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What is a Psychiatrist?
He is many things to many different people. For instance, to the sophisticated urban American, the psychiatrist is probably as familiar a figure as the general practitioner is to a European American doctors talk jokingly of 'calling up your friendly neighborhood psychiatrist!' To an Englishman or a Frenchman, however, the psychiatrist is a somewhat remote figure, and it is probably true to say that most Europeans still regard psychiatry with some puzzlement - and even downright suspicion.
In the more primitive areas of the world, the psychiatrist as a professional person is usually completely unknown, since medical priorities are as a rule directed toward physical rather than mental illness. Yet many of these backward countries do in fact have the equivalent of 'psychiatrists', but under another name. The African witch-doctor is undoubtedly a practitioner of psychiatric medicine, and the techniques of suggestion used by the most skilful witch-doctors are, making due allowance for differences of culture, not very far removed from those used by some of his Western equivalents.
One of Britain's leading psychiatrists in fact makes quite frequent trips to Africa in order to study the effect of the witch-doctor's rituals upon primitive minds. To take a simple example, a witch-doctor can readily help a neurotic patient who believes that a spell has been cast upon him to make him fall ill. All he has to do is tell the patient he is casting an even more powerful spell to make him well again; whether the witch,doctor himself believes in this explanation is not always certain. Undoubtedly in rather more advanced communities, such as the West Indies, where some people still believe in the power of the 'obeah man', this worthy often casts spells for his 'patients', but has the good sense to tell those in whom he suspects serious illness to go to the hospital as well. This can lead to rather odd situations, in which patients in hospital beds are for instance found to have such items as dead bats under their pillows! However, as long as they take the drugs prescribed by the hospital doctor, no-one minds.
So, in primitive societies, and, to a lesser extent, in more advanced countries, we find that there are usually 'medicine men' who practice a basic form of psychiatry. This is a parallel of what happened in the early history of Western Man. If we look at cave paintings and similar records, we find that most, if not all, societies equipped themselves with a magician - a powerful figure whose help could be relied on in time of trouble. Ancient Greek vases show such men apparently inducing trance states in patients, rather as some modern psychiatrists use hypnosis.
However, as Man became more sophisticated, he tended to develop a rather different attitude to disease, to some extent because of the spread of Christianity.
The new religion drove out paganism, and those who claimed supernatural powers and to be able to weave spells were likely to be tortured and to end up at the stake. On the other hand, it is certainly true that the psychiatric health of Christian communities became to a considerable extent the responsibility of the priest, where once it had been that of the magician. After all, there are some scholars who hold that the gentle and persuasive techniques used by Jesus Christ with mentally disturbed people are very much in line with modern psychiatric practice - they would say, for instance, that Christ's method of dealing with the man possessed by devils (telling him that the fiends has passed into the bodies of the Gadarene swine) was simply an example of cleverly using the powers of suggestion to heal a mentally disturbed man.
Undoubtedly, in the last few hundred years of the Christian era, priests of all denominations have tended to exercise a simple form of psychotherapy over their flocks. Nowhere is this more obvious than in the instance of the confessional. 'Confession is good for the soul' is a trite saying, but a true one. In Roman Catholic and many Anglican churches, the priest regularly unburdens the guilty consciences of his congregation, practicing what a psychiatrist would call abreaction, which means drawing a patient out so that he feels better about his problems for having talked about them.
Unfortunately, while the clergyman has been very much in the front line of dealing with the mild neuroses and day-to-day worries of Western Man, the banishing of magicians meant little was done to try and help people with more serious mental disorders.
In the Middle Ages, the insane were often regarded as being possessed by devils - yet few people showed them the patience and tolerance exercised by the founder of the Christian religion. Men who were mad were locked up in dungeons, kept on chains, and treated like animals. In fact, we still see echoes of this kind of behavior towards the mentally ill even today.
A great advance in psychiatric techniques was made by the Quakers, who founded hospitals where mentally deranged people were treated kindly, and given attention and proper food. What a contrast this was to the 'official' hospitals of the day, whose conditions are made all too clear in Hogarth's painting of the Bedlam hospital.
Certainly the greatest step forward in the history of psychiatry came with the work of Freud, the first person to attempt to study both the conscious and the unconscious mind in the same scientific way as others studied the body.
Freud was an analyst of the human mind- a psychoanalyst. It is here, perhaps, that we run into the difficulty laymen have in understanding this branch of medicine - the question of terminology.
Except in the United States of America, where some people spend as much as two afternoons a week talking to their own analysts, few people understand the distinction between psychologists, psychiatrists and psychoanalysts.
A psychologist has special training in the study of the mind, and normally has a degree or diploma in this subject. He is not necessarily medically qualified; nor, even if he is, is he necessarily engaged in the treatment of mental disorders.
Psychologists are often employed in industry, where their knowledge is useful in such fields as marketing, advertising and personnel management, and in the larger educational establishments.
