What is a psychiatrist anyway?

One of the things about being a psychiatrist is that people are often very unsure what you do. They often ask me questions like, ‘Can you read my mind?’ To which I always reply, ‘Yes, I can, but it's not very interesting.’ Then they change the subject.

People don't really understand what psychiatry is, or what we do. Psychiatrists are doctors. Like all doctors, we're interested in the workings of the human body. Just as a surgeon is interested in the workings of the gut, we’re interested in the workings of the brain (a much more interesting organ, I think you'll agree). But we're not the same as neurologists, who also have that interest. We’re interested in what the brain actually does. We’re interested in the workings of the mind. But we’re not the same as a psychologist.

Finally, we’re interested in how society affects our health through discrimination, through racism, through exclusion, by making us sick or helping us to get better. But we aren't sociologists or social workers.

We're basically all three. We think about the brain, about the mind and about society. I'm not sure what you get if you take any one of those away, but it's not a psychiatrist.

Why psychiatrists argue

I became interested in psychiatry when I was a medical student. People in England will remember the great and much-missed Anthony Clare, probably the best psychiatrist of that generation and indeed of any generation.

Anthony Clare hosting television discussion programme After Dark in 1987. Wikimedia Commons. Public Domain

Anthony Clare had written a book called Psychiatry in Dissent. All doctors row and argue; all scientists row and argue. Psychiatrists row and argue as well, but we do so in public much more than the others do, because people tend to understand what our debates are about. By contrast, the work of my best friend, a haematologist researching the classifications of leukaemia, is incomprehensible to all but around 12 other people in the world.

When I read Psychiatry in Dissent, the questions that were convulsing the profession seemed fascinating to me. They were about madness and badness and the question of when sadness becomes depression. They were about nature and nurture and all sorts of issues that seemed genuinely interesting and which other people could understand and debate with.

I tell students who want to do psychiatry that if they just want to be looked up to and admired, not to do psychiatry. But if they want to have arguments that matter, they might like it.

This takes us to the issue of classification. Anthony Clare talked a lot about that and the debate is ongoing. There are people who believe that we can't classify mental disorders, that they are essentially so individual that it makes no sense to do so. I don't agree with that. I think that you have to classify some things in order to start the journey of helping people. If everyone is so completely different that you can’t learn anything from anybody else, there's no point in training in psychiatry at all, because you'll never be able to bring what you've learned from other people into the conversation, the therapy and the treatment. And as soon as you can do that, you are classifying.

Prejudices about psychiatry

Virtually anyone who's a psychiatrist will tell you that when they first tell people that they want to do psychiatry they get certain reactions. ‘Oh, that’s strange,’ people will say. Or: ‘You're too good to do psychiatry, aren't you?’ Or: ‘I don't know how you can deal with these people. They're not really ill, you know.’ A moment's thought will tell you how awful that is and that the big psychiatric disorders, such as schizophrenia, autism, OCD and bipolar, are some of the worst things that can happen to anyone. Anyone who's aware of that will know that these are terrible disorders for which we still don't have adequate treatments.

So, you get a lot of prejudiced views. And indeed, rather surprisingly, those prejudiced views are often stronger in medical professionals than they are in people outside medicine. The latter are frequently more understanding of people with mental illness than health professionals are. That's a sad fact which I think has something to do with what we do to students in medical school.

From asylums to the community

Most people will now be familiar with the history of psychiatry over the last 100 years. From the beginning of the 19th century, when psychiatry started to emerge, most patients were treated in big asylums. These were huge, hulking hospitals on the outside of town, often with 1,000 or even 2,000 patients. We originally thought they were good places to be. People were free from the disease, the corruption, the drugs and the drinking and all the other bad things that happened in the city. If they went to these places of asylum, where they could be calmer, safer and closer to nature, they would surely get better.

Unfortunately, that didn't work out and the asylums became places of despair and hopelessness. By the second half of the 20th century, we started to move away from that. That’s been one of the biggest social transformations in medicine. We've been talking across medicine about the need to move into the community. But apart from primary care, the only speciality that has made that move is psychiatry.

Psychoanalyst making notes in notepad during appointment with young man resting on sofa by Baza Productions

Reforming the Mental Health Act

What's happened in the last 50 years has been a massive transformation. We’ve gone from 95% of care delivered in hospitals to 95% of care delivered in the community.

Very few people would disagree that this is the right thing to do. But of course, it's much harder to do in reality than in theory. Community care is still oversubscribed and not responsive enough. And it's not only about resources. We also need more volunteers to help treat patients, including those with severe mental illness. In recent years there’s been a tremendous increase in the number of community resources based around churches, cafes, workplaces and schools, all of which are trying to bring the principles of psychological care into everyday life and living. That can only be encouraged.

I've spent the last two years leading the reform of our Mental Health Act to stop people with the most severe mental illnesses being detained in hospitals. We need to develop alternatives to coercion and hospitalisation for those with severe mental illness. And these will be community based, often volunteer run, sometimes even peer led and run by service users themselves. That, I think, will be the next transformation for psychiatry over the next 20 to 30 years.

Less stigma, more awareness

When we tried to change mental health law 20 to 25 years ago, it was a bit of a mess. At that time, there had been some terrible disasters of care and some very high profile murders committed by people with severe mental illness. The politicians we were dealing with were really focused on this and the result was an increase in coercion in the delivery of mental health care. But times have moved on and now all the data suggests that people are much more tolerant towards mental illness. They're much less frightened of people with mental illness than they were, and quite rightly so because murders committed by people with mental illness are extremely rare.

The younger generation “gets” mental health in a way my generation never did. And we’re also seeing that with politicians. The new reforms of the Mental Health Act have been widely welcomed by all of the parties and are now slowly becoming law. That would not have happened 20 years ago. We've seen a decrease in stigma and an increase in political awareness of mental disorders. When asked, young people say that improving mental health and wellbeing should be the top priority for the National Health Service.

WARRINGTON, UK - MARCH 6, 2016: View of the NHS (National Health Service) logo at the Springfields Medical Centre in the centre of Warrington, Cheshire by Marbury

If you don’t like people, psychiatry’s not for you

I'm an optimist in terms of finding cures for serious neurological disorders. I think it will happen. The transformation of neurology from being a very Victorian discipline to something recognisably modern didn’t happen overnight. It took around 50 years before you saw real improvements in the care of people with major neurological disorders. I think that neuroscience will develop new understandings about the brain, which of course is what we study.

I’m also an optimist in the sense that I think all this talk about how AI and digitalisation will completely replace medicine and psychiatry is wrong. We will understand the brain better and develop more advanced treatments. One thing that won’t change, however, is that when people are at their most disturbed or distressed, they will always want to see a real person. Maybe that’s irrational, but in my experience it’s true. And when you’re a psychiatrist and someone tells you something they’ve never told anyone else in the world, you realise what it’s all about and why psychiatry will always remain. Psychiatry will always be something that depends on having a basic interest in people. If you don’t like people, don’t do psychiatry.

Discover more about

psychiatry and society

Wessely, S., Lloyd-Evans, B., & Johnson, S. (2019). Reviewing the Mental Health Act: delivering evidence-informed policy. The Lancet Psychiatry, 6(2), 90–91.

Smith, G., & Wessely, S. (2015). The future of mental health in the UK: An election manifesto. Lancet, 385(9970), 747–749.

Arie, S. (2017). “Simon Wessely: “Every time we have a mental health awareness week my spirits sink””, BMJ 358.

Psychiatry, awareness and stigma in today's society