Psychiatrist Sidney Bloch talks about psychiatry

Interview by Michael Short in The Zone
smh.com.au (transcript and video)
November 28, 2011

Michael Short: Sidney Bloch, welcome to The Zone. Thank you for your time. You have worked in psychiatry for some 40 years and you are here because you believe that the public controversy that often surrounds psychiatry can add to confusion and fears people might have about mental illness and its treatment. So can we start please, Sidney, with an overview? It would seem that psychiatry at its best has a body and soul; a melange of science, that’s the body, and the art and the ethics, which comprise the soul, to borrow from how you portray it. In what sort of shape are the body and the soul of psychiatry?

Sidney Bloch: It depends on what sort of spectacles one wears, or to use another metaphor, whether one sees the glass as half full or half empty. I myself have always seen it as half full since I have learned through my clinical and research endeavours that I have many validated treatment strategies at my disposal to assist people with troubled minds.

But having come to the end of my clinical career and stopped working with patients (I am now semi-retired), I am not as optimistic as I was in the past. I have thought deeply about my profession and see a number of difficulties, particularly as they relate to the public. As you have mentioned in your introduction, the average lay person has a very distorted view of the nature of mental health, mental illness and the treatments we apply.

Confusion and fear are the two main reactions to the possibility of a mental illness in oneself or a loved one; it’s amazing to me how even well-informed people are utterly puzzled about psychological distress that they experience in themselves or a family member.

Consider an adolescent who has lost a considerable amount of weight. Her parents are baffled as to whether this is merely due to excessive dieting or is the prelude to an eating disorder like anorexia nervosa. They may have an idea that anorexia nervosa can be a nasty illness and that they have to seek professional help. But knowing what sort of help, and how to obtain it, is far from straightforward. Moreover, consulting a psychiatrist may induce fear about what will be uncovered as well as a sense of stigma.

The picture I have drawn is compounded by what I suspect is ambivalence on the part of psychiatrists to communicate openly and honestly with the public. One notable factor is that our profession lacks the scientific knowledge about so much in the field of mental illness and its treatment. This is the half empty glass. For example, we have little idea about the nature of schizophrenia, the major psychosis that afflicts young people.

We have an illness which affects almost one in a hundred people, is encountered universally and in every culture, and is often lifelong. Only a small proportion will improve substantially; many more will remain disabled psychologically, occupationally and socially and only get by with a lot of professional and family support.

A snag in these frightening circumstances is that we can’t convey accurate information to patient and family who are usually struggling to deal with the radical change in their lives. We certainly can’t do what our surgical colleagues can in terms of conveying unambiguously the details of a disease, the required surgical intervention, and its likely outcome.

By contrast, psychiatrists recommend treatments that they have been applying for half a century and whose mode of action remains obscure and about which we can only theorise. In most cases, these medications were first deployed for another purpose and then serendipitously noted to be of benefit for certain psychiatric conditions.

MS: So psychiatry is operating in a difficult area because it is dealing with a situation that is opaque and terrifying?

SB: This is a good way to put it. It’s opaque because the brain is so difficult to examine directly. For most of the time that scientific psychiatry has been in existence, we could only study the brain at post-mortem. Fortunately, we now have sophisticated neuroimaging techniques such as MRI, PET and other scanning procedures to study both the structure and function of the brain in a range of psychiatric disorders.

Although the cause and brain pathology of many mental illnesses remain elusive, we are gaining valuable information and our knowledge is steadily increasing. I am optimistic that together with rapid developments in genetics, modern technology will pave the way for learning about the biological factors that operate in major psychiatric conditions.

The terrifying nature of psychiatry relates mainly to how severe and long-lasting mental illnesses can be, leading to dreadful suffering in the patient and a sense of pessimism in the family. The possible vulnerability of other family members through the inheritance of abnormal genes only adds to the fear.

MS: Beyond the opaque element, which is being mitigated by the technology of which you speak, and the terrifying element, of which you speak also, why does psychiatry encountered so much public static? Is there some fault here that the profession should take responsibility for?

SB: The reason we encounter static, as you put it, is associated with the fear. When we are frightened of something that we find threatening, we tend to conceal it from ourselves and, even worse, resort to ridiculing it.

