Leading the Way.

Did anybody remember the map?

A recent article by Alag and Wakefield on psychiatrists as leaders in the field of mental health described their role as of “paramount importance” in displaying “dynamic leadership” through their “astuteness and compassion”:

Beyond merely grappling with the escalating challenges in mental health, these leaders are called upon to redefine the narrative, becoming architects of transformative policies, champions of innovative practices, and advocates for the radical dismantling of pervasive stigmas enveloping mental health …(psychiatrists act as) dynamic catalysts for societal transformation … nurturing mental well-being on a global scale … promoting holistic well-being and resilience in individuals and communities…

Clearly, the world today is in a chaotic state and appears to be getting worse by the hour, inevitably causing increasing levels of mental disorder within the community. As these authors see it, psychiatry has a pivotal role to play in reducing mental distress, social stigma and the institutional forces that precipitate and perpetuate mental disorder. Psychiatry has to extend its role beyond the purely clinical to encompass dealing at a community level, which would have to include government – “a proactive engagement within the corridors of power, shaping policies, championing innovative solutions” - and not just locally but at the national and transnational level. A global perspective is required, which psychiatry is well-equipped to deliver due to its “…deep appreciation for cross-cultural nuances, and inventive approaches tailored to resonate with diverse populations.”

While this is definitely uplifting and may even encourage recent medical graduates to consider training in psychiatry, it isn’t entirely clear just what psychiatrists bring to the table. What is it in their training that equips them to take on such a Herculean role, especially as the crises seem to be multiplying, from unemployment, domestic violence, drugs and alcohol and homelessness at the local level to wars, massive social dislocation and climate disasters internationally? In simple terms, given all these tasks, why psychiatrists and not someone else? That isn’t clear but we’ll leave it for the moment to focus on a mental health crisis closer to home.

For the past few years, public psychiatrists in New South Wales (population 8.5million, including over 5million in Sydney) have been complaining about a variety of matters, especially their pay. A few weeks ago, after negotiations bogged down, well over half of them submitted their resignations, which has thrown the Health Dept into turmoil. NSW has 416 approved posts for specialist public psychiatrists but only about 295 are currently filled, with over 200 of those are due to leave in a week or so. The current salary for a specialist psychiatrist employed on the staff of a government hospital starts at $186,000 pa (about US$120,000 or GB£95,000) and goes in five grades to senior specialist at $252,000. Apparently, their salaries are about 30% less than other states.

At present, 50% of staff psychiatrists are on the senior grade. In addition, they receive 11.5% paid into their superannuation (pension) funds, plus 5 weeks annual leave with 17.5% leave bonus, plus 2 weeks sick leave, plus about a week study leave (variable), plus they have the right of 25% private practice, plus variable penalty rates for being on call, plus managerial allowance, easily giving a total of about $360,000 a year. That, I should point out, is a lot more than I earned running a bulk-billing (government-funded) private practice to provide free services to pensioners, unemployed and other disadvantaged people. As a privateer, of course, I had to pay rent, staff, IT services, etc.; fund my own superannuation scheme; and I wasn’t paid for holidays, sick leave or study leave (just for comparison).

In any event, NSW psychiatrists are sufficiently annoyed by their circumstances to get out. What will happen to the patients isn’t clear but already, hospitals are closing beds and even wards as they try to get ready to cope. Where will the patients go? That hasn’t been announced but suggestions include authorising general practitioners to diagnose and prescribe for ADHD. What will happen to all the other people with serious conditions is also in the pending basket. Good question, we’ll get back to you. Where will the psychiatrists go? Some will move interstate but that’s not so easy, so it seems most will head for the greener pastures of private practice. Apart from being your own boss and not having to go to boring meetings, the major attraction is that, in Sydney as in most cities in the country, there is a six month waiting list to see a private psychiatrist.

