I have a patient whom I shall call Adam here. When Adam first came to see me, he had not been working for a while and it was not from want of trying. On the contrary, he felt tremendous and relentless pressure to work - from messages that came from an array of sources urging, cajoling, hectoring and berating him to work.
But each time upon starting on a job, he said, he would within hours experience a barrage of criticisms that he wasn't performing, that he was "stupid" and "useless". He saw this from the expressions of those around him, from their tones when they spoke to him, from their action, and even from the way they cleared their throats, coughed or sneezed.
These indications of disapprobation and derision would inexorably build up until they became so unbearable that he would leave the job - often within days. Stopping work, however, brought no relief as these tormenting messages and signals continued incessantly.
Adam has paranoid schizophrenia, a condition which he would not acknowledge. He denied it with a fierce vehemence and considered any attempt to get him to accept this diagnosis as yet another stab at belittling him. He baulked at any trial of medications.
The clinic consults were not easy: I couldn't be as natural and spontaneous as I could be with most of my other patients. I found myself constantly composing my demeanour, considering my words before speaking them, and moderating my tone. It was necessary as his paranoia could unexpectedly twist even a gently phrased and well-intentioned suggestion into an accusation or criticism that could easily escalate to an angry outburst.
At times, the consult was like navigating a minefield - something that I would start and proceed with trepidation and anxiety, and end with relief. But there were also times when we could have a fairly relaxed and rancour-free conversation.
These serendipitous respites didn't come from some clever therapeutic manoeuvre on my part - they just happened as we talked.
Although they had no ameliorating effect on his paranoia, these to-and-fro exchanges about mundane things made for as near a normal human connection as possible and lifted him out of that desperate isolation his delusions had built around him.
Such consults would usually take up more time, but having such unhurried conversations has become increasingly uncommon, a luxury and an indulgence in our current practice.
How did we end up this way?
BRAINLESSNESS TO MINDLESSNESS
One of the doyens of modern psychiatry, Professor Leon Eisenberg of Harvard Medical School, wrote that psychiatry in the late 20th century had moved from a state of "brainlessness" to one of "mindlessness".
By this, he meant that prior to the widespread use of psychotropic medications (drugs that alter mental functioning), psychiatry had largely subscribed to the psychoanalytic school of thought, where mental illnesses were viewed as arising from unconscious emotional conflicts and affecting the mind, rather than from some biological aberrations of the brain. But with the introduction of psychotropic drugs, the focus shifted to the brain.
The medication era for psychiatry began with the discovery in the mid-20th century of an effective drug called chlorpromazine for psychosis.
It precipitated a flood of other antipsychotics, sedatives, antidepressants and mood stabilisers which were designed to target certain neurotransmitter systems in the brain. With that came the ascendancy of the idea that mental illnesses were caused by abnormal brain chemistry - an idea that the pharmaceutical industry also promulgated. (This was how one company described the benefits of its antidepressant in its promotional material: "Just as a cake recipe requires you to use flour, sugar and baking powder in the right amounts, your brain needs a fine chemical balance.")
While there is still no definitive proof of neurochemical imbalances as the cause of mental illness, the idea stuck and psychiatric treatment became increasingly medication-intensive.
As a result, many psychiatrists now see themselves more as psychopharmacologists who specialise in using the drugs in our pharmacological armamentarium to treat various disorders, and less as psychotherapists who delve into the life stories of their patients for clues of their distress. (Like many of my fellow psychiatrists, I would refer my patients to a psychotherapist if they need some "talk therapy".)
A CHECKLIST APPROACH
Without any fully established biological understanding of mental illness, there is also no laboratory means - no blood test nor brain imaging - that we can use to clinch a diagnosis of a mental disorder. Instead, we depend on the history that we can obtain from the patient and those who know the patient well.
To impose some standardisation in the way we make our psychiatric diagnoses, we have largely relied on a guidebook called the Diagnostic And Statistical Manual Of Mental Disorders , that has been created and regularly updated by the American Psychiatric Association. The latest edition lists the hundreds of mental disorders - each with its cluster of symptoms - that groups of experts have decided consensually to be characteristic of that disorder.
The unintended consequence of having that manual at our elbow is that we could wind up taking a checklist approach to our patients, where we focus on extracting symptoms to match a diagnosis while ignoring other things that are important, such as the psychological and emotional impact of social and material situations, the adverse effects of childhood trauma, and other vicissitudes in the patient's life.
The sheer number of patients who need to be attended to, coupled with the increasing administrative and regulatory requirements for healthcare delivery, has further encroached on the time we could spend with our patients.
Brief consultations have become common in psychiatry and we have corralled ourselves and our patients to confine our interactions to the business at hand. This comes at a cost of a telling loss of intimacy and connection between us and our patients - something that is unsatisfactory to all.
Psychotropic medications are often necessary and they do help, but there is no magic pill that can medicate away all psychological and emotional problems.
Healing begins when patients and their doctors build trust - a process that often takes time, and time too is needed for us to part that scrim so that patients can look into themselves and gain some insights.
And time too is necessary for us to feel that we have done right by our patients, but that assuring feeling and time itself are increasingly difficult to come by these days.
That was then and before the Covid-19 pandemic, which has since upended so many aspects of our life, including our usual practice of medicine. There is now a push to do telemedicine, including giving consultations over the telephone or by video conferencing - something that I have yet to do.
I like the ritual of going to the clinic, greeting my patients, seeing the way they walk into the consultation room and arrange themselves on the chair, and watching out for those non-verbal cues and signals that are tell-tale signs of their mental state. Some would also come with their family and I get to see the panorama and colour of their interaction that are usually so instructive.
But I could also see the potential advantages of teleconsulting. Such remote communications would save time and costs for patients in terms of travelling (and possibly reduce that stigmatising feeling that some patients experience coming to the clinic). These sessions would probably be less digressive and more to-the-point.
Some patients might actually feel safer and more relaxed when they are in familiar surroundings, which also provides an opportunity to gain insights into the interplay of their illness and their home environment. As a means of connecting with patients, it is far more accessible. As with so many other things that will change in the aftermath of this pandemic, this way of seeing patients could yet be another of the new normal that I will have to accept and adapt to.
I called Adam recently over the phone to suggest we could have a session over the phone (he dislikes using a computer screen as it gives him a bad headache). But he was quite adamant about wanting to see me as we had scheduled, saying that our face-to-face sessions do make him less distressed and not think so much of killing himself.
In this dispiriting and uncertain time, that validation lifted me a bit, though there is this niggling worry about exposing him to this invisible assailant which could be anywhere.
• Professor Chong Siow Ann, a psychiatrist, is vice-chairman of the medical board (research) at the Institute of Mental Health.
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