Striving for understanding in psychiatry
Guidelines shouldn’t replace critical thinking
Simon Wessely is head of the department of psychological medicine and vice dean for academic psychiatry at the Institute of Psychiatry, King’s College London. He was elected president of the Royal College of Psychiatrists in 2014. He graduated in medicine at Oxford University and has been a consultant liaison psychiatrist at King’s College Hospital and the Maudsley Hospital since 1991. Research interests include unexplained symptoms and military health. He set up the first NHS service for chronic fatigue syndrome at the Maudsley, and is a civilian consultant adviser in psychiatry to the British Army. He was knighted in 2013. (@WesselyS)
What made you want to be a psychiatrist?
At medical school it was the best taught subject. I went to Oxford, and the guy who ran the programme was Michael Gelder, very fierce and very good. And I enjoyed the psychiatry attachment as it was the first time I got to write in notes and go on ward rounds. It was the first time people would ask me questions and be interested in my responses, rather than just testing my knowledge. I finally firmed up what I wanted to do while on rotation in Newcastle. In those days you were encouraged to do general medicine before specialisation, but I realised that when I read in my free time, I was reading psychiatry. Books like Psychiatry in Dissent—the absolute classic by Anthony Clare—had an intellectual brilliance about it that made psychiatry seem very relevant, interesting, and challenging. So I applied to the Maudsley Hospital [now part of the South London and Maudsley NHS Foundation Trust, and the UK’s largest mental health training institution], and really I’ve been there ever since. This month, actually, is the 30th anniversary for me.
How has psychiatry changed during those 30 years?
The greatest change has been the use of modern psychological therapy. When I started, we would still be taught psychoanalytical approaches, which I wasn’t comfortable with. I did like the book The Art of Psychotherapy and [it] made me realise that there was more to talking to patients than just talking to them. That was a real psychiatric skill—like listening to murmurs is a cardiological one.
Then there’s the rise of a more defensive, administrative, risk based, bureaucratic practice, which I don’t like and don’t find very helpful. During the 1980s there were failures of psychiatry and community care and there was a big dramatic reaction. Psychiatrists were held responsible for the actions of the patients in a way that other practitioners aren’t, in a way that I still don’t understand.
Do you think it’s overly bureaucratic?
Medical students today have never known a world when guidelines weren’t there. I was part of the Cochrane Foundation when it first started, which went on to develop the National Institute for Health and Care Excellence guidelines. At the time this was needed because there was an awful lot of idiosyncrasy in medicine. People were doing studies but doctors weren’t changing practice, so this is something I wanted to help change.
Do you think that evidence based medicine and increased bureaucracy go hand in hand?
I do, but as with most things, as it’s grown larger it’s lost its flair. They are just guidelines, but you wouldn’t think so—they’re treated like the law. The whole point is that they have to be combined with what the doctor knows about the person. But nowadays if one deviates from the guidelines you run the risk of running into trouble, and I don’t like that. It often replaces critical thinking.
For instance, when you become a doctor you’ll get a lot of mandatory training. And you may wonder why. It’s usually to reduce the hospital’s legal bill. There’s no evidence that it works to make you a caring doctor. Harold Shipman was a competent doctor who also happened to be a murderer. It probably wouldn’t have stopped him, but it makes life difficult for the more eccentric practitioner.
Do you think public awareness of mental health has changed at all?
Not as much as some people say. Because change is a slow business and the first thing that changes is people learn to answer questionnaires on stigma better. They don’t actually change their views, but they learn what’s socially acceptable.
Mental health is difficult. I was at a conference the other day and someone pointed out that some of the things our patients do deserve to be stigmatised: rape, murder. If you go to Broadmoor [the high security psychiatric hospital for treating people at high risk of harming others], people have done things that need to be stigmatised. We can strive for understanding, but not for approval. In this way, we can empathise with some of the resistance to change
How have you found the last three months as president of the Royal College of Psychiatrists?
Pretty hard. The sheer scale of it has been something of a shock, and it’s brought me back to branches of psychiatry that I’m not familiar with.
Can you take me through a typical week?
No, because there’s no such thing. I’ll tell you what I’ve been doing today. I’m still involved in military research and health protection emergency response. So this morning was a research session on emergency preparedness, talking about Ebola, and the research we’re doing on terrorism. This afternoon I was meant to be in education, but I couldn’t go because I was talking with Simon Stevens [chief executive of NHS England]. And then tomorrow I’m giving a talk on community treatment orders, of which this morning I knew nothing, but by tomorrow afternoon I’ll have to be an expert on. Yesterday I was in Brighton talking about adult psychiatry, as well as trying to finish off a court report. And the day before I had a clinical morning that dragged on because one of my patients got very sick, so I had to be a proper psychiatrist again. In the evening I addressed 400 King’s alumni on the history of shellshock. And I’m still an academic chair, clinician, and teacher at Maudsley.Matthew Benjamin, fourth year student
1King’s College London Medical School
Correspondence to: email@example.com
Competing interests: None declared.
Provenance and peer review: Not commissioned; not externally peer reviewed.
Cite this as: BMJ 2015;23:h726