28. Removing labels, without toxic chemical solutions.

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Cows are basically hippies.

Who are those people hiding behind the boiler house, just outside the strict boundary of the Foundation Trust premises? Are they common or garden smokers? Are they A and E attenders, who have finished all the books they brought to read while they wait? Or are they escaped but tagged dementia patients?

If you go near them they shy away, like geese, toward a small clutch of untidily parked Fiats and Volvos. Finally, I realise who they are – they are my colleagues who work in community psychiatry.

They are hiding for a good reason though. People are pursuing them, ‘wanting a diagnosis’. And those people are angry.

The history of mental health tends to characterise psychiatrists as predatory. The accepted wisdom is that psychiatrists are part of the forces of social control. Their traditional prey, according to folklore, is a harmless eccentric or political dissident. Their modus operandi is to label these folk with an invented illness concept in order to render them powerless in the eyes of society and the law, so as to drug them or lock them up or both. Such is the myth of ‘anti-psychiatry’.

People used to fear the psychiatrist like a 70s DJ fears the child protection team. But now the tables are turned. Some people are desperate to get labelled as mentally ill. None of my colleagues know why, but they mutter about the internet, celebrities and the drug companies, not to mention the benefits system.

The world seems to have turned upside down, like Twelfth Night. Not as regards boys playing women on stage whose characters are pretending to be men. Rather, more in terms of poacher turning game-keeper.

The story usually starts this way. A short GP letter ending with the words ‘this man thinks he has bipolar disorder, please do the needful’. A patient with a large bundle of papers downloaded from the net. Stating that the description of bipolar disorder fits him perfectly right down to the last semi colon.

The psychiatrist tries to explain that diagnoses are merely conventions about what to call things, that in the UK at least people are rather conservative about the use of diagnostic labels, that labels in their own right can become dangerous and lead to people thinking of themselves in an unhelpful way, even getting stuck in a sick role and benefits trap.

That he doesn’t really seem to have bipolar disorder, at least according to the absurdly narrow conventional diagnostic system that bow tie wearing people in Geneva have written on our behalf in quill pen on parchment.

Finally the meeting ends under a cloud, unless the psychiatrist gives in and recommends a tablet with Q or Z in its name.

It’s tempting to blame our cousins in the US and /or big pharma. There is money to be made from atypical antipsychotics, but only if a group of people can be convinced they need to take them. I have not tried this (Your Honour), but I’m pretty sure atypical antipsychotics and mood stabilisers have practically no street value.

Last time I went to the US I saw some hilarious direct to public advertising for these substances, where the baritone disclaimer tag – ‘may cause impotence, heart failure, convulsions coma and sudden death, take with caution’ – was longer than the advert itself.

I’m not sure why labels are fashionable now. Labelling theory was all the rage in the 1970s and we were all taught not to label people and put them in pigeon holes. Perhaps it started with designer clothes, where the Nike swoosh added $20 to the value of a $2 tee shirt. People who took labelling theory too literally even got tattoos. When we make a diagnosis, we always play it down – we say it’s just a name people give to this type of problem area.

My proposal is that we use a barcode instead. This is a cheap shot, but I think  one or two of my colleagues would be happy to advise people where to stick it.

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