With over 15 years of experience under his belt, Dr. Greg Mak is a seasoned psychiatrist with a special interest in transgender mental health and schizophrenia, holding honorary clinical assistant professorships in the Department of Psychiatry for both HKU and CUHK. As a psychiatrist in HK, he frequently treats conditions such as insomnia, depression, and anxiety — ‘urban dweller’ conditions, common amongst Hong Kong citizens.
Before we began, Dr. Mak amiably asked us if we would rather conduct the interview in Cantonese or English. Psychiatry is a more cultural and humanistic aspect of medicine, and it relies heavily on the connection of trust between the doctor and the patient. While other areas of medicine return to technical Latin or English terms for conditions, psychiatrists aim to understand patients, and it’s important that the patient feel comfortable with the language in use. We decided on Cantonese, to put our interview team at ease, so please forgive this writer for any mistranslations.
So why did Dr. Mak enter the field of psychiatry? Well, not unlike many other students, prior to graduation, he considered entering the surgical field, as it was more direct and simple to pick up, whilst he felt that the thinking style of internal medicine was not suited to him. However, due to the limitation of physical dexterity, he was unable to do so. After graduation, he realised that he enjoyed talking to people and connecting with them, and that he preferred to keep things simple. Psychiatry, as a specialty requiring 2-sided interaction, soon revealed itself as his ideal role. Furthermore, with the closeness fostered in psychiatry, he could avoid the problem of being a doctor put on a pedestal, distanced from his patients. Lastly, through experience and gradual study, Dr. Mak came to realise that a lot of physical discomforts and conditions are linked to mental health. He wanted to alleviate the suffering of others from a different angle, and thus psychiatry became his passion.
However, the field is not without its challenges. One of the most common problems Dr. Mak encounters is the unwillingness of patients to be treated. It’s easy to work with those who actively seek help, as they are more willing to open their hearts and minds and be helped. Due to the social stigma of mental illnesses, it’s a daily occurrence for him to struggle to convince patients to undergo treatment. Most patients in this case either feel stigmatised or believe that it’s not a need for them, and this is partly due to the Chinese implications of the name of the field (精神科, connoting mental disability and insanity).
As a doctor, Dr. Mak cannot force people to be treated, and thus he must find alternative ways to open their minds to treatment. Common extremes are family intervention or suffering to the point of being unable to take it. However, what Dr. Mak usually does is attempt to understand their difficulties and fears, and assuage them one by one. One of the more common fears is the label of ‘insanity’, and it is a fear countered by knowledge. Furthermore, Dr. Mak prefers to approach it from the perspective of the patients, as point-blank communication often leads to an offended patient and an increased unwillingness to be treated. A doctor is not there to accuse, they are there to understand the patient and help with their struggles. By empathizing with his patients, Dr. Mak helps them become more open to follow-ups and treatment seeking. Dr. Mak pours his heart into convincing them and persuading them, and in his opinion, the thanks of someone who’s accepted help and is doing better is one of the most touching things.
Of course, there are especially challenging or delicate cases, for instance, working with children. Kids frequently ‘present with’ mental problems such as ADHD, emotional control, etc., leading to them being labelled as a problem child. In such cases, Dr. Mak will involve the family in the treatment, as the underlying tension in a family highly contributes to the child’s acting out. However, this leads to delicate situations in which the family, especially the parents, might play the blame game and accuse the doctor, as they are unwilling to face their problems and imperfections, even when their children are aware of them and bring them up. For Dr. Mak, these are some of the more heartbreaking and pitiful cases, as the parents often end up terminating treatment for their child, even when it’s clear that the child is aware of the problems and that they themselves also need help.
As a psychiatrist, Dr. Mak is also involved in research, specifically studying psychotherapy treatment for schizophrenia and transgender mental health. For him, research is a way to explore areas he’s personally interested in, and not a result of coercion, he jokes. Schizophrenia is a frequent topic of research in psychology and psychiatry, having been thoroughly explored from a multitude of perspectives. Dr. Mak noted that most of its literature focuses on either medicinal or combination treatment, and rarely on just psychological intervention. Psychotherapy is challenging to quantify, as it depends heavily not only on the skill of the psychiatrist, but also on the willingness of the patient to cooperate. However, Dr. Mak believes that there is an inherent value in psychotherapy, as combination treatment, which utilises talk therapy, improves a patient’s quality of life more than purely medicinal treatment. He was interested in quantifying and creating benchmarks for psychotherapy to achieve guaranteed results, and thus undertook research in the area.
As for his work on the mental health of transgender people, Dr. Mak states that these clients are the same as any other human being, they just face more emotional struggles due to societal stigma and gender incongruence. Trans people simply want to live in their own preferred way, but are frequently unable to due to hardships and discrimination from society. While they are as capable as any other, jobs may pass them over due to fear of ‘damage’ to company image or discriminate against their gender identity. Thus, the work of a psychiatrist is to find ways to relieve their stresses caused by society, for instance helping them deal with discrimination at work or gaining acceptance from their family. Furthermore, transgender research in psychiatry is an underdeveloped area, as the lack of clients leads to increased difficulty in the conduction of research. To complicate things further, trans people are impacted by a multitude of social issues, and it’s difficult to fully quantify their needs. Dr. Mak hopes that by doing this research, not only will he and others be able to help them better, he can also provide a scientific basis for trans people to push for their healthcare rights (e.g. gender reassignment surgery).
