It is time for psychiatrists to tackle the toughest philosophical questions in their field.
Criticisms of psychiatry in our society are ubiquitous and inescapable, coming from friends, family, acquaintances, the news, and multitudes of other sources. These criticisms can range from questioning the medical status of the profession to asserting that it has overstepped its bounds and has medicalized everyday life.
In retrospect, perhaps these controversies are what drew me to the field of psychiatry. In the course of my training in psychiatry, I became acutely aware that there are so many unresolved conceptual questions looming over the field and the only way the next generation of psychiatrists will steer the conversation and shape the field is by directly engaging with these controversies.
Conceptual and critical psychiatry
At my residency program–Case Western Reserve University/University Hospitals Cleveland Medical Center–Awais Aftab, MD, offers an elective rotation for psychiatry residents in “Conceptual and Critical Psychiatry.” It consists of personalized reading assignments coupled with guided discussions to explore some of the deeper questions in our field. I undertook the elective this academic year and, given paucity of such opportunities and resources for psychiatry residents, I believe that sharing my experience may benefit my fellow trainees.
The connection between philosophy and psychiatry felt like one that was important for me to grasp, but it was always just out of reach. I intuitively grasped some of the complex issues at stake, but I did not have the vocabulary or the background to be able to verbalize my thoughts. I found out that I was not alone. In a prior survey completed at my program, a majority of psychiatry residents endorsed wrestling with philosophical questions related to psychiatry, but only a small minority reported that they felt their training had adequately prepared them to face these intellectual challenges.1
We can no longer afford to let education about the conceptual and philosophical underpinning of psychiatry take a backseat. Even as psychiatry faces this crisis of identity, there are record numbers of applicants going into psychiatry each year.2 Maybe some of them, like me, are drawn by the unknown and the chance to make a lasting change in the field. Dr Aftab’s proposal that “conceptual competence” be one of the goals of psychiatric training articulates the importance of this and resonates with me.3
As I started this elective, I chose to focus on a broad topic that I knew could encompass all of my questions and those I did not even know I had yet: the future of psychiatry. I wanted to understand the conceptual challenges facing our field, and the various revolutions and reforms that have been proposed. It felt important to know where the current ideological battleground was, and where I stood on it, not only for the sake of understanding my specialty on a deeper level, but also for the sake of helping me align my career with a vision of what I believe the field of psychiatry should be. I wanted to hear perspectives from different points of view, both radical arguments that demand a complete rehauling of the way we diagnose and treat, as well as counter arguments that justify why we practice psychiatry the way that we do.
Pro and contra
In discussions with Dr Aftab, I started with readings that are listed in section B of Table. These readings introduced me to the conversations happening in the psy-professions about the strengths and weaknesses of the DSM-5, and how mental disorders are classified. In the course of these readings, I was intrigued by some of the more radical proposals that call for an abandonment of medical diagnoses and the technical approach to psychiatric care and, instead, advocate for a more personalized approach that depends on therapeutic alliance to diagnose and treat mental health disorders. The debates highlighted the importance of relationships, values, and context, and why an overly technical approach that seemingly dismisses such factors can appear sterile and harmful.
Dr Aftab picked up on my interest and recommended readings that focused on these debates. In this second round, I read works by Kenneth Kendler, MD,24 and colleagues on empirical pluralism, an exchange of commentaries by Duncan Double, MD, and Mohammed Rashed, MD, as well as several interviews from Dr Aftab’s series “Conversations in Critical Psychiatry” for Psychiatric Times (see section C in Table).
I enjoyed the interview with Ron Pies, MD who is well-known for his defense of psychiatry in the face of various criticisms. Dr Pies acknowledged the market influences pushing psychiatry into the biological domain but defended a vision of psychiatry with the biopsychosocial model at the forefront. In his commentary, Dr Double argued for the value of critical psychiatry, pointing out that it is part of a long tradition that encourages the integration of mind and body, such as psychobiology as described by Adolf Meyer, MD, and the biopsychosocial model by George Engel, MD. Dr Rashed acknowledged the influence of critical psychiatry on the orthodox psychiatry that is practiced today but emphasized the need to go beyond the debates that continue to be grounded in the concepts of the 20th century.
