Dr. Gerry Rafferty's guest blog

One of the nice things about a blog is that it can remain dormant for a while and then be suddenly reinvigorated by new material. 

So when Dr. Gerry Rafferty recently sent me on his excellent essay on the uncertainty within psychiatry, it was a clear opportunity to reawaken this blog. Gerry is a Trainee in Child and Adolescent Psychiatry in south Tipperary and, as you can see from his essay below, he is a deep and expansive thinker.

When I asked Gerry about artistic accompaniments to his essay, he replied 'Anything by Goya' and I've included a few images from that artist, works relating primarily to mental illness. 

So many thanks to Gerry for this stimulating piece and for introducing me to the (sometimes quite dark) world of Francisco Jose de Goya y Lucientes (1746-1828).

The Madhouse, by Goya (1812-1819)

'In psychiatry we must tolerate partial knowledge, ambiguity and uncertainty'

 

Dr. Gerry Rafferty

 

 

'Science has not yet taught us if Madness is or is not the sublimity of intelligence'

Edgar Allan Poe

There is an urban myth that circulates amongst undergraduates of every discipline , usually approaching their final exams, about the philosophy student sitting their finals in metaphysics. There is only one question on the paper which is “Why”. The hero of the myth answers “why not “ and leaves. He is awarded a distinction.

There are several attractions to this story: the precision of the answer, the wit or possibly the dream of minimal effort gaining maximum reward, which is particularly appealing when you are stressed before an exam.

However, underlying it there is an academic or at least scientific distaste for philosophy, its vague questions, seemingly pointless musings and the lack of useful product. Drill further and you find a deep distaste for something which promotes thought for thoughts sake and the existence of opposing views with no possibility of definite resolution, no winner, no definitive paper which resolves the debate at hand. For example, is it better to be good or right? 

The dialectic of scientific contempt for philosophy is the equally famous quip about the medical student who asks the Professor: “What qualities does it take to be an orthopaedic surgeon?”. “Strong as an Ox and half as intelligent”, replies the learned physician. Here is exposed a contempt for the doer, with no deep thought or complicated investigation, the lack of wrestling with a series of difficult results and then breaking the code of the thorny problem. 

I would argue that this dialectic has existed in medicine for centuries. This is hardly surprising given the diverse parentage of what is now called Medicine. Born of the first professors in universities, i.e. those of physic who bore the title doctor and the upwardly mobile Honourable Company of Barber surgeons, who had to carry the title Mr. just so people knew they were the newest members of the family. 

Times change and things evolve and Mr. is now worn as a badge of inverted snobbery by surgeons. With the passage of time the family of medicine grew strong and more influential, and with its status the profession increasingly portrayed that it was an authority that was certain of what it knew. Medical opinions carried weight in law. At work and in general these opinions were not argued with. The intellectual development of medicine was to consolidate to produce an Orthodoxy. Definite books of reference were written and read, research and development did not stop, new technologies and breakthroughs in other sciences were taken on board, but they had to proven as fact. Healthcare assumed there were facts beyond doubt and it was sure of them.

In to this noble family a cousin was adopted, Psychiatry, its parentage uncertain but definitely with some questionable heritage and its impure lineage was obvious, its behaviour wild and unpredictable. Patients were locked away for life, electrocuted or tortured with little sound reason. We spoke of lunacy as if a celestial body could affect the afflicted, as a consequence it was humoured and not taken entirely seriously. 

The consequence of this is understandable to psychiatrists now, like an invalidated teenage girl teased for her weight, psychiatry developed an adverse relationship with uncertainty, its behaviour changed, it restricted on uncertainty, purged on doubt and over exercised on classification. Such behaviour doesn’t do anorexics any good and it hasn’t done psychiatry much favours either. 

With this background in mind, not only should psychiatry tolerate partial knowledge and ambiguity and uncertainty, we should embrace them. For it is these concepts that will advance our science or craft. In the following I will seek to persuade the reader of this.

