This “worst of both worlds” quality of DSM has a curious analogy in psychiatry’s present predicament. As many critics have observed—reference Senior Clinician #1—the typical psychiatric practice today puts little emphasis on such traditional biomedical concerns as the physical and neurological exam, neuroendocrine measures, and the use of validated assessment instruments. (How many psychiatrists, these days, perform even a rudimentary neurological exam on a new patient? How many check the patient’s pulse or blood pressure when monitoring medication side effects?) On the other hand, the inexorable pressure to constrict the therapeutic “hour” and eschew psychotherapy means that we have been less able to pursue the more subjective and humanistic elements of our calling.
Perhaps underlying this predicament is the continued ideological divide that has bedeviled psychiatry for decades and that was eloquently described in Tanya Luhrmann’s12 classic book Of Two Minds. Very roughly put, Lurhmann described the dueling models of biomedical science and pharmacotherapy, on the one hand, and psychodynamics and psychotherapy, on the other. Thus, psychiatry seems to be trapped in a conceptual dilemma—in part, of its own making—akin to what the philosopher Ludwig Wittgenstein termed, “the fly bottle.” If so, how does psychiatry escape “the fly bottle”? Put another way: how does psychiatry maintain itself as a science-based, medical discipline while also remaining a humanistic, healing art?
In an important essay brought to my attention by Dr Sara Hartley, the psychoanalyst Harry Guntrip13 explores the concept of a “psychodynamic science.” In the process, Guntrip goes on to anatomize a number of terms, such as “physical science,” “natural science,” “material science,” and “mental science.” He also alludes to a “science of human experience.” All these terms, of course, share the designation “science,” and it seems we must pause to offer at least a rough, notional definition of what that term may mean. Unfortunately, this turns out to be a complicated and controversial enterprise, perhaps best left to philosophers!14 For purposes of this essay, however, I will define a “science” as any discipline that studies some aspect of the world by means of repeated, systematic observations and investigations; constantly attempts to validate and invalidate its own hypotheses and theories; and which accords a high value to the replicability, reliability, and validity of its findings.15
The term “scientific” is thus closely related to the term “objective.” In so far as a discipline carries out such systematic, empirical investigations, and demonstrates that its findings have good “inter-rater agreement,” the discipline is engaging in an “objective” activity.16 This point holds, even when the discipline’s “object of investigation” is the patient’s subjectivity. This, indeed, is a tenet of some types of phenomenological psychiatry, such as that of Karl Jaspers. Jaspers regarded phenomenological psychiatry as an “empirical” and descriptive process.17 Neurology and psychiatry share this dual, “objective/subjective” dimension; for example, the sensory exam in neurology “. . . relies on a patient’s subjective report and is therefore prone to additional variability.”18
Now, Guntrip makes the following critical points. First, he warns us of the “false antithesis between a scientific and a human approach” to the patient. Thus, Guntrip13 observes that “a surgeon can be capable of sympathy with his patient, however objectively and impersonally scientific he is in his medical theory and practice.”
Just so! How, then, can psychiatry be both medical science and healing art? I believe the way forward is via what I call “polythetic pluralism.” “Polythetic” refers to several shared characteristics, none of which is essential for membership in a particular class. “Pluralism” refers to the use of several different models, approaches, or methods, not all of which may be appropriate in any given situation—the best model or method being dependent on the evidence supporting it and the facts at hand. Thus, the model of psychiatry I have in mind is characterized by the use of several different approaches to diagnosis and treatment, sharing some features in common, no one of which defines the “essence” of psychiatry. In this sense, I fully agree with Kontos’s conclusion that “ . . . the complexity of contemporary medicine is such that it cannot be served by just one model at either the macro (ie, scientific and clinical) or micro (ie, within clinical) levels.” So much for airy abstraction—how might polythetic pluralism work in clinical practice?
