Principles in practice: Or learning to listen to the music of psychiatry

To the Editor,

Principles are important in life, and the recovery principles have become the central and invaluable theme in public mental health service provision (Wand, 2015). This, however, is in the context of psychiatry practice where the professional role of psychiatrists and their social contract with patients are ambiguous, the funding for the services are suboptimal, simplistic checklist approaches to assessment and treatment are common, and the clinical judgement and responsibility have been disconnected.

Over 30 years ago, while providing a cautious tone for the reliance on the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III), Dr John Ellard argued that although science is an essential part of psychiatry, it is not the essence of psychiatry; there is science, there is metaphor, then there is what he called the music of psychiatry (Ellard, 1985). It was further argued in a corresponding letter that there is much more to language than simply labelling. It can acquire meanings and inferences, both consciously and subconsciously. The choice of a particular word can signal a whole theoretical framework (McGrath, 1985), or one may say, principles. Today, we have the fifth edition of the DSM. The correct terminology for the people we care for have changed from patients, consumers, clients to ‘experts by experience’. It is hard to keep up but one wonders about the unintended consequence of calling people all these different names. Is there an unconscious hidden message there? Are we saying that they are not sick enough to be called patients? What does this imply to our professional role if we are not treating patients?

Most of us chose to be doctors because we wanted to help people. But even as a registrar, I occasionally find myself asking, are we doing this for our patients or for ourselves? Are we listening out for the music or are we too busy writing down the lyrics? To re-quote an old proverb, the darkest part of a room is found underneath the lantern’s base (McGrath, 1985). I sometimes wonder whether all the rhetoric, paperwork and benchmark targets may have pushed our patients underneath the lantern.