“Are you a psychiatrist? Can you analyse me?” I was at a small airport heading home from my regular clinic in a rural town. Like many Australian towns it’s a friendly place where everyone welcomes you warmly, sharing casual banter. He pretended to lie down on the row of airport seats but was prevented by the molded plastic armrests. His colleagues, check-in completed, joined us. “You’ll never cure him in a million years. Analyse me.”
As a psychiatrist I’ve learned this comes with the territory. Everyone has an image of the New York psychiatrist’s couch and One Flew Over the Cuckoo’s Nest, even if, like me, they’ve never seen it. Some are wary: “I’d better keep away or you’ll think I’m crazy.” Many see an opportunity to understand someone close: “Can I ask you something? (hushed voice) It’s about my (friend/husband/father/daughter).” Or solve a problem: “What do you think I should do?” Or receive a caring word, comfort. Curiosity is common – everyone has a psyche.
In truth, modern psychiatry bears little resemblance to that associated with Woody Allen or Jack Nicholson or most depictions in popular culture. Our hospital psychiatry department comprises teams of doctors, nurses and allied health. In my six-person team, four are female, two male, three are Australian-born people of colour, three are white with UK and US accents reflecting migration – a typical health workforce snapshot – no elbow patches or Sigmund Freud beard in sight.
My job, like that of other medical specialists, is to listen to the patient’s symptoms, understand how they arose, and, importantly, determine if they’re part of a condition for which we can provide effective treatment, based on evidence reported in scientific literature.
That doesn’t mean it’s all about medications. Some conditions, such as panic attacks and agoraphobia, have proven better response to non-medication treatments, psychological therapies. Some conditions benefit from a combination of medication and non-medication therapies and, for a few conditions, scientific literature suggests psychological therapy has no added benefit over physical treatment alone and may delay effective treatment.
My specialty, medical psychiatry, sits at the interface of physical and mental health. I see people with cancer, trauma, stroke, infections etc and treat mental health conditions due to these illnesses.
I also look after people for whom psychological distress causes physical impairment and, sadly, people recovering in hospital from injuries due to attempts to take their own lives. The latter are a significant proportion of our work and the reasons which lead a person to this are highly varied.
Another trope not understood or depicted well in film is the relationship between mental health and psychological trauma, whether from a childhood traumatic event, abuse, bereavement, or fearful incident.
A typical storyline goes something like this: a relatable protagonist is tormented by mental health issues, crippling anxiety, low self-worth, self-hatred, even losing touch with reality (psychosis). At some point the subject, and the audience, become aware of a trauma from the past and this hidden explanation and “confronting” the trauma results in healing and reconciliation with the past. While this is a satisfying narrative resolution, it can do a disservice to those who have experienced trauma.
The majority of patients whom I see with trauma are acutely aware of what occurred. The traumatic memories are a source of distress and can result in intrusive painful memories which flood back with the same sickening horror and despair as when the events occurred. Trying to seek some relief from these unbearably painful experiences is neither a lack of courage, nor inability to face reality, but an attempt to tolerate their living existence.
Blocking out of memories and pain is usually far from total. “Confronting” or “releasing” these memories does not magically make things OK or even better. It can make things much worse. I’ve seen patients who feel re-traumatised, as if reliving the original trauma over and over, when exposed to painful reminders. Having no control of strong traumatic feelings can be confusing, depressing, debilitating.
They can feel guilt that they’re stuck and misunderstood because of the common expectation that “working through” the trauma is a necessary step, like lancing a boil. Contemporary drama productions like Wakefield and Mare of Easttown depict an empathetic perspective but also succumb to the temptation to explain all psychic distress with traumatic memories. We can help patients with trauma but it needs to be very, very gentle and we know even healthcare providers can do harm by causing re-traumatisation.
At the end of an intense day’s consulting, the light banter at the country airport was a welcome break. But if they knew what it’s really like to carefully, tentatively step through past traumas with a psychiatrist, they would probably have ventured some other repartee.