That’s one reason why mentally ill people are often referred to as “nutters”, “loonies” and the like. We use these pejorative terms because we want to distance ourselves from mental disorders. Michel Foucault, the French philosopher, argues in his book, Madness and Civilisation, that unreason poses a profound threat to us; after all, to lose our reason is akin to losing our identity and sense of self.

I’m referring here to severe illnesses like dementia, bipolar, schizophrenia, delusional disorder, recurrent depression and anorexia nervosa. It’s frightening to consider that I perhaps one of my relatives may become a victim. The fact that one in five will suffer from a diagnosable mental illness over a 12 month period is constantly drummed into us.

MS: What can the profession do, then, to reduce the buffeting it sometimes gets in the community, Sidney?

SB: My paramount thought is for psychiatrists to be entirely honest about what they can and cannot do and, in conveying relevant information, be as coherent as possible. If they are afforded the opportunity to communicate with the public.

(As I am doing now via The Zone) they should do all they can to alleviate the community’s sense of bafflement and anxiety.

We should be proactive in this context. Indeed, I would assert that we have an ethical obligation to communicate with the community. In my experience, however, psychiatrists tend to shy away from taking on this role. For one thing, they are extremely busy in their day-to-day clinical work.

They are also concerned that they will be misrepresented; I have to say that they probably will be. The media are apt to focus almost exclusively on deficiencies of the mental health system, often sensationally. I do not detect much effort in their trying to gain an understanding of the challenges that face mental health professionals. We cannot win.

For example, we are criticised either because we allegedly hospitalise people unjustifiably and deprive them of their civil rights or we are insensitive to the severity of a patient’s mental suffering and fail to admit him to hospital or discharge him prematurely.

A balanced picture is rarely presented; negativity is typical. As psychiatrists we constantly have to fight against these distortions.

In my opinion, psychiatrists are among the very few people who can take up the cudgel since they are trained to view the mind, both normal and abnormal, in an exceptionally comprehensive way. After all, they are required to study general medicine and then psychiatric medicine for over a dozen years to qualify as a specialist.

MS: What are the main ethical challenges?

SB: We have the need, and it’s legislated for in all developed societies, to force our treatments on a sizable proportion of severely ill patients, especially when they are at risk of self-harm or self-neglect. This is one of the most awesome tasks that I have had to perform throughout my career. I can assure you that it is a most unpleasant process. Thus, if I encounter for instance a student who shows evidence of dismay and gloom and shares hints about feeling suicidal, I can’t just invite him to pop in at another time to explore his difficulties.

On the contrary, I have to act promptly and decisively; this may mean hospitalising the student against his will. This is sufficiently common to induce a state of anxiety in us. We also have to keep the patient in hospital for quite some time in order to win his trust and work for his improvement.

MS: Is part of that ethical consideration that when you are making this subjective assessment of likelihood of self-harm or harm to others, is there an ethical requirement, or is it ethically desirable, you that you err on the side of prudence?

SP: Absolutely. I have taught the ethics of suicide over many years and always contended that it is preferable to err on the side of conservatism; it’s better to save a life than let it be lost. And this sometimes means a false positive, because the person is not as suicidally inclined as we thought. It puts a huge onus on us since we obviously don’t wish to deprive people of their liberty unnecessarily.

We strive to do this as sensitively as possible by explaining the necessity for the involuntary admission. With a positive response to treatment there is usually an acknowledgement by the patient and his family that compulsory treatment was indeed required. The dilemma has been compounded by a procedure that is now frequently used — Community Treatment Orders.

Victoria was one of the first jurisdictions in the world to institute this radical option. A CTO gives us the legally sanctioned power to supervise closely people who are living in the community and to enforce what we judge to be essential treatment. The CTO can last up to 12 months although patients can appeal to an independent tribunal at any time and as often as they wish.

MS: Is this a good development in the system?

SB: There are pros and cons. Nobody wants to be robbed of their liberty. On the other hand, treatment may be vital to save a life, prevent deterioration or spare others from harm. We’re between a rock and a hard place. Fortunately, contemporary mental health law provides measures to forestall unjustified deprivation of people’s civil rights.

MS: But over all the CTO is an appropriate attempt to balance competing needs?

SB: I believe most members of our profession see it as a pragmatic advance given that it’s far better to treat somebody under these conditions than forcibly admit them repeatedly to a psychiatric ward.

MS: What have been the main changes, and the main advances in other areas perhaps, of the profession in your clinical time?