To begin with, let’s consider partial knowledge in the context of Schizophrenia. The difficulty in following the history of Schizophrenia is proof (1,2). The disease that we now call Schizophrenia as originally described by Bleuler (3) was not in fact a positive diagnosis. He just described what it wasn’t, i.e. it wasn’t dementia simply based on the grounds that people sometimes got better with Schizophrenia and didn’t with dementia, but he didn’t know why.

In the same way Newton didn’t discover gravity - it had always existed and he just described it, the same can be said of Bleuler - he didn’t discover what is now called Schizophrenia, he described it. Now that in itself is noteworthy because it was led by a process of intellectual development driven by partial understanding to an important set of paradigm shifts in the development of psychiatry. 

Many argue about the historical validity of schizophrenia as a discrete entity or whether it represents a culturally specific set of symptoms(4). However, what is not possible to deny is that by the turn of the 20^th century , the concept of insanity had been replaced by one of mental diseases (5). Following an Aristotelian desire to classify, important shifts were made. Psychoses began to be seen as an entity. 

Kraepelin in his classification separated manic depression out as a separate entity and ultimately as a consequence of this epilepsy was moved from Psychiatry to Neurology, which is a Copernican revolution because now the link between psychiatric symptoms and brain function is made (6).

Clearly the timeline as described his distorted Kraepelin described a systemic disturbance which was called multi system failure in early life and several people used various versions of the term dementia praecox in what retrospectively sound like schizophrenia, such as Sir Thomas Coulson (7). 

Whilst a full history of understanding (or lack of) Schizophrenia in the 20^th century would be a topic worthy of more detailed analysis than I can give it here, a brief overview further reinforces my argument that acceptance of partial knowledge drives us to look for better understanding, whereas assuming what we know is the unalterable truth leads to abuse and stigmatization. 

In the first instance Schneider tried to more specifically define symptoms that suggested Schizophrenia as a separate entity. His first rank symptoms are still of use today (8,9).

In contrast, eugenics grew in popularity worldwide, it was used as a justification for forced sterilization and murder because mental illness was considered to be inherited by Mendelian genetics and the world would be better off without it. This is only possible as an intellectual construct if you believe with certainty that you know this is a condition without cure, thus leading to the conviction it should be eradicated.

The advent of pharmacological interventions has led over recent decades to strive for a greater understanding of the brain chemistry behind Schizophrenia and the development of newer antipsychotics (10,11). Even if the motivation is financial in part the tolerance of incomplete knowledge leads us to strive for improvement. 

The questioning of the 'anti -psychiatry' movement in the 1960s and 1970s can be argued to have forced mainstream psychiatry to be more open to the biopsychosocial model of mental health (12).

The drive for greater understanding, because we accept we have partial knowledge, has led in recent years to continuing developments in new directions. CBT seems to have a role to play especially in relapse prevention (13). Early intervention programmes in psychosis are now well established in Europe and the US and seem to be beneficial in preventing prolonged periods of psychosis (14,15). I think this portion of my argument is best summed up by a poet 'Ah but a man’s reach should exceed his grasp, or what is heaven for' (Robert Browning). 

The Sleep of Reason Produces Monsters (1799)

I am not sure how I feel about ambiguity. In fact, my career to date in Psychiatry has made me more accepting of ambiguity. I think that this may be in part due to the Balint component of training, the component of self-reflection and awareness of transference and counter transference that has made me see the world differently. It has increased my empathy in a sincere way and led me to personal acceptance and the practice of mindfulness, most specifically the loss of judgement, which in turn leads to greater personal contentment, which I am of the opinion makes you a better psychiatrist and a nicer person.

It is from this personal perspective that I wish to argue that tolerating and embracing ambiguity is not only necessary for a psychiatrist but highly desirable.

