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Psychiatry's identity crisis
Psychiatry’s Identity Crisis A Critical Rational Remedy Theo C. Manschreck, M.D., M.P.H. Director, investigative Boston, Massachusetts
Psychiatry
Program,
Department
of Psychiatry,
Harvard Medical School,
Arthur M. Kleinman, M.D., M.A. Professor and Head, Division of Social and Cross-Cultural Psychiatry, Department of Psychiafy Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington
Abstract: Psychiatry has several partial identities reflecting its biologic, psychoanalytic, and social subspecialties. It has, however, no encompassing professional identity. This identity requires three features: (a) a common language and procedurefor assessing psychopathology, (b) a common method for evaluation and use of knowledge from outside psychiatry, and (c) a common set of values regarding clinical and research activities. The authors discuss the clinical, biologic, and sociocultural psychiatric traditions to identify the roots and consequences of psychiatry’s fragmented state. Psychiatry’s identity problems cannot be solved by ignoring them or simply becoming more “medical.” Rather, the authors propose a remedy--critical rationality-to help resolve the crisis. Critical rationality requires a disciplined approach to psychiatric knowledge that underscores the necessity of methodologic rigor, practicality, and mid-range theorizing (rationality); and the equal necessity for systematic self-criticism, reform, self-awareness, and attention to the ethical dimensions in teaching, practice, and research (critical).
In recent years, thoughtful individuals throughout psychiatry have commented on the “identity crisis” facing the psychiatric profession (l-3). What is psychiatry, what are its responsibilities, what is it best suited to do, where is it going? These questions reflect persistent concern. The reasons are several. First, psychiatry’s domain has extended well beyond the insane asylums characteristic of the late nineteenth century. Psychiatry today finds itself involved in wide areas of human activity-from politics and death to the search for fulfillment in work and sex. 166 ISSN 0163-8343179M20166-081$02.25
and
Second, psychiatry’s knowledge base has remained small compared with that of other medical specialties and has not expanded as hoped for. Too few psychiatrists are engaged in research; too little money is being spent to prepare younger investigators for the demands of psychiatry’s growth (4). Third, the traditional sources of psychiatric identity-psychoanalytic theory on the one hand and medical descriptive psychiatry on the otherhave come under attack. The persisting absence of rigorous and empirical testing of psychoanalytic theory (5, 6) has alienated behavioral scientists and nonpsychiatrist physicians to the point that, increasingly, psychiatry is either ignored or denigrated. And medical descriptive psychiatry has its critics among the social labeling theorists (7) and from some within psychiatry (8, 9). The questioning also persists because the major responses are unsatisfactory (1, 10). One position maintains that what psychiatry faces now is not an identity crisis but a “phase” of opportunity and change. The psychiatrists in this camp are less medically oriented. They deemphasize disease formulations of mental disorders, biologic models of behavior, and somatic treatments and tend to emphasize psychosocial aspects of psychiatric disturbance, “functional” etiology, and psychotherapy. The other position is characteristic of those psychiatrists who see themselves primarily as physicians. Those in this camp consider medicine (2) to be the wellspring of psychiatry. They deplore those trends that deemphasize traditional interests in
General Hospital Psychiatry @ Eisevier North HoIIand, Inc., 1979
Psychiatry’s Identity Crisis
mental illness, and they encourage a toughminded skepticism among their students (10, 11). Psychiatrists, the argument goes, should be more disease oriented. Neither position provides an adequate solution. Certainly, psychiatry has drifted to a point where its knowledge base can scarcely support the demands made upon it. But the identity problem in psychiatry calls for more than optimistic platitudes or pessimistic retrenchment. Let us consider an alternative viewpoint. There is nothing intrinsically wrong with pursuing special interests in psychotherapy, psychopathology, psychobiology, or even crime and social change. The problem is that each of these separate areas of psychiatric activity has developed within narrowly conceived frames of reference. Psychiatry has, in fact, multiple partial identities, each of which has its own rules, terminology, data, and a theoretical overgrowth that has obscured its empirical foundations. Because we do not have a generally agreed upon field theory that integrates