SB: I feel most fortunate to have witnessed many advances in the course of my career. Our diagnostic methods and treatments have improved in an unprecedented way. I often tell my students that they should feel optimistic in that we have accomplished more in the past 50 years than in all preceding centuries since the birth of medicine 2,400 years ago.

I am referring to both medications that act on the brain and the psychotherapies. In both domains there has been tremendous progress. For example, before 1953 when the first antipsychotic was discovered serendipitously, no effective drugs were available. People hospitalised with severe conditions languished– in many cases for years on end.

Let’s talk about disorders of mood for a moment: If patients had severe retarded or agitated depression, they had to be hospitalised to prevent suicide or death from dehydration and lack of nutrition. But such afflicted people can now be helped very effectively with the aid of the treatments that I am talking about.

The comparison between the pre-50s and the last half century is like chalk and cheese.

If I had not had access to modern medications, I don’t know how I would have managed. My predecessors must have been extraordinarily patient and compassionate. The psychotherapies are another key landmark in the treatment landscape. The intensive form of talking therapy, psychoanalysis, was prominent between the 1940s and 1970s but were modified thereafter to make them much shorter in duration without loss of efficacy except for extremely disordered personalities.

I can avail myself today of a whole range of psychological therapies. I have done so for many years as a central feature of both my research and clinical work. What a blessing it has been for patients. Using family therapy we can help dysfunctional families who are grappling with severe conflict or tension.

Our research team have used group-based therapy with women living with breast cancer with the aim of promoting effective coping and adjustment as they face profound existential challenges. We are currently applying a similar model for men with prostate cancer together with their spouses. The psychotherapies in general have been assiduously studied and also validated. We now know that they work effectively for many psychological states.

MS: So, under what circumstances might one benefit from seeing a psychiatrist?

SB: When you mention benefit, we have to qualify the term. Consider adolescents as illustrative. They may consult a psychiatrist when experiencing intense inner turmoil. They are confused about their sense of identity and have low self-esteem in the wake of adverse or painful circumstances within their family or peer group. The benefits are usually impressive. Through an honest dialogue between patient and therapist, the troubled adolescent acquires fresh insights about what ails them and applies new knowledge in their lives.

On the other hand, if I saw someone of similar age with clinical features of schizophrenia which had their onset a couple of years previously, the benefit achievable is much more limited because of the severity of the illness and our ignorance of its cause. They may tragically never accomplish the sort of benefits we would like to see in a person embarking on adulthood. We are then faced with the task of trying to make their lives as bearable as possible and promoting their quality of life.

MS: You mentioned earlier that one of the complexities is actually getting to a psychiatrist. Can you just expand a bit on that please?

SB: We know that about 60 per cent of people who need psychiatric help don’t receive it. We mentioned earlier one of the reasons – their reluctance to admit to themselves that they are mentally unwell and in need of professional treatment. Ambivalence is at the heart of their experience. They may also fear the stigma that is so often associated with a psychiatric disorder.

MS: Ambivalence or delusion or cognitive dissonance?

SB: If the illness has reached the level of a psychosis, as manifest by loss of contact with reality and lack of insight, the sufferer fails to appreciate that they are ill. The resultant delay in initiating treatment means that the patient can be grossly disturbed when, as is usually the case, they are brought to a hospital emergency department by family or friends.

It’s not a straightforward referral process, as is the case of a person with say high blood pressure or pneumonia or appendicitis. Stigma is absent, the clinical features are obvious, and treatment specific.

MS: Can you give by way of explanation about the potential upside of seeing a psychiatrist a case study that you think resonates?

SB: Consider the research that my colleagues and I have carried out with cancer patients over the past two decades (mentioned above) they are obviously most distressed by the cancer diagnosis. Moreover, they were usually active and functioning well in their lives until confronted by the potentially lethal condition.

Their whole world has turned upside down. We conducted a large study in which we invited women with breast cancer to meet in small groups at weekly intervals over a period of six months. We encouraged them to be honest with one other and to provide mutual support. They clearly benefited from the group experience compared to controls who were randomly excluded from group counselling.

More dramatically, I remember an elderly lady who was in a medical ward to look for a physical cause for her considerable loss of weight and dehydration. It soon became apparent through talking with her husband and children that she had suffered from episodes of depression in the past.