The reason is there are queues of people clamouring to be given the seal of approval for their Dr Google diagnosis of ADHD, which authorises them to have a lifetime of amphetamines at government expense. They qualify for numerous other benefits but they’re just the fine print. In order to get this jackpot, applicants need shell out only a few thousand dollars and the diagnosis falls into their laps. The going rate for a psychiatrist’s diagnosis of ADHD is $2-3000, for perhaps an hour with the doctor and including filling in a couple of questionnaires that confirm, Yes, you are the lucky bearer of a genetic disease, here’s your tablets, pay as you go out and please send all your relatives so we can stamp them, too. All this comes from the expansion of the new childhood diagnosis of ADHD into adulthood. YouTube hosts thousands of videos explaining how you too can self-diagnose ADHD and, with the tablets, your life will be transformed. It would be interesting to see the proportion of people given this diagnosis by particular psychiatrists, as well as the proportion who self-diagnose and then have it confirmed, but we’ll never see these figures. As to what happens to them in the long run, we’ll have to wait for the long run to eventuate, as in “Treat first, discover the adverse effects down the track.”

Perhaps, then, this would be a good time to suggest a little experiment: close the hospitals, especially the useless, money-grubbing private psychiatric hospitals, and set up a proper community-based mental health service. By that, I do not mean psychiatrists and their patients should all rush to elegant buildings in posh suburbs with CCTV and plenty of room for the patients to park their Mercedes Sports or their bloody Teslas. I also do not mean forbidding buildings with lots of staff and meetings and cars and mission statements and key performance indicators and security staff and phones that say “Press 9 to leave a message,” no, none of that public service empire-building stuff. Instead, I mean an actual outreach service based on the Willie Sutton principle. When asked why he robbed banks, he replied: “Because that’s where the money is.”

So where should all the newly-liberated psychiatrists go? To the slums. To the distant working class suburbs with poor public transport and struggling schools where young mothers with two small children and no childcare are forced to catch two or three buses to see a hugely expensive psychiatrist in a prestigious city centre because that’s where psychiatrists like to cluster. And when she gets there, what will she get? Pills. And when they don’t work, more pills in bigger doses. Years ago, I moved to a town of 100,000 and, as usual, rang the GPs to say I was there and open for business. Most were delighted but one wasn’t: “I can prescribe antidepressants as well as any psychiatrist,” he sniffed. I told him to call me when his antidepressants failed. He was quite right because if all psychiatrists do is push pills, and ECT when the pills fail, then who needs psychiatrists, especially when nurses and social workers already take the histories?

To me, the principle is simple: as “architects of transformative policies, champions of innovative practices, and advocates for blah blah,” psychiatrists should go to the country and the outlying suburbs where the troubled people are. That’s what duty dictates, as the authors of the article made clear:

As we navigate the complexities of this transformative journey, the profound significance of psychiatric leadership becomes increasingly apparent, offering a beacon of hope for a world where mental well-being thrives on a global scale.

Wonderful. Heart-warming stuff. Except they won’t. Like crows in a tree gleefully watching a dying calf, psychiatrists cluster in the very places where the wealthy like to hang out. For them, the thought of leaving their “comfort zone,” meaning where you can safely park the Porsche without the local urchins taking to it with a broken bottle, fills them with a vague sense of discomfort. Being out of sight of other psychiatrists worries them, it makes them twitch and look around nervously while checking they’ve still got reception. In 1987, when I announced to the psychiatrists of Perth that I would be going to work in the far north Kimberley region of West Australia, they all said exactly the same things in the same order: “You’re going to the Kimberley? You must be mad. What will you do when you get back? Oh well, we’ll be able to come and visit you.” None of them did, of course.