Consider Borderline or Emotionally Unstable Personality Disorder - the model for ambiguity even in its own lexicon. It provokes severe negative countertransference in many mental health professionals (16). I find this curious. Whilst I accept that the behaviour of people suffering from personality disorders can be challenging and the splitting defence mechanisms can be anxiety inducing, they are a group who have in the majority had their condition inflicted upon them. Up to 70% are the victims of child sexual abuse, and in most of the rest the damage and invalidation is usually obvious from their history (17). Why do they provoke such ambiguous responses in psychiatrists and other mental health professional?  

There is considerable evidence that medical professionals find both risk assessment and ambiguous decisions difficult, particularly around end of life decisions (18). Surgeons report difficulty in a personal sense when deciding on operations with marginal gains and high risks (19). They often rank the patient’s own preference to make these decisions as poorly informed (20). 

Cynically, you could say that they don’t want their statistics distorted, with an increasingly blame centred culture. They are understandably uncomfortable around interventions which may have a negative outcome. A more compassionate view might be that all of us in our medical training are taught “first do no harm” it is ego syntonic to save or help and deeply ego dystonic to fail or for someone to die in our care. 

The consequence of this is we have very ambiguous attitudes to the only thing we can be certain of - death. Death is seen as being someone’s fault, it can be prevented. We do post mortems frequently (21). This is a false belief and at our core we know it but it’s painful and distressing from a personal point of view to think about it.

Nobody enjoys existential crises so we repress it. This leads to psychological stress which expresses itself in ambiguity in difficult decisions. Psychiatrists are not often confronted with such battlefield decisions but we are often confronted with giving advice or making decisions where none of the outcomes are particularly appealing, or dealing with resource allocation where there is clear ambiguity.

In the case of Borderline personality disorder, especially severe or refractory cases, we are presented with a number of options: long-term hospitalisation which we know may well be counterproductive and may be damaging to our patients, access to DBT which is resource intense and may be sabotaged by the patient, medication for which there is little evidence for efficacy or, if resources permit (and they rarely do), admission to a therapeutic community. The alternative is tolerating the ongoing risk of someone we have no effective treatment for. 

These options are all unattractive. In an ideal world there would be limitless DBT or psychotherapy, but we don’t live in an ideal world. Our imperfect world is full of ambiguous choices or moral positions.

Sometimes we are confronted with taking the least worse option and this challenges our desire to do the best we can for our patients. We find ourselves doing something less than perfect but it’s the best we can do. We need to be able to function in a world full of ambiguity and in order to do this we must learn to not only tolerate ambiguity but understand it and be comfortable so that we can treat and advocate for those we care for 

As Tolstoy says in The Devil “the doctor arrived towards dinnertime and said of course that although the recurring phenomena might well elicit apprehension nonetheless there was strictly speaking no positive indication, yet since neither was there any contraindication, it might, on the other hand, be supposed. And it was therefore necessary to stay in bed and  although I don’t like prescribing nevertheless take this and stay in bed”.

Yard with Lunatics (1794)

Finally, we turn to the cumulation of ambiguity and partial knowledge, which is uncertainty. Much of what has gone before could be presented again to advance the argument that we must tolerate uncertainty.

But I wish to expand my proposition, to a case were our certainty gives rise to harmful and negative consequences for us as psychiatrists regarding situations over which we have little control and yet are perceived to be responsible for.

The case in point is that of suicide. 'It is a very frightening world where one professional group is given the impossible task and then censured by society (and themselves) for failing to achieve it”(22).

The previous quote is a free text response from a psychiatrist who had been involved with a patient who had completed suicide. It illustrates two important points. 

Firstly, there is a societal expectation upon us that is unreasonable. The emotive topic can spark newspaper headlines and the perceived censure from the public and the profession. 

There is resentment that Cardiologists are not subject to such scrutiny after someone dies from a myocardial infarct having been recently seen. However, I would contend that most branches of medicine feel the pressure of unreasonable public expectation. 

The most startling part of the statement is that we the mental health professionals buy into the notion that we can prevent suicide, this in spite of a substantial body of evidence that most suicide victims have no contact with mental health services or that less that 2% of suicides are rated as intermediate risk by accepted risk assessment tools (23)(24). 

