One cruel April day in the last millennium I sat my Membership exam in London. Coming home on the Edinburgh train I sat next to a friendly woman who had told me her life story before we left Kings Cross. And what do you do? she asked. When I told her I was a psychiatrist she fell silent. Soon afterwards she went to look for a seat elsewhere on the train, but it was crowded. We sat in silence for the next 400 miles.
That was more than a quarter century ago. Mental Health is more fashionable now, isn’t it? This summer I was an examiner in Medical Student examinations. We have patient partners who volunteer to act out a standardised clinical scenario. This was repeated forty times over the course of the day, and in the gaps and breaks I chatted with the man who was pretending to have such trouble breathing. Are you a respiratory specialist? He asked. No, I’m a psychiatrist. Oh dear, I don’t want to speak to you anymore, he said. It was a sort of joke.
These days, frank horror has mostly been replaced by defensive humour, and to my shame, I play along, and allow friends to avoid serious consideration of my profession. There is sometimes admiration. It’s usually along the lines of - I couldn’t possibly do what you do - this particularly from fellow doctors. I have a chip on my shoulder, obviously, and interpret this to mean that only a special kind of failed surgeon would want to enter my profession. Non-doctors are more likely to ask whether it’s the same as being a psychologist or psychotherapist.
When patients denigrate us it’s easier to frame their opposition and fear as an inevitable feature of many mental illnesses. The Christchurch study recently found that more than 80% of us meet diagnostic criteria for several mental disorders by mid-life, so perhaps it’s inevitable that most of us mistrust those people who might dissect and challenge our mental experiences and consequent behaviours.
My poor parents couldn’t help their disappointment that, after they’d remortgaged the house to help pay for my medical training, I didn’t end up as a “proper doctor”. True, I had flirted with some of the alpha male specialities - cardiology, vascular surgery - so it seemed logical to deduce that psychiatry was a second choice. In fact, medicine itself was my second choice. I really wanted to be a nurse and worked in an old people’s ward for several months. When they discovered I had epilepsy they wouldn’t allow me to apply for training, or even work there again. So, I had to settle for medicine, where having seizures was no obstacle, although being female was openly criticised.
My generation, particularly those of us who are not male, not white, not from fee paying schools or medical families, had to shrug off myriad microaggressions, even from within our own discipline. It’s taken me a while to recognise the extra prejudice there is against psychiatry itself - those teasing remarks about trick cyclists, lying on couches, beards and pipes, Freudian quips. We get a double dose of prejudice when other mental health professionals complain that we “medicalise” minds and meanings, whilst other medical professionals see us as outsiders.
Actually, there are macroaggressions too. The anti-psychiatry movement is alive and well, and generally accorded the sort of respect not routinely shown to anti-vaxxers, for instance. Most doctors have the confidence and endorsement of their patients. I don’t know of an anti-cardiology movement and haven’t heard anyone complain of orthopaedic surgeons for “medicalising” fractures. My favourite College campaign is the one that seeks parity for mental health with physical health services. As we say, “there’s no health without mental health”. Until that is respected by the public and by colleagues of all sorts, it’s hard to internalise self-respect. I loved Dinesh Bhugra for saying not that we need to recruit more psychiatrists but that we want “the brightest and best” to choose psychiatry. The growing eminence of the Royal College of Psychiatrists amongst UK institutions, and here in Scotland too, has been the best way I’ve found to build a powerful positive professional identity.
If, like me, you still choose psychiatry despite all this, then I encourage you to become an active part of the College. It provides opportunities to empower our profession and our patients that we can’t do individually. Even small faculties have influenced Government and transformed services. The Perinatal Faculty recently created a National Network and mobilised millions to treat the unmet needs of mothers, babies and their families. Several of us have worked on SIGN guidelines. It’s been important to represent mental illness as well as physical conditions in the work of this reputable body. In the process, we’ve influenced SIGN methodology, which is waking up to the value of rigorous qualitative research as well as of giant RCTs. It’s been a privilege to chair the SIGN Eating Disorders Guideline and to be launching it synchronously with the Implementation of a Service Review and dedicated government resource.
Ultimately, though, the best thing about College involvement is the chance to work with wonderful role models. Office bearers, member participants and College staff are passionate, political, intelligent, kind, funny and full of energy. They make you believe that if these are the people who practice psychiatry, then that’s definitely something to aspire to.
So yes, I do choose psychiatry, over and over again. I repeatedly fall in love with its different specialties. For me as the daughter, sister and mother of teachers what could be more natural than to gravitate towards CAMHS? As an English Literature graduate, I relish the narrative aspects of medical psychotherapy. Basic physiology training informed my work in eating disorders and on a neuropsychiatry ward. I love psychiatry - its intimate individual formulations, the holistic nature of it, the multi-disciplinary and multisystemic aspects. But for too long it has been a love that dared not speak its name.
I used to avoid even hinting that I’m a doctor in case anyone asked what kind. Most of the local taxi drivers think I’m a nurse. I’ve been to the same hairdressers for 20 years and let them assume I was a teacher. A few years ago, the College provided a media course and I agreed to speak on TV. I thought I had finally come out of my closet. One Saturday I went into the salon after appearing on BBC Scotland. They called out “Jane, I saw you on the telly!” I held my breath for their reaction, but the verdict was “You really should have come in for a blow dry first!”
Dr Jane Morris, Vice Chair, RCPsych in Scotland