A psychiatrist says most patients can live with their symptoms

A former head of the Royal College of Psychiatrists says most patients can live with their symptoms if they have a job, money, a home and relationships. Work is one of them.

Dinesh Bhugra has been president of the Royal College of Psychiatrists, the British Medical Association and the World Psychiatric Association. So this isn’t a critic of psychiatry talking. It’s someone who led it.

In an August interview with Mad in America he said this: “Quite often, you see in clinical practice that most patients can live with their symptoms, provided they have a job, money in their pocket, a roof over their heads, relationships. But many a time, we focus on symptom reduction.”

Most of what makes a life liveable doesn’t come on a prescription. And one of the four things on his list is work.

A success story with the symptoms still there

He tells a story about a young man he looked after, who had had schizophrenia since he was 15. The young man was doing well on medication, but his father phoned to say the family thought he was possessed. Bhugra put them in touch with the hospital chaplain. He has no idea what they did. The last he heard, the man had married, had children and had a job.

“For me, that’s a success story,” he says, “and that goes back to staying with the symptoms but getting other things sorted.”

Most of the system works the other way round. Get the symptoms down first, and the rest of life is supposed to follow.

Ten labels and not one conversation

Between 1988 and 2000 I was given ten psychiatric labels. Some of them I only found out about years later, when I got hold of a copy of my own notes. Not one of the ten was ever talked through with me.

They cost me, too. When physical health problems started, it took twelve years to get a diagnosis, because no GP would run the test. There’s a name for that: diagnostic overshadowing, when physical symptoms get put down to the mental health record and never looked into.

Bhugra asks the question I’d put to every one of those ten: “We need to be very clear what diagnosis is for. Is it for clinicians, to make us feel better that we’re doing something?”

Earlier in the same interview he puts it simply: “You learn that patients actually give you the diagnosis. They tell you what’s going on.” That only works if somebody asks.

When the checklist reads poverty as a symptom

Back in 1989, Bhugra and a colleague published a study using an eating disorder questionnaire developed in Canada. They translated it carefully into Hindi and gave it to 580 teenage girls in North India. 29% scored above the threshold.

When they looked at which questions were causing it, one of them was “Food controls my life.” As he puts it: “If you’re poor and you don’t know where your next meal may be coming from, food will control your life.”

That’s a checklist reading someone’s circumstances and calling it a disorder. Work has its own version. Ask “I lie awake worrying about money” in a staff survey, and an honest yes tells you about the pay, not about the person.

Work is one of the four

A job, money, a roof, relationships. Work touches at least three of those. It pays the rent, it decides whether there’s anything left at the end of the month, and it’s where most of us spend more waking hours with other people than anywhere else.

So a workplace is never neutral. It’s either part of what makes life liveable, or part of what makes it harder.

Yet when someone struggles at work, the usual response does the same thing on a smaller scale. A number for the employee assistance line. “Have you been to your GP?” Six sessions of counselling. A return-to-work plan once the symptoms have settled. Every one of those is aimed at the person. None of them touches the job.

Bhugra names that too. Talking about tobacco and ultra-processed food companies, which he counts among the commercial causes of ill health, he points out that where their products are made “there is very little or very limited control of the working environment. The workers are then getting physical illnesses and psychiatric disorders.” And: “If we’re not looking at those factors, then we are just treating the endpoint, the patient.”

That’s the same argument I make about work-related stress. We count the absence and stop asking what caused it. We send people on resilience training and leave the workload where it was.

You don’t need a label to help someone

At work, nobody should need a diagnosis before they get help. Acas is clear that a worker does not need a diagnosis to be considered disabled under the Equality Act 2010. In its guidance on neurodivergence, it says employers should offer support and adjustments whether or not someone has one.

So ask what someone needs. Does the deadline need to move? Is the rota working for them? Is the pay enough to live on? Is there anyone at work they can talk to? Those are Bhugra’s four things, asked by a manager instead of a psychiatrist. I wrote about what people carry into work last week, and this is the same point from the other side: what they need around them to carry it.

If Bhugra is right, most patients can live with their symptoms. The question for every employer is whether they can live with the job.

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