Yet there is considerable evidence that psychiatrists who are involved with a completed suicide feel responsible for it and this exacts a heavy toll (25)(26)(27). What is of considerable interest from surveys is that most psychiatrists had high expectations about their own capacity to prevent suicide (22). 

The dialectic is clearly formed here. We believe we can prevent suicide, society thinks we should be able do so but the evidence is clear that our ability is very limited.

There are no validated risk tools which perform well, no single set or sets of risk factors which allow us to accurately predict suicide or usefully guide decision making (28) 'Given this, the attribution of personal responsibility for suicide prevention is clearly challenging' (22). 

The question to be addressed now is, why? 

Why do we take personal responsibility for something that the evidence clearly shows we have little control of. Leave aside unreasonable public perception, the point of interest here is unreasonable expectations of a profession that craves the accolade of being evidence based, yet we are happy to disregard a fairly convincing body of evidence when we apply it to ourselves. 

This is clearly not a logical or analytical approach. This is clearly an emotional, ego driven and, dare I say it, irrational response.

Now previously I have outlined the desire of modern psychiatry to be taken seriously and shy away from anything that is not statistically analysable.

What is the root cause of this dialectic which causes so much distress, makes psychiatrists change career and prevents people from entering psychiatry? 

It is uncertainty. More precisely, it is the inability to tolerate uncertainty. 

We could clearly seek to educate the public to the facts, but we don’t do that. We don’t do that because our unwillingness to acknowledge our limitations and acknowledge the gaps in our knowledge has the power of a ruminant thought in OCD. We generate temporarily soothing rituals: more risk tools, obsessive data collection and note keeping and, although they provide temporary relief , all they really do is increase the power of the resisted thought.

It appalls and offends our collective egos to say “I can’t” or “I don’t know''.

We collectively suffer and undermine our patients' faith in us because we cannot accept uncertainty.

Uncertainty is all around us in every aspect of the world: the weather, the stock market, Brexit or whether we will wake up tomorrow. 

The dawning of the reality that even in a place where we have studied, trained and practiced for years is no surer than anywhere else provokes anxiety and distress and causes something of an identity crisis.

It is upon this analysis and conjecture that I base and assert my almost certain conclusion that psychiatrists must learn to tolerate uncertainty, and not only tolerate but understand and embrace it and accept it for the universal reality that it is. 

Uncertainty is the fear food to the chronically invalidated teenager with anorexia, constantly seeking to please the expectations of overbearing parents: exposure to it exposes are deepest insecurities. 

I think Douglas Adams outlined our conflict the best: 'We demand rigidly defined areas of doubt and uncertainty'.

Saturn Devouring his Son (1819-1823)

References

1. Yuhas, Daisy. ”Throughout history ,defining Schizophrenia has remained a challenge “ Scientific American Mind(March 2013)

2. Berrios G.E., Luque R.,Villagran J (2003) “ Schizophrenia :a conceptual history” International journal of Psychology and psychological therapy. 3 111-140

3. Bleuler, Eugen(19080”Die Prognose der Dementia Praecox- Schizophrenigruppe Allgemeine Zeitschrift Fur Psychiatrie 65:436-464

4. Cutting, John and Shepherd, Michael (1987)” The clinical Roots of Schizophrenia concept: Translations of Seminal European Contributions to Schizophrenia. Cambridge: Cambridge University press, pp59-74

5. Berrios GE, Hauser R (1987)”Historical Aspects of the Psychoses :19^th Century issues ”.British Medical Bulletin.43(3) 484-498

6. Berrios GE, Hauser R(1988)” The Early development of Kraepelin’s idea on Classification .A conceptual History” Psychological Medicine.18(4) :813-821

7. O’Connell P., Woodruff PW, Wright I, Jones P, Murray RM (February 1997) “Developmental insanity or dementia praecox:was the wrong concept adopted . Schizophr.Res 23(2) 97-106

