Policy Reflection Systems

Belonging in Psychiatry.

I recently finished reading The Art of Community: Seven Principles for Belonging by Charles Vogl. He starts the book with this definition of “community”:

a group of individuals who share a mutual concern for one another’s welfare.

He continues:

[A community] is distinct from a group whose members may share ideas, interests, proximity, or any number of things but lack concern for one another.

He argues that communities (as he defines it) have “shared values”, “membership identity”, “moral proscriptions”, and “insider understanding”.

The American Psychiatric Association (APA) held its annual meeting this past week in San Francisco. I did not attend.

I have never been a member of the APA. There was a time when I took some oppositional pride in this, though I was aware of how this attitude is problematic: I cannot help change an organization if I do not join it.

Why do I resist the APA, even though it is the organization that represents the work I do?

This excellent post over at Slate Star Codex captures many of my reasons: All of the pharmaceuticals! The overt and covert intersections with politics (which can lead to overmedicalization of life and underrecognition of psychiatry as an agent of social control)! And while I know that there are members of APA who care about people, families, and communities that experience severe psychiatric symptoms (e.g., schizophrenia, bipolar I disorder, co-occurring mental health and substance use disorders), I’ve never gotten the impression that these are priority populations for the APA.

If we use Vogl’s definition, the APA, to me, doesn’t feel like “a group of individuals who share a mutual concern for one another’s welfare”.

Maybe professional organizations aren’t intended to be spaces where people have mutual concern for the welfare of others.

In the past I wondered if my lack of affinity for APA had to do with how different my clinical practice is compared to other psychiatrists. There are other psychiatrists who work with people living on the streets and do housecalls for people who live at or near the poverty line… but we are few and far between. I live in the largest county in Washington State. There are hundreds of psychiatarists here. Yet I know of only two other psychiatrists who share my work experiences!

Consider emergency physicians. They all work in generally the same setting and thus have similar clinical practices. I don’t know the membership of their professional organization (American College of Emergency Physicians), though it at least seems that their specialty organization is more cohesive and united. Because their clinical practice is more uniform, perhaps it is easier to have mutual concern for the welfare of their fellow physicians.

Meanwhile, how much does my work have in common with the private practice psychiatrist who provides psychoanalysis? I’m just trying to get the guy who lives outside due to relentless paranoia to look at me long enough so I can say hello in a manner that won’t scare him off.

A few years ago a local psychiatric association contacted me. They anticipated an upcoming vacancy in a committee involved in government relations.

During the phone call, I learned that most of the members were psychiatrists in private practice. The leadership expressed a desire for the association to get more involved in government affairs (e.g., local and state legislation). Because of my role in local government, they highlighted the value I could contribute to the association.

“You’ll have a lot of influence,” they said several times.

They also commented that they were trying to increase the diversity in their organization. In addition to the “influence” I could bring, I could also bring my non-white, non-male self.

By the end of the phone call, I said that I wanted time to think about it. What I actually thought about was the responsibilities I had to myself versus those I would have to the organization. I cannot help change an organization if I do not join it. Could I bring issues related to underserved communities to the association? Would the membership find these issues compelling? Would they have interest in legislation that did not focus on their own patient populations?

A few weeks later, I told them that I wouldn’t join. This decision stemmed chiefly from the substance of the work. However, it was also a reaction to their recruitment methods: They thought I would respond favorably to an appeal to my vanity. “You’ll have so much influence!!!” Perhaps the corollary to that was that my influence would help get stuff done, but the emphasis was on the vast amounts of influence I could wield over the group. That didn’t interest me.

And while I did appreciate the blunt commentary about how my participation would help increase the diversity of the association, it made me tired just thinking about it. Increasing diversity doesn’t just mean increasing the amount of color in a photograph. There’s a lot of work in introducing and maintaining various perspectives in a group. I didn’t want to be the only person responsible for that simply because of my non-white, non-male status.

The association certainly had concern for its own welfare. I wasn’t convinced that the association members had concern for mine.

To be clear, this doesn’t mean I’m great.

At least once a week I wonder if I would be more effective in my medical director role if I were involved in more associations and groups. What if I could bring the “forces” of the local medical society and psychiatric association to my job? What if I could use my status as a medical director in government to influence the priorities of these organizations? Would my “success” in each sphere be greater?

What responsibilities am I shirking? I believe one function of government is to convene people so we can figure out how to collaborate with each other. How many opportunities am I missing to improve the community because I am not participating in these other organizations? If I really care that much about underserved populations, don’t I have some responsibility to persuade these organizations to support initiatives that will serve the the underserved? Isn’t there more strength in numbers?

What would it be like if I shared and coordinated ideas, plans, and concerns with these big organizations with large audiences instead of here on my blog?

This has been true from the very beginning: I am a reluctant psychiatrist. I was never supposed to become a psychiatrist.

But, for reasons known and unknown, people experiencing psychotic symptoms feel comfortable talking to me.

So, here I am, working as a psychiatrist.

And, perhaps because of my affinity for complex problems, this is also why I am more comfortable working at the boundaries of fields. Yes, it is possible that the APA will create and disseminate the cure schizophrenia.

I doubt it.

I don’t think a pharmaceutical product will cure schizophrenia. But, at the intersection of nutrition science and psychiatry we can maximize the likelihood that pregnant women will have access to foods that will decrease the risk of their babies developing schizophrenia. At the intersection of legal systems and psychiatry we can reduce (if not eradicate) the use of solitary confinement so that jails and prisons do not worsen psychiatric symptoms. At the intersection of education and psychiatry we can teach kids and their parents skills to better cope with the adversity that life throws at all of us.

I will continue to struggle with joining APA and other organizations. But I already know that I’m not alone. Those of us—and not just psychiatrists—who care about the welfare of people with severe psychiatric symptoms are already part of a community. Sometimes we’re just harder to find.