The reason for setting up the service in such a remote region was to prevent people, especially Aboriginals, being transferred to the city for treatment. Routine evacuation was costing a fortune as they had to travel in the Flying Doctor as detained patients and, once in the city 2000km away, where nobody spoke their language and they hated the climate, it proved very difficult to get them back home. The average stay for the fifty or so patients sent south each year was about twelve weeks, so having a psychiatrist on the spot made sense. In my first complete year, the number of transfers dropped by 96%. The few admissions to the local hospital were days, not weeks; there was no stigma as they all knew the psychiatrist; and families were kept very much involved in management. Patients could be seen at home, the community nurses functioned as case managers and it saved the department at least ten times my annual salary (although if the Health Dept were grateful, they never told me).

Similarly, after moving to the Big Smoke of Greater Brisbane (pop. 2.7million), I set up shop in, literally, a shop, although it was as part of a busy general practice in a sprawling working class suburb with lots of unemployed people, single parents, immigrants, crime, school drop-out, drug and alcohol and DV problems and so on. It was in the main shopping centre so a lot of patients could walk to their appointments. Of 200 new cases a year, mostly seen only half a dozen times, only two or three would go to hospital, and almost always patients who had been before. These were exactly the same types of patients whom I had seen while working for the government mental health service, except MHS admitted up to 25% of their outpatients for reasons I could never divine (mostly it was fear of something going wrong because they actually had no relationship with their patients and couldn’t tell when the wheels were falling off. Why not? Because the psychiatry staff didn’t take the patients’ histories, they simply scanned what the intake staff had recorded on the 12 page admission proformas).

Anyway, the message is this: chase the shrinks out of the hospitals into the slums and the bush and make them actually do the work of psychiatry, as distinct from pushing pills, and things will get better. Quelle surprise, such a revolutionary message, who could have expected it? All this was published in various ways to get the message out. Very good, you say, mainstream psychiatry must have been delighted to learn that they were doing it all wrong and could treat five times as many patients for the same budget just by getting out of hospitals? You’re kidding. No way. The hospitals are their security blanket, they need that sense of authority to hold themselves together. The last thing they want to hear is some radical plan to close hospitals.

The article by Alag and Wakefield which says the future psychiatry will “transcend conventional hierarchical frameworks … a beacon of hope … dismantles obstacles that impede access and engagement etc.” is very much what you hear in the opening lectures for psychiatric conferences, only more so. Psychiatrists do not go to conferences to be criticised or to be offered a radically new way of looking at things. That’s not why they’ve taken all the trouble to fly to a luxury resort far from the wife and kids, to spend a week wining and dining with their friends from medical school or even from their expensive private schools, far from it. What they want to hear is the sort of undiluted bullshit that oozes from that article, self-comforting, self-aggrandising, pointless, useless fantastical self-deceptive nonsense that says absolutely nothing about the real world. You should read it, but not while you’re having lunch.

Why am I so sure it’s crap from beginning to end? Because if psychiatrists are to be leaders, what are they going to lead with? If you’re the leader of a hiking group, or a fishing trip, a building team or even just taking the kids to a new beach, you need a map or a plan. If you’re the intellectual leader of a project, you need a program. In science, that plan is called a model of your subject matter, and it leads to a research program. Psychiatry doesn’t have that. It doesn’t have a theory of mind, or a theory of personality, so it can’t have a model of mental disorder or a model of personality disorder. Sure, it has an ideology of mental disorder but does it have a valid scientific basis? No, nothing, not a jot nor even a tittle. But they still want to be leaders and will use all their influence with governments to see that nothing changes. I’ll write to their crappy journal to point this out, politely, of course, but I’ll bet they won’t publish it.

As for psychiatry’s “leaders who possess a comprehensive global perspective … play(ing) a vital role in fostering a collective and culturally sensitive response that addresses the multifaceted dimensions of mental well-being on a global scale,” it is worth mentioning that 96% of surviving children in Gaza fear death is imminent, and half want to die. The response of the RANZCP to this unfolding catastrophe has been to refuse to acknowledge it. So much for their vaunted leadership: “We’re their leaders, which way did they go? Did they? Oh no, that’s too scary, we’ll wait here until they come back.” (fantastic song, I used to sing it driving through the wonderland of WA’s Kimberley region).