Dinesh Bhugra:
Psychiatry needs a broader focus
The first gay president of the World Psychiatric Association wants a
radical rethink of mental illness and for the profession to apologise for the
harm it has inflicted on gay people and women
Patrick Studwick, theguardian.com, 27/11/2013
What do we mean by mental illness and what do we want psychiatrists to do
about it? These are just the opening questions posed by Professor Dinesh
Bhugra, the incoming president of the World Psychiatric Association. The
Indian-born Briton is calling for a radical rethink not only of services for
the mentally ill but for the entire societal and medical approach to
psychological illness.
"The question is whether we focus on symptom reduction or social
functioning," he says.
Controversially, Bhugra, 61, suggests the latter – getting people back to
work rather than eliminating symptoms.
"I have patients who, in spite of hearing voices, are still holding
down perfectly responsible jobs. By my account they are a success – they have
managed to contain their symptoms and function."
He wants all medical, psychiatric and nursing students to be trained first
in sociology and anthropology so they understand the culture in which they will
practice and for a return to the "menu of options" available for
psychiatric patients before care in the community – more day centres, emergency
clinics and rehabilitation centres. All of which he believes will help rectify
two urgent crises: the
shortage of beds and of "demoralised"
psychiatrists. Furthermore, he says, two
groups need statutory regulation: psychotherapists and NHS managers, so they can be struck off when failures occur.
"Part of the characteristic of a profession is regulation. Managers at
the moment may be answerable to somebody but there are no professional
standards."
Another prime imperative for the government, he argues, is to tackle youth
mental illness, as the onset of three-quarters of psychiatric disorders occurs
between the ages of 15 and 24. "Every school should have a health
professional knowing the basics about mental health. That would be a great step forward."
GPs' surgeries need a rethink too, he adds. Family doctors either need to
undergo an extra six months of training in mental health or to have a
psychiatrist attached to every surgery.
Part of the reason for the lack of resources – coalition spending on mental
health has decreased two years in a row – is down to the psychiatric profession
failing to convince successive governments of its value, argues Bhugra. This
has led to mental illness being "at the bottom of the priority list – it's
cancer and heart disease that's prioritised," says Bhugra. But he claims
that for every £1 invested in childhood trying to prevent conduct disorders, it
will save £6 of public funds in the long run.
Bhugra issues a stark warning – his "nightmarish vision" –
regarding the impact of the Health and Social Care Act on psychiatric patients.
"There will be a lot more fragmentation, which means bits of the service
will be sold off," he states. This will work for those with mild to
moderate conditions – anxiety and unipolar depression, he predicts. But, he
says, people with schizophrenia and bipolar disorder "will probably
languish somewhere. There isn't profit in schizophrenia. A third of patients
with schizophrenia develop chronic illness, so nobody's going to look after
them. This is a serious danger."
He also fears psychosexual problems will go untreated for those who cannot
afford to go private, in what will become "more than a two-tier
system" – private (the top tier), followed by NHS services of varying
levels of quality; a second tier for mild conditions and a third or fourth tier
for acute and chronic conditions.
A further area of concern, he says, is the mental wellbeing of gay people.
Although Bhugra, professor of psychiatry and diversity at King's College
London, and chair of the Mental Health Foundation, is "out" in his
personal life, he has not spoken publicly about it before.
"Being gay is an important part of me, but a private part,"
explains Bhugra.
Growing up in Yumuna Nagar, a small city in northern India, he didn't have
a word for his feelings. But after coming to the UK to train as a psychiatrist
he realised he was gay, which he says "wasn't difficult – it gave meaning
to how I felt". When Bhugra met Mike, his partner of over 30 years, he
helped him to come out to friends and family.
"My father freaked out completely, my mother was really pragmatic and
said, 'Who's going to look after you in your old age?'"
Bhugra will next year become the first gay president of the World Psychiatric
Association, which represents and supports 200,000 psychiatrists worldwide. The
significance of this appointment can scarcely be overstated in a profession
whose history is tainted with the abuse of gay patients. For decades, in an
attempt to "cure" homosexuality, electro-convulsive therapy (ECT) and
chemical castration were administered.
"There are still countries where it's seen as an illness," he
says. "We need to make a stand." He is still deciding how best to do
that. In Britain, gay people are at greater risk of a range of mental health
problems, and, it is believed, are more likely to take their own lives. But the
law needs to be changed, Bhugra argues, to force coroners to record the sexual
orientation of suicides.
Does he believe psychiatry should apologise for the harm inflicted on gay
people? "There is no doubt psychiatry hasn't covered itself in glory. I
think we ought to be apologising for all of the areas, not just one bit – like
the treatment of women," he says. "I remember seeing a patient
admitted to a psychiatric hospital when she was 16 because she got pregnant
outside marriage. She died there in her 80s."
Yet, it is racism that Bhugra recalls more than homophobia. He says:
"When I was dean of the Royal College of Psychiatrists, a fellow came up
to me saying, 'What do we have to do to get you speaking proper English?'"
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