Scattergood Ethics

Healing Psychiatry: Bridging the Science/Humanism Divide by David Brendel, MD, PhD

The human sciences at the beginning of the twenty-first century remain mired in a quiet but serious and abiding conceptual crisis. Nowhere is this crisis more urgent than the area in which I practice, psychiatry, which faces an ongoing ethical challenge to define what it means to be a human subject in an increasingly scientific era of genetics, neurobiology, and psychopharmacology--and in a fast-paced world that craves self-help books and that seeks the kind of quick fix that popular television psychologists dispense to millions of their viewers each day. Thoughtful, deliberative, tentative accounts of human experience and suffering are hard to come by these days. Our society has grown more impatient to find the gene or the drug or the manual or the website that will explain and help to resolve our most profound existential anxieties. In the rush to understand, explain, and treat with new rapid-fire technologies, many psychiatrists have disengaged from more plodding, uncertain, and ambiguous forms of approaching patients, such as insight-oriented psychotherapy and psychoanalysis. Empirical science has led to some astonishing discoveries and cutting-edge psychiatric treatments that were unimaginable to previous generations. But what, we may ask, have we sacrificed along the way? What role might individual subjectivity and humanism still play in contemporary medical and psychiatric science? How might clinical practitioners of these disciplines apply the emerging scientific technologies judiciously while respecting the dignity and individualized needs of each of their patients?

These questions have bothered and fascinated me for many years. They first struck me in a deeply personal way at the very same time that they captured my intellectual curiosity in medical school and graduate school in philosophy. At that time, I was in my midtwenties and in a state of emotional chaos following a painful breakup with a girlfriend. The breakup, my obsessive focus on academic work, and my exciting but precarious plan to take a leave of absence from my medical school studies to pursue graduate work in philosophy left me in a state of confusion, inner turmoil, self-doubt, and sleeplessness. Feeling that I had no place else to turn, I made an appointment with a psychiatrist at the university health service and began an arduous process that would lead to years of psychotherapy and four-times-per-week psychoanalysis. It solidified my long-standing aspirations to pursue a career at the interface of philosophy, ethics, and clinical psychiatry, and it deepened my fascination with a broad spectrum of abstract and practical questions about the human mind and its pathologies. Would future discoveries in genetics and neuroscience eventually explain why I had become so overwhelmed and obsessive? Would the right medication targeting relevant neurotransmitters prevent me from having to live through future episodes of anxiety and despair? Did the content of my dreams and my free associations in therapy sessions tell me anything meaningful about my emotional state and about my disquieting pattern of reacting to a difficult break up?

As I pondered my situation, I wondered to what extent my struggles were the result of a biological vulnerability to an anxiety disorder. Was psychotropic medication necessary to correct an inborn derangement ofbrain neurotransmitter functioning? What was the role of complicated family dynamics, including my nervousness and guilt that grew out of a daunting set of parental expectations for my success as well as the vigorous competition I had experienced from siblings who challenged my pride of place in the family? Was it my inborn temperament or my early childhood experiences (or both, or neither) that had rendered me susceptible as a young adult to feeling distraught when an intimate relationship went bad? Perhaps psychotherapy and psychoanalysis were the principal agents of personal growth as I matured into my thirties, married, launched a career, and started a family. On the other hand, is it conceivable that there was no bedrock explanation for the complicated ups and downs, the unforeseen twists and turns, which my life had taken? In essence, is there, or is there not, a plausible and coherent account of these developments? And if there is a coherent account, how does that account need to be revised as I confront new psychological challenges that have emerged in my thirties? These questions reverberated with those I asked myself about my own patients during my years in medical school and psychiatric residency, and which I continue to ask myself every day in the course of clinical practice.

