i.e. small business or large business private hospital) practitioners will often see a dire need for caesarean section more than their public hospital counterparts were they to see the same patient at the same time, and certainly more so than their nemesis nurse midwives would think necessary. Notwithstanding patient preference, the cynic would say this is in virtue of the Caesarean section being more lucrative in private land than that of an old fashioned vaginal birth. In the public system the obstetrician is paid the same regardless of how the newborn enters into the world, so why risk anything under the scalpel?
Returning to psychiatry, take for example this hypothetical case; the young woman named Amburr attends the psychiatrist (funky names and spelling are almost diagnostic). She is emotionally troubled and feels herself to be out of control, causing distortion in her everyday life as the American guild would say. That is to say she is open to abdicating personal responsibility from her actions in the word play of being “out of control” and requiring a locus of control to be placed with the psychiatrist. The psychiatrist asks questions. Do you have a family history of mental illness? Yes, Aunty Bertha was manic depressive (the psychiatrist immediately considers her genetically at risk of the same, and it will be difficult to escape this diagnosis sooner or later given such genetic “loading”). Do they have mood swings, sometimes this lasting days of highs and days of lows? Yes. Do they sometimes have abundant energy and drive, sometimes lacking the same? Yes. Do they spend too much money or engage in promiscuous sex that is out of character, i.e. that they later regret when the chickens come home to roost or behaviours they want you to believe they regret? Yes. Do they sometimes have difficulty focusing and others tell them they flit from one subject to another, sometimes even thinking at an accelerated rate? Yes. Do they sometimes feel like they are on top of the world and can do anything, not literally anything as in leaping over tall buildings with a single bound, not to the point of taking leave of their senses and reality (whatever reality is, please tell me if you find out). No. Just enough of a high mood to have been significantly elated and long to be back there? Yes. And so more than enough of the boxes are ticked. It does not take much more for the psychiatrist to diagnose the patient with type II bipolar disorder, or what might have otherwise been called mild manic depression had the DSM decided to invent a new construct whilst keeping the Kraepelian name “manic depression”. Mild mania, which is pathognomonic of type II bipolar disorder, is called “hypomania”, a kind of state of being almost yet not quite insane of an elevated mood. What causes it? The psychiatrist will say it’s a brain disease of course, albeit a poorly understood one. This is code for there being no evidence of it being a brain disease whatsoever. They will say it’s genetic within an environmental context of events “triggering” of episodes, invoking automatically within the unconscious the vision of victimhood, for who pulled the trigger? “Surely not I”. Consequently, in one stroke and though not explicitly stated, the secular priest will absolve them of the sins of excessive spending and excessive sexing, of impatience and verbal abusiveness and many more besides. This is a pastiche of priesthood; confession and absolution, passing through a muddled dualism. For the sinner is the disordered brain and its fallen nature, perhaps even the “sin” is in, though not of, the father (or mother) and their genes of mental illness. “I cannot be responsible can I, having been dealt the genetic hand” they might say. And so the absolver is not only the priest psychiatrist, yet also the patient themselves. This is to say in the absence of God, the ultimate source of absolution is the ritual between the psychiatrist (qua priest object) and the patient as collectively one agent, the other object being the brain without responsibility as the sinner who never need suffer pain of conscience. In point of fact, no one need suffer pain of conscience. Even substance use will not be seen as co-causative of the problem or heaven forbid a personal choice to befuddle one’s mind. Instead substance use will be framed as a result of the mental illness itself driving them to use. Their only act of penance will be to take valproate, lithium or quetiapine or some other powerful psychotropic medication that is touted by the pharma representatives (we must not be too harsh with pharmaceutical representatives, see elsewhere). Inevitably all these drugs will have a partial effect, insomuch as they all have non-specific sedative and emotionally blunting actions, leaving alone for now the actor that stands on every pharmacological stage, i.e. placebo. But these drugs will not effect any cure. Whatever it is, the basic fault will still be working its way within the psyche, likely created in childhood and cultivated by choices each day of what one wishes to be and become. There will be regular reviews and tinkering with the medication, as the psychiatrist leans over the caldron and adds a sprinkle of this, a pinch of that. There will be further confessions and absolutions under the heading of “psychoeducation”, and “relapse prevention” or exploration of “early warning signs”. And there will be a steady stream of income for the practitioner. Psychotherapy, the so called talking cure, will only ever be suggested as a method to manage the psychological consequences of the burden of the illness itself, not as a remedy suited for addressing the illness directly as a psychological thing in and of itself. Likely the psychiatrist will outsource the therapy to a psychologist. The vast majority of psychiatrists do the ever decreasing bare minimum of psychotherapy during their training, and do as little as possible afterwards.
Now let’s look at the same young lady from a different angle. Perhaps since her teens and perhaps before she had difficulty keeping a reign on her emotions. Like a cork bobbing up and down in a sea of (usually relational) events without any internal ballast, she is “out of control”. When things go well her mood sits high upon the crest of a wave. When things go poorly her mood falls below the horizon, and cannot see the sun afar. Sometimes paradoxically when things go well her mood is low, perhaps out of fear the good times won’t last, which of course in life they never…..ever….do! In virtue of her dissatisfaction with herself and her lot there may always be a tendency for the mood to drift down, and likely she will have been diagnosed with a ‘major depression” before. Often this “depression” is stated to be a harbinger of the hypomania to come in cases of alleged bipolar disorder, with bipolar disorder a justification for why the antidepressants did not work (no doubt is cast upon the antidepressants themselves, or the veracity of the diagnosis). She may or may not have been sexually or physically abused or neglected as a child, this being arguably more likely than not, yet far from being universal as is often assumed. Often somewhere in her upbringing there was at least some loss or lack of even what Winnicott would call “good enough parenting”, for perfect perfecting never exists and were it to exist would be paradoxically bad parenting in ill preparing the perfectly coddled child for a fallen imperfect world. This basic psycho-developmental fault can come in infinite forms; The parents broke up or were never together, ergo the perceived rejection from one or both (though this being at odds with the politically correct notion that broken homes and single parent homes are necessarily equivalent, my extensive experience would suggest exactly the opposite and the solo parent to face an uphill battle, often to their credit against the odds crafting the well-adjusted child), the perceived rejection of peers might have occurred, there is the parent who hovered too much or hovered at the wrong time and for the parents own reasons, the parent too busy nestling the cannabis bong in their arms as opposed to the child to their bosom. Perhaps the child did not see mirrored in the parents face and heart how and when to be emotionally calm, and when to delay gratification and how and when to delay it. And so on and so forth. The possibilities are as endless as the list of twentieth century theorists and experimental psychologists who did the work giving us all the hypotheses we might map onto this particular person who is Amburr. Yet we mustn’t take up