To our professional eye, this looked like another attack of her mood disorder. Periodically, we encounter this form of depression; people stop eating and drinking as part of their loss of interest in the world. Everything is slowed down. On this occasion we felt that electroconvulsive therapy (ECT) was indicated as a life-saving measure.

Antidepressant medication would have taken too long to produce improvement. There is always a two-to-three-week delay before the positive effects of antidepressants are felt. Moreover, we don’t always achieve such effects. The anaesthetists resisted our recommendation of ECT; I suspect even they were prejudiced towards the treatment but also had genuine reasons to avoid administering an anaesthetic to such a frail person.

We persuaded them that ECT was a life-saving measure in this case. Within three weeks and after six ECT sessions, she had improved dramatically. She resumed eating and drinking and expressed her gratitude for the intervention. Thus, we can see that we achieve impressive results in particular situations whereas in others we have to be tolerant of the slowness of improvement or even minimal change.

MS: Sidney we are hideously out of time and I wanted to ask you a couple more questions. That leads us to, if I may, your personal experience with depression. Are you able to, in the context of our discussion, talk a little bit please about that?

SB: All of us are vulnerable to psychiatric maladies, even the most robust personality. The rate is high. Doctors, including psychiatrists, are vulnerable as well. Until I was 50 years old, I coasted along quite nicely without any major psychological disturbance.

Quite suddenly, after a trip overseas and my arrival home with ghastly jetlag as well as a debilitating bronchitis, the world looked awfully gloomy. Then to my astonishment, I plummeted into a deep abyss of hopelessness and helplessness.

I became extraordinarily needy, crying my heart out, and seeing the world as bleak and black. I didn’t know what to do because one is reluctant to share this with colleagues. Neither does one telephone one’s secretary and say: “I’ve just developed a horrific depression and won’t be coming to work for a few weeks”.

All this is about stigma. Ironically, I am a member of a profession where we are desperate to reduce discrimination, and here was I feeling wary of disclosing my own brush with mental illness. I therefore practised the customary deception of indicating that I had been laid low by a severe virus and felt utterly exhausted and apathetic.

Fortunately, I had a colleague who I could trust without reservation. My wife asked him to examine me as soon as possible. Once he had diagnosed my severe mood disorder, he prescribed an antidepressant immediately. Luckily, I responded well and emerged from my awful state and thankfully have been spared such profound depression ever since.

But I have remained exquisitely vulnerable to mood changes, especially when experiencing jetlag. This was certainly a sobering experience which enabled me to empathise more accurately with patients. I joke with my students that they should all undergo a severe illness, preferably a curable one, to obtain an idea about how distressing it can be.

MS: Thank you for your openness with that, because I think it helps us see everybody’s vulnerability and that things get better. I ask everybody in The Zone Sidney at the end, and you have sort of answered it perhaps, what is the hardest thing you’ve ever had to do. Is the experience with depression the hardest thing you’ve dealt with?

SB: It was hard because it was so painful. I thought I was losing my mind. On another occasion, I contracted a rare disease. I could not breathe or swallow because of a large abscess behind my throat. The diagnosis was not made for several days by which time I was seriously dehydrated.

I was hospitalised and told I had this rare disease which I had never heard of. Life-saving surgery was urgently required but prior to that I had to have a tracheotomy in order to breathe. In years gone by, Lemiere’s Disease was lethal. The surgery was performed by a charismatic ENT surgeon who stated confidently:” I know about this condition and you will come out of this”.

I relied on him absolutely and when he operated thought: “Thank goodness I have got into the right hands”. Little did I know that the surgical intervention was not going to cure me. My temperature remained elevated indicating that the infection had not resolved.

The surgeon came by one day and said “I must confess that I don’t know what’s going on”. He was utterly honest– something I appreciated very much despite my fear that inexplicable complications dominated the clinical picture.

He then informed me that he had “better go in again” even though he had no idea why I was still running a temperature. On this occasion he did not find any residual abscess. He advised me to allow nature to take its course. Somehow or other, his confidence and warm support got me through the ordeal with the temperature dropping to normal within a few days.

MS: It sounds terrifying, to use that word we used at the start of the interview. We are out of time. Sidney, thank you very much for your time today.

SB: It’s been a pleasure.

This transcript and video were published on the Sydney Herald website at: http://www.smh.com.au/opinion/society-and-culture/full-transcript-professor-sidney-bloch-20111128-1o25b.html