Being a psychiatrist, Dr. Mak is heavily invested in the future development of psychiatry. Currently, there are two schools of thought in psychiatry, with one of them believing that psychiatric problems all stem from a biological cause, originating from the brain. The psychiatrist’s understanding of the brain is compatible with a neurologist’s, but this leads to a lot of overlap between the two areas. In such cases, patients prefer to go to neurologists for treatments such as medication, as that carries less stigma. This leads to the issue of neurologists playing a psychiatric role, with the boundary between the two specialties blurring further and further. In Dr. Mak’s opinion, the strength of psychiatry is knowing how psychological intervention, for instance psychotherapy, can help clients understand what they’re going through and approach the problem from a more emotional angle. He believes that only by utilizing both sides fully — combining meds for tackling the biological cause with therapy to understand the familial/social context of the problem — can a psychiatrist carry out their duty to the best of their abilities.
With the development of these schools of thought, surely technology must have advanced along with it? Well, psychiatry deals mostly with the brain, and the brain is one of the areas that medicine does not yet deeply understand. There is potential for further research on the brain, but it’s greatly limited as we cannot take too many risks with the brain, nor can we use technologies that could potentially harm it. Science knows that there are specific parts of the brain that control movement (the cerebellum). Yet, the parts for emotional control and expression are very tiny and delicate, with many of them overlapping, and hence there is no perfect or fancy technique to fix it. The most recent technological development is the development of transcranial magnetic stimulation (TMS), in which a magnetic pulse is delivered, affecting the production and expression of neurotransmitters. Originating from stroke treatment, it was adapted for psychiatry sometime in the past 10 years. Approved by the FDA for use on depression in 2008 and OCD in 2018, it’s only used in very serious cases where medicinal treatment is ineffective. Another technology is deep brain stimulation (DBS), in which two thin electrodes are used to poke certain parts of the brain to stimulate them, releasing dopamine. This is used in the treatment of thought process disorders and OCD, improving the quality of life for patients. However, these technologies are only used as a last resort, as it’s more challenging to classify and isolate brain function, and thus technologies are both risky and hard to develop further. The risks are high, including brain bleeds, affecting other parts, etc., and frequently outweigh the benefits. Dr. Mak agrees that the usage and development of technology in psychiatry has a long way to go.
In medical history, psychiatry has only become clearly defined recently, after medicine evolved. Societally known as the ‘weird’ aspect of medicine, it has carried heavy stigma since its development due to the stereotype of asylums and the lack of quantifiable treatment. In the future, there’s a high chance that the overquantifying of psychiatry will merge it into neurology. Dr. Mak believes that there is a high need to increase the awareness of the general public. Mental health is closely related to physical health, and psychiatry is becoming more and more needed and relevant. As Dr. Mak says, it is impossible to name a condition that is not affected by mental health at all. For instance, cardiovascular conditions such as blocked coronary arteries are affected by stress level, which affects one’s blood pressure, as well as poor eating habits, which can be influenced by the reward system. The further stress of knowing the existence of the condition can further exacerbate the seriousness of the condition. Another instance is cancer pain, as patients going through cancer treatment frequently suffer great pain and anxiety. Good pain management and positive attitude has shown to help in recovery, and psychiatry helps cancer patients cope with their situation and manage their mental state, boosting their recovery.
One of Dr. Mak’s more memorable cases is helping an old lady in her seventies. She had suffered a lower back injury after a fall, rendering her unable to regain full range of motion. Before her fall, she was a very active old woman, but the seriousness of her injury, as well as her age, limited the treatment she could receive. Even when she came in for her appointment, she came in a wheelchair, scared of both the pain of walking and of falling again. She lacked the motivation to attend physical therapy, giving it up as a lost cause, and simply deteriorated over time. Dr. Mak was able to give her emotional support, as well as helping her face her fears and soothe them. As her mood improved, so did her pain tolerance, and thus she became more motivated to recover. After two years, she regained a range of movement formerly thought impossible.
The case above demonstrates the importance of psychiatry. Mental health limits recovery potential, and psychiatry is able to give hope and enlighten people about the situation they find themselves in. A lot of small problems of your body’s condition are linked to your mental health, and it’s important that people realise that now. Psychiatry aims to change the small things, and by helping patients in this way, they can regain their dignity and dissolve the dark clouds hanging over their head. For Dr. Mak, one of the most rewarding experiences is when a patient joyfully tells him that after 10 years of insomnia, they finally slept well for a night.
Concluding the interview, Dr. Mak offers a word of advice to aspiring medical students, especially those who want to study psychiatry. One should always keep an open mind and learn how to listen, as it’s important to be accepting of many things. To be a psychiatrist, you cannot taint the patient’s perspective with your own thoughts, as that will lead to blind spots and a lack of doctor-patient trust. He emphasizes that psychiatry is not like the other more technical-minded specialties with dictionaries of jargon. Instead, psychiatry relies on the connection between the doctor and patient, and needs the input of both parties. Without trust, it will be impossible to carry out the treatment.
Dr. Mak gives us a clear overview of the field of psychiatry, as well as offering us in depth perspective of his work and philosophies. We hope that you are able to take something away from this article, no matter how minor or meaningful it may be, and that this assists you in choosing your future path.