This depiction of my personal struggles raises universal questions: what (if any) concepts might account for why people suffer as they do and would allow psychiatrists to diagnose and treat them in a beneficial and humane fashion? In the era of genetics, neuroimaging, and psychopharmacology, will the concepts of the biological and behavioral sciences be adequate to this task? Or are people so complex that the concepts of the humanities and the liberal arts will remain at the core of clinical psychiatry regardless of how far psychiatric neuroscience happens to advance in the future? Is psychiatry an empirical science that aims to diagnose and treat abnormal human behavior, or is it a form of humanism that addresses the inner workings and meanings of people's subjective experiences and existential concerns? Motivated equally by my existential anxiety and intellectual curiosity as a student, I began to immerse myself in these academic and practical questions--and quickly discovered that there are longstanding and deep divisions between the science and the humanism of psychiatry. Over the years since then, as I built my career in psychiatry and worked to heal some of the emotional wounds in my own life, I remained intrigued and troubled by the failure of psychiatry to heal itself. The field continues to be torn apart by strong and divergent pulls toward a science that studies brain functioning and a humanism that studies the mind in its broad social and cultural context.

But these conceptual ruptures and rifts in psychiatry provide some unique opportunities for synthesis and integration. The process of seeking the conceptual reparation of psychiatry is now the core ethical mission of a field that is trying to heal itself so that it is better equipped to heal the patients whom it aims to serve. Healing psychiatry is about resolving the conceptual dichotomy between science and humanism so that patients in the twenty-first century can receive the best possible mental health care. The title of this book is meant to capture both of these aspects of the healing process. My principal aim in the book is to heal certain dimensions of the science/humanism rupture by delineating a novel approach to psychiatric reasoning.

The healing of psychiatry demands a thorough appreciation of the field's explanatory models, which are the sets of fundamental concepts and systematic approaches to understanding and treating mental illnesses that psychiatrists use to ground their clinical practice. Explanatory models in psychiatry reflect what clinicians deem valuable in rendering a person's behavior intelligible and thus help to guide treatment choices for mental disorders. Most current explanatory models in psychiatry are either primarily scientific or primarily humanistic. The former are attractive inasmuch as they aim to justify clinical explanations and treatments by way of empirical evidence and scientific rigor, but they are flawed inasmuch as they tend to restrict options for diagnostic and therapeutic paradigm choice. The latter have the advantage of acknowledging the complex, subjective, and multifaceted features of most mental disorders, but they are imperfect because they often lack a coherent and well-defined basis in empirically derived scientificevidence.

The scientific and humanistic approaches stand in a dialectical relationship to one another insofar as psychiatric clinicians often find themselves moving from one approach to its antithesis, ultimately striving to forge a synthesis that satisfies the clinical needs of the moment. Dialectical reasoning, which can be traced to the early nineteenth-century work of German philosopher G. W. E Hegel, entails serious consideration of both sides of a conceptual dilemma, recognition of the possible relevance of both sides, and active efforts to articulate the appropriate relation between them. The dialectic is an interactive, dynamic process in which each side of the conceptual divide constantly informs, shapes, and responds to the opposing side. Dialectical reasoning is well suited to the challenges of psychiatry, in which the conceptual foundations of practice remain in dispute, the causes of symptoms are frequently indeterminable, diagnosis depends largely on patients' self-reports of symptoms, and appropriate treatment of most clinical syndromes remains a matter of trial and error. In the absence of a broad consensus regarding appropriate concepts and methodologies to be employed in their work, clinical psychiatrists need to tolerate ambiguity and uncertainty as they try to integrate diverse scientific and humanistic concepts in a dialectical and ethical manner.

This is the most basic challenge that psychiatrists of all stripes face on the contemporary scene. How are they to proceed when they greet and embark on a course of treatment with a complex individual who presentshis or her current struggles and dilemmas, past experiences and relationships, and longstanding patterns of coping with conflict, stress, and loss? This question becomes all the more daunting and complicated when considerations of biology—perhaps in the form of response to prescribed medications, substance abuse, neuropsychiatric illness, abnormalities on brain scans, or family history of mental disorders—are factored into the equation. The psychiatrist must organize an enormous mass of clinical data, form plausible hypotheses about the origins of the patient's distress, and develop treatment recommendations to help relieve the patient's suffering. This multifaceted process requires paying careful attention to an incredibly broad array of biological, psychological, and interpersonal considerations. At the same time, the clinical psychiatrist always must remain aware of his or her limitations and mindful of the fact that the patient is in some sense entirely unfathomable.