Consider Ms Thumos, a 34-year-old single woman who complains of “terrible, lifelong, depression” that has worsened in the past 6 months. The patient’s mother died when she was only 4 years old, and she was raised “an only child” by her father, an emotionally detached man who spent little time with his daughter. The patient describes herself as “severely shy,” with few friends or social contacts and as “lonely most of the time.” Her family history is positive for a maternal grandmother and 2 uncles with severe major depression. The patient recently lost her job as a computer programmer and has experienced increasing fatigue, weight gain, constipation, and lethargy over the past 4 months. She also complains of “feeling cold all the time,” despite adequate heat in her apartment. A physical examination showed slightly delayed ankle jerk (Achilles reflex), but findings were otherwise normal. However, laboratory studies revealed a TSH level of 15 mIU/L (normal, < 10 mIU/L), with normal T3 and T4 levels.
No single “model” of medical or psychiatric diagnosis adequately “explains” Ms Thumos’s depression, in my view. Her family history suggests a strong genetic diathesis for major depressive disorder (MDD); the loss of her mother at an early age is also a risk factor for subsequent development of MDD.
From an object relational standpoint, the patient’s emotionally distant father may have further impaired her ability to form a positive sense of self, which, in turn, may have led to her pathological shyness and social avoidance. Her lack of close friends may have contributed to her lifelong depression, which may now be exacerbated by recent unemployment, and subclinical hypothyroidism. Comprehensive psychiatric treatment of Ms Thumos must consider all these psychodynamic, interpersonal, and biological factors. Our treatments, however, must reflect the best available evidence for the particular disorder (or disorders) in question—and that is quite different from throwing “a little of this, and a little of that” at the patient, thereby misapplying George Engel’s teachings.
Psychotherapy, perhaps of the interpersonal type, could be very helpful to Ms Thumos. But the best available evidence would suggest that correction of her thyroid problem should be the first step in caring for the patient, in that depression is not likely to respond optimally until underlying hypothyroidism is adequately treated.19 If the patient’s depression persists despite euthyroid status and psychotherapy, then antidepressant treatment may be warranted. (Incidentally, in my own practice, I would typically prescribe the thyroid hormone in cases such as that of Ms Thumos, usually in consultation with an endocrinologist.) So, in a sense, the holistic psychiatrist must indeed be prepared to do biology in the morning and theology in the afternoon!
In my view, psychiatry should not aim to be a “physical science” or a “natural science”—but neither should it confine itself, in Cartesian fashion, to being a “mental science.” Psychiatry ought to be both a medical science and a healing art—and must find a way to embrace and meld elements of both. Psychiatry should be a medical science in so far as it studies conditions of health and disease; adheres to the best available controlled evidence; and uses the tools of “objective” medical practice, such as laboratory studies and brain imaging. At the same time, psychiatry should be a healing art, in so far as it concerns itself with the intimate subjectivity and “inner world” of the patient. There is no incompatibility or conflict between these complementary realms: “molecules” and “motives” are simply two lenses through which we view one and the same human condition.
What I am describing is akin to what Ghaemi20 describes as the “biological existentialism” of Karl Jaspers. And—although some physicians may chafe at this—the model I am proposing is also close in spirit to the “nursing model” described above: ie, “a holistic . . . assessment of all dimensions of the person (physical, emotional, mental, and spiritual) that assumes multiple causes for the problems experienced by the patient.” However, as Kontos commented to me (personal communication, October 12, 2011), this putative “nursing” model really represents the qualities found in all good physicians, independent of any theoretical “model” of medical care and treatment.
Albert Einstein once observed, “The intuitive mind is a sacred gift and the rational mind is a faithful servant. We have created a society that honors the servant and has forgotten the gift.” In order for psychiatry to escape the “fly bottle” in which it now finds itself, we must bring together the intuitive and the rational mind. And we must do this not in service of a theory or ideology, but in the service of reducing suffering and enhancing the quality of life for our patients.
Acknowledgments—I would like to thank Nicolas Kontos, MD, for his helpful comments on an early draft of this paper; and Sara Hartley, MD, for referring me to the paper by Dr Harry Guntrip. I also wish to thank Max Fink, MD, and Melvin Gray, MD, for their important insights into psychiatric diagnosis and practice.