Many specialize in limited fields- such as child psychologists, who may work in child guidance clinics. A psychiatrist is a fully qualified doctor who specializes in the treatment of mental disorders. He has undergone training in all the basic branches of medicine, and then taken up a more intensive study of the special problems of mental health. This further study may take many years, particularly if the doctor wishes to become a psychoanalyst. Psychoanalysts, or analysts, learn the technique of interpreting people's thoughts and reactions, and helping them to understand the way that their minds work. Analysis is a process which may take a very long time, possibly years, during which the patient will spend several hours a week with his analyst.
At each session, the analyst sits by a couch, on which the patient lies and talks.
He talks of anything and everything that comes into his mind (perhaps prompted by the analyst). The process of simply voicing all one's secret thoughts, hopes, fears, and memories as they occur is called free association.
The object of all this is to free the patient of the repressions which, according to Freudian theory, have been present in his mind since early infancy. Whatever the mechanism, there is no doubt that many of those who have undergone psychoanalysis find that it gives them a whole new approach to life, with a fresh understanding of the petty and childish impulses to which all people are prone at times. Training in psychoanalysis is a long process, because the student has to undergo analysis himself.
But what about the ordinary psychiatrist, who does not practice analysis? (It can be seen by simple calculation that most psychiatrists have not the time to carry out this procedure - at least, not with the vast majority of their patients; the amount of time involved would necessitate an army of thousands of psychoanalysts.) How does he treat his patients? Before Freud, there were virtually no special methods of psychiatric treatment available, other than kindness and listening to what the patient had to say. Today, although we have advanced only a little way toward unlocking the secrets of the mind, the psychiatrist has quite a wide range of methods of treatment at his disposal, to deal with the more common psychiatric disorders.
Mildly neurotic patients are often simply treated by the time-honored method of abreaction (or confession) aided by mild sedation. This in many cases produces surprisingly good results.
Anxiety neuroses can be treated along similar lines, but new methods of treatment are coming into use. For instance, quite commonly patients exhibit undue anxiety about a particular object or situation (for example, being in a lift). Such patients can be desensitized - that is, relieved of their anxiety by being induced to imagine the dreaded situation and talk about it while under the influence of a drug.
Useful ancillary methods of treatment include the use of tranquillizing drugs.
These preparations, which came into use only in the late 1950s and early 1960s, have the effect of 'damping down' the symptoms of stress and strain, without producing the drowsiness which is characteristic of the older sedative drugs.
Where neurotic symptoms are quite severe, the psychiatrist uses such measures as suggestion and persuasion - sometimes in the form of hypnotic suggestion. He may also be able to assist the patient with social measures - for instance, getting a psychiatric social worker to look into the home background and see if anything can be done to ease problems there.
Many of the patients seen by psychiatrists suffer from severe depression. Again, an understanding, friendly attitude on the part of the psychiatrist, encouraging the patient to talk about his troubles, may work wonders. Other patients with depression may benefit from the use of antidepressant drugs, which have been developed within the last decade or so, and which often give good results. A particularly good outcome in depressive patients is often achieved with electro-convulsive therapy (ECT).
Owing to unfortunate publicity in the past, and occasional rather silly and misinformed attacks on the method, ECT has a slightly fearsome reputation amongst the public at large. It should be clearly understood that this procedure is not in the least painful, is carried out when the patient is fully anesthetized, and can be done on an out-patient basis, so that the person involved can come up to hospital for an hour or so each week, and have a treatment session. Most important, ECT completely revolutionizes the lives of many very unhappy people.
Leucotomy, a form of brain surgery, has also attracted much unfavorable publicity in the past. This operation is carried out much less often than it used to be, but psychiatrists find that it brings much benefit to some patients, particularly certain of those who suffer from severe forms of the tragic mental disorder known as schizophrenia.
This disease, which is said to affect about five people in every thousand, is one· of the greatest mental health problems facing Mankind. In most countries, over 50 per cent of the chronic inhabitants of mental hospitals are schizophrenic. Fortunately, in the last ten or fifteen years, the use of tranquillizers has enabled psychiatrists to help many schizophrenics to live outside mental hospitals, and even, in some cases, do useful jobs.
These, then are the main methods of treatment used by the modern psychiatrist.
He has to some extent taken over the psycho-therapeutic function of the ancient medicine-man, and, in more recent times, of the priest. He is neither superman nor someone to be feared (and those who do fear or mock psychiatrists are in fact only betraying their own deep insecurities).
The psychiatrist is in fact simply a doctor, like any other, doing his best to help the sick. Because his patients' sickness is of the mind rather than the body, his particular branch of medicine is at a much less advanced stage than are some others; but the progress in treatment which psychiatrists have made in the last ten to fifteen years offers great hope that they will be able to do a great deal more for their patients in the future.