The main argument I will develop in this book is that pragmatic values can help to transcend the science/humanism divide in modern-day psychiatry. What does this claim amount to? The work of classical American pragmatists (including such thinkers as Charles Sanders Peirce, William James, and John Dewey) and the work of contemporary pragmatic bioethicists have suggested that certain core ideas and principles ought to guide the pursuit of science in general, and medical sciences in particular. These thinkers urge us to pay close attention to the practical applications of scientific study, the multiplicity of phenomena that render such study useful, the participation of many individuals in formulating collaborative and workable hypotheses, and the provisional nature of scientific understanding. Along these lines, pragmatism in modern-day psychiatry can be understood as a clinical sensibility and methodology that aims for favorable treatment outcomes for patients by respecting the practical, pluralistic, participatory, and provisional aspects of psychiatric explanation. Clinical pragmatism demands that psychiatrists have the skill and flexibility to employ multiple explanatory concepts (spanning the entire biopsychosocial spectrum) in an interactive and collaborative process with patients, which under most circumstances can lead to open-ended but useful clinical explanations and treatment plans. It is by way of clinical pragmatism that the conceptual wounds in psychiatry and the emotional wounds in the lives of individuals can begin to heal.

This book explores these themes from clinical and theoretical standpoints. Chapter 1 delineates the dialectic of science and humanism in contemporary philosophy of science and clinical psychiatry. Chapter 2 presents an argument for working through and transcending this dialectic by applying basic principles of classical American pragmatism and contemporary pragmatic bioethics to psychiatric reasoning and practice. Chapter 3 contains several psychiatric case histories that highlight the benefits of integrating science and humanism in an ethical, patient-centered, and pragmatic fashion. These first three chapters layout the basic argument that a deeply problematic science/humanism dichotomy continues to plague clinical psychiatry, that this dichotomy can best be managed and overcome by employing principles of clinical pragmatism, and that clinical case histories provide a clear rationale and justification for applying the principles of pragmatism to everyday psychiatric practice.

The remainder of the book unfolds as follows. Chapter 4 includes a discussion of the relevance of pragmatism to current philosophy of mind and the mind/brain relation in psychiatry. Chapter 5 traces the evolution of Sigmund Freud's understanding of the mind/brain relation and his pragmatic move from clinical neurology to psychology, a shift that retains significant contemporary relevance. Chapter 6 is a plea, based on pragmatic values, for an ongoing separation of neurology and psychiatry as distinct and autonomous clinical disciplines. Chapter 7 contains an argument for a liberal and flexible, yet scientifically informed, notion of causal explanation in clinical psychiatry and presents implications of these pragmatic values for psychiatric diagnosis in general, and for the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) in particular. The future of psychiatry is explored in chapter eight, where the principles of clinical pragmatism are applied to a wide range of ethical concerns and challenges in psychiatric training and research. This final chapter contains reflections on the origins and the vicissitudes of our stubborn tendency to divide persons into objects for scientific study and subjects of irreducibly human experience, and it explores the promise and limits of clinical pragmatism today and in the years to come.

David H. Brendel, M.D., Ph.D. practices psychiatry in Boston and teaches in the ethics and professionalism course at Harvard Medical School. He previously served as chair of the institutional review board (IRB) and as associate medical director of the Pavilion evaluation and treatment program at McLean Hospital in Belmont, Massachusetts. His academic work focuses on psychiatric ethics and on the complex relationship between scientific and humanistic approaches in psychiatry. He has a particular interest in clinical and ethical issues relating to online social networking in medicine and psychiatry. He has taught and published extensively on these topics. His book, Healing Psychiatry: Bridging the Science/Humanism Divide, was published by the MIT Press in 2006 and released in paperback in 2009.