8. Clinical Psychopathology. 5th ed.New York: Grune&Stratton:1959

9. Nordgaard J, Arnfred SM, Handest P, Parnas J. The diagnostic status of First Rank symptoms. Schizophrenia Bulletin. 2008; 34(1) :137-54

10. Meyer, J.S., & Quenzer,L.F (2005) Psychopharmacology: Drugs, the brain and behaviour. Sunderland, MA,US:Sinauer Associates

11. Goran C Sedvall MD.Ph.D & Per Karlsson MD “Pharmacological manipulation of D1-Dopamine receptor function Schizophrenia . Neuropsychopharmacology 21 S181-S188(1999)

12. Crossley, Nick (1 October 1998) “R.D.Laing and British anti-psychiatry movement :a socio- historical analysis” Social and Science and Medicine .47(7):877-889

13. G.Haddock,N.Tarrier,A.P. Morrisson, R.Hopkins ,R.Drake ,S.Lewis .”A pilot study evaluating the effectiveness of individual inpatient cognitive-behavioural therapy in early psychosis” Social psychiatry and Psychiatric Epidemiology (May 1999 34(5) 254-258)

14. Birchwood M; Tood P; Jackson C.” early intervention in psychosis the critical period hypothesis” British journal of psychiatry Supplement 33(33):53-59

15. Killackey E,Yung AR,McCorry PD92007)”Early psychosis : where we’ve been , where we still have to go” Epidemiol Psychiatr Sci. 16(2) 102-8

16. Black DW, Pfohl B, Blum N, McCormack B, Allen J, North CS et al “Attitudes towards Borderline personality disorder : a survey of 706 mental health clinicians “CNS Spectr 2011;16:67-74

17. Lieb,K. Zanasrini, M.C,Schmahl,C.,Linehan,M.M,.& (2004).Borderline Personality Disorder. The Lancet,364,453-461

18. Beresford, EB. ” Uncertainty and the shaping of medical decisions,” Hastings Centre Rep. 1991;21:6-11

19. Allison,JJ.Kiefe,CL,Cook,EF, Gerrity,MS,Orav,EJ,Centor ,R.”The Association of physician attitudes about uncertainty and riak taking with resource use in the MedicareHMO. Med Decis Making 1998; 18:320-329

20. Entwhistle,VA,Watt,IS.”Treating patients as persons :a capabilities approach to support delivery of person centred care”, Am J Bioethics (2022) 26: 242-250

21. Morris, DB. Illness and culture in the post-mortem age. Berkley and Los Angeles.CA: University of California Press ; 1998

22. Nurse K.L Brand,F. Carbonnier, A.,Croft,A.,Lascelles, K., Wolfart, G.,Hawton,K.”Effects of patient suicide on psychiatrists : Survey of experiences and support required”(2019) BJPsych Bulletin 43 (5) ;236-241

23. Large, M ,Ryan,C, Carter ,G, Karpur,N.”Can we usefully stratify patients according to suicide risk? “Br Med J 2017; 359

24. Healthcare Quality Improvement Partnership.” National Confidential inquiry into homicide and Suicide 2018. HQIP 2018

25. Sequin, M., Bordeleau, V., Drouin, M., Castelli-Dransart,D., Glasson, F. ”Professionals’ reactions following a patient suicide :review and future investigations , Arch Suicide Res 2014;18:340-62

26. Alexander, D.,Klein,S.,Gray N.M , Dewar,I.,Eagles ,J. “Suicide by patients a questionnaire study of its effects on Consultant psychiatrists . BMJ 2000;320:1571-4

27. Dewar, I.,Eagles,J.,Klein,S.,Gray,N.,Alexander, D.,” Psychiatric trainees experience of and reactions to patient suicide. Psychiatr Bull.2000 24:20-3

28. Rahaman,R., Gupta,S., While,D.,Rodaway R.,Ibrahim,S.,Bicckley ,H. et al “Quality of risk assessment prior to suicide and homicide :A pilot study, June 2013. National confidential inquiry into suicide and Homicide by people with mental illness. University of Manchester,2013