Given my interest in addiction and alternative philosophical conceptualizations of mental disorders, Dr Aftab recommended the recent work by Jerome Wakefield, PhD, arguing that “dysfunction” in disorders such as addiction can nonetheless be present in the absence of neuropathological disease processes.25
Psychiatry in the political sphere
Dr Aftab noticed my interest in some of the discussions of human rights and social justice in psychiatry. I wanted to see how individuals were taking these theoretical concepts and applying them in practice. Dr Aftab introduced me to recent work on social justice in psychiatry: the proposals by UN Envoy Dainius Pūras, MD15 and the life and work of Nev Jones, MD19 (a psychologist with lived experience of mental illness) who argues for inclusion of service user/patient perspectives in our academic discourse (section D, in Table).
I was particularly fascinated by Dr Pūras, who is the United Nations special rapporteur on the right of everyone to enjoy the highest attainable standard of human health. He is a psychiatrist from ex-Soviet Union Lithuania who, during his training, first-hand saw the harm that ignoring the social determinants of health could do first. During his mandate as special rapporteur, he has released several reports that emphasize the importance of the social determinants of health and criticized the overreliance on the biomedical model and medicalization of mental illness. One example that Dr Puras gave stuck with me: there is a list of UN essential medicines in psychiatry, including antipsychotics, but there is no list of essential psychosocial interventions, even though evidence for psychosocial interventions is just as strong if not stronger than for medications.
When considering the causes of mental illness, we cannot separate the disorders from the social and economic conditions in which they arose. Structural factors such as housing, transportation, walkable space, and incarceration all contribute to disease processes, especially in mental illness. Psychiatrists need to be more aware of how these forces interact to influence disease processes in each patient. Our responsibility extends past the individual patient in front of us to society at large. These concepts reminded me of the famous quote from Rudolf Virchow, MD: “Medicine is a social science and politics is nothing but medicine writ large.”20
As I learned more, I started to think about the reasons we have ended up with our current psychiatric practice. I realized that much current research that identifies and categorizes disease processes adopts a nomothetic approach, which sees disorder entities as distinct from the unique individual histories. This is opposed to the idiographic approach, which focuses on the individual and unique personal experience of humans.
I also studied the approach of the psychodynamic diagnostic manual (PDM)21, which complements the nomothetic approach of the DSM with its own idiographic approach. My hope is that we can find new ways to incorporate idiographic aspects of psychiatry into the research, education, and practice of psychiatry. The Perspectives of Psychiatry by Paul R. McHugh, MD, served as an example of a pluralistic approach to integrating idiographic and nomothetic perspectives.20 In her recent work on enactive psychiatry, Sanneke de Haan, PhD, introduced me to philosophical discussions related to the integration problem in psychiatry.23
Our current paradigm in psychiatry needs to evolve radically and this cannot happen unless we take a fearless and honest look at where our profession currently is, how it got here, who it currently serves, and how we can restructure it in a way that helps fulfill the needs to the patient population. The average psychiatrist receives little training in doing so. The academic philosophical literature is often inaccessible to psychiatric clinicians. My foray into the conceptual and critical debates in our field has only strengthened my belief in their importance. I aspire to continue this journey and I hope that my fellow psychiatry trainees will also find opportunities to explore the often-mystified realms of conceptual and critical issues in psychiatry.
Dr Malidelis is a second-year psychiatry resident at Case Western Reserve University / University Hospitals Cleveland Medical Center.
I would like to thank Dr Aftab for his mentorship during the elective and for his guidance in the preparation of this manuscript.
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2. Lucas F. Match day 2019: psychiatry sees double-digit growth. Clinical Psychiatry News. March 15, 2019. Accessed October 12, 2020 https://www.mdedge.com/psychiatry/article/196471/business-medicine/match-day-2019-psychiatry-sees-double-digit-growth
3. Aftab A, Waterman GS. Conceptual Competence in Psychiatry: Recommendations for Education and Training. Acad Psychiatry. 2020:1-7.
4. Bhugra D, Tasman A, Pathare S, et al. The WPA-Lancet Psychiatry Commission on the Future of Psychiatry [published correction appears in Lancet Psychiatry. 2017 Nov;4(11):e25]. Lancet Psychiatry. 2017;4(10):775-818.
5. Stephan KE, Bach DR, Fletcher PC, et al. Charting the landscape of priority problems in psychiatry, part 1: classification and diagnosis. Lancet Psychiatry. 2016;3(1):77-83.
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7. Bracken P, Thomas P, Timimi S, et al. Psychiatry beyond the current paradigm. Br J Psychiatry. 2012;201(6):430-4.
8. Society for Humanistic Psychology. Regarding the reform and revision of diagnostic systems. February 12, 2020. Accessed on September 17, 2020. https://www.apadivisions.org/division-32/publications/newsletters/humanistic/2020/03/open-letter
9. Aftab A. The battle for the soul of psychiatry: Ronald W. Pies. Psychiatric Times June 23, 2020. Accessed September 17, 2020. https://www.psychiatrictimes.com/view/battle-soul-psychiatry-ronald-w-pies-md
10. Aftab A. Weaving conceptual and empirical work in psychiatry: Kenneth S. Kendler. Psychiatric Times.May 26, 2020. Accessed September 17, 2020. https://www.psychiatrictimes.com/view/weaving-conceptual-and-empirical-work-psychiatry-kenneth-s-kendler-md
11. Aftab A. Psychiatry and the human condition: Joanna Moncrieff. Psychiatric Times. April 10, 2020. Accessed September 17, 2020. https://www.psychiatrictimes.com/view/psychiatry-and-human-condition-joanna-moncrieff-md
12. Aftab A. Institutional corruption and social justice in psychiatry: Lisa Cosgrove. Psychiatric Times.March 9, 2020. Accessed September 17, 2020. https://www.psychiatrictimes.com/view/institutional-corruption-and-social-justice-psychiatry
13. Double DB. Critical psychiatry: an embarrassing hangover from the 1970s? BJPsych Bulletin. 2020:1-4.
14. Rashed MA. The critique of psychiatry as we enter the third decade of the 21st century [published online ahead of print, 2020 Feb 27]. BJPsych Bull. 2020;1-3.
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16. Metzl JM, Hansen H. Structural competency and psychiatry. JAMA Psychiatry. 2018;75(2):115-116.
17. Hansen H, Braslow J, Rohrbaugh RM. From cultural to structural competency—training psychiatry residents to act on social determinants of health and institutional racism. JAMA Psychiatry. 2018;75(2):117-8.
18. Metzl JM. Mainstream anxieties about race in antipsychotic drug ads. Virtual Mentor. 2012;14(6):494-502. Published 2012 Jun 1.
19. Dobbs D. The Touch of Madness. Pacific Standard. November 26, 2018. Accessed September 17, 2020. https://psmag.com/magazine/the-touch-of-madness-mental-health-schizophrenia
20. Virchow R. Doctor, Statesman, Anthropologist. University of Wisconsin Press; 1953.
21. McWilliams N. The psychodynamic diagnostic manual: an effort to compensate for the limitations of descriptive psychiatric diagnosis. J Pers Assess. 2011;93(2):112-122.
22. Aftab A. Explanatory methods in psychiatry: The importance of perspectives: Paul McHugh. September 5, 2019. Accessed September 17, 2020. https://www.psychiatrictimes.com/view/explanatory-methods-psychiatry-importance-perspectives
23. de Haan S. An enactive approach to psychiatry. Philosophy, Psychiatry, & Psychology. 2020;27(1):3-25.
24. Aftab A. Toward a philosophical approach to psychiatry Metapsychology Online Reviews. 2020; 24(20). Accessed October 12, 2020. https://metapsychology.net/index.php/book-review/toward-a-philosophical-approach-to-psychiatry/
25. Wakefield JC. Addiction from the harmful dysfunction perspective: How there can be a mental disorder in a normal brain. Behav Brain Res. 2020;389:112665.