these approaches (nor is one likely to emerge in the near future), communication among psychiatrists with different identities has been difficult. Hence, we have the “special psychiatries” : the psychoanalytic, biologic, social, and community. Despite their diversity, Callaway (12) has pointed to one common feature: “intellectual tunnel vision.” Psychiatry has become an undisciplined discipline, unable to capitalize on potential intra- and interdisciplinary research and to respond to increasing demands for psychiatric services. This is the crisis in psychiatry: There is an urgent need to define a general identity anew. A definition would prove a reasonable basis on which to reexamine the specialized endeavors now regarded as part of the profession, to determine their appropriateness and limitations, and to improve the teaching and learning of psychiatry. A general or encompassing identity in psychiatry requires at least three features: (a) a common language and procedure for assessing psychopathology, (b) a common method for evaluation and use of knowledge from outside psychiatry, and (c) a common set of values regarding clinical and research activities. The unifying attribute of these features is a methodologic discipline for psychiatry. Presently, the measures, principles, and values with which we approach problems and examine ideas are neither clear nor consistent. Let us examine the major traditions in psychiatry in order to identify the reasons that psychiatry has lost a sense of identity. Thereaf-
ter, we propose a critical rational approach for psychiatry as a potential means to remedy its current lack of definition.
The Clinical Tradition Until recently, Freud and Meyer have had dominant influence on clinical training and practice in the United States. Now, Kraepelin’s views on psychiatric diagnosis and disease have gained increasing influence on the mainstream of American psychiatry.
Freudian and Meyerian Tradition Freud developed a brilliant closed system of psychologic theory, a promising attempt to explain behavior, which linked motivation, unconscious The inexperience, and emotional development. vention of the psychoanalytic treatment technique for psychologic problems refractory to simple reassurance initiated a new clinical era that conspicuously lacked a strong research tradition. This is particularly noteworthy because of the experimental quality of the initial analytic investigations and the tentative nature of the formulations Freud put forth (5). At Johns Hopkins, Adolf Meyer proposed ideas similar to those of Freud, stressing life history as crucial in the production of mental disturbance. His work eventually expanded under the influence of Harry Stack Sullivan’s concern for the interpersonal dimension of psychology into the first truly American school of psychiatry. The traditions fostered by Freud and Meyer have had an important humanizing effect on medicine. Rather than merely categorizing difficulties that patients present, under the influence of these traditions, practitioners have learned to listen and try to understand the suffering of their patients, have treated personal biography as an essential aspect of illness, and have recognized the important clinical implications that result from the meaning that symptoms and treatments hold for the patient.
Kraepelinian
Tradition
Emil Kraepelin pioneered in efforts to classify medical psychiatric illnesses. His work became a standard for clarity in the description of psychopathology. Research into natural history, genetics, 167
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and the neuropathology of psychiatric entities flourished. Kraepelin, however, like Freud and Meyer, must be criticized for a lack of openness to alternative views. Kraepelin clearly linked himself to nineteenth century medicine, its methods, assumptions, and limitations. The search for biologic causes became a passionate bias. Kraepelin has only recently become influential in American psychiatry. One consequence of his influence has been renewed interest in diagnosis. Over the past 30 or so years, studies of diagnosis have frequently demonstrated the drawbacks of current nosology and the unreliability of psychiatric ratings of psychopathology when carried out by clinicians who have been given little systematic training (13, 14). The importance of phenomenologic diagnosis shrinks to the extent one believes that the key issues are psychodynamic; far greater value is attached to clarifying early relationships and the impact of developmental crises. Although the picture of clinical psychiatry we have painted appears gloomy, there are reasons for optimism. Through research in psychopathology, real progress has been made in the development of common language and standardized clinical procedures (10, 15, 16). Interdisciplinary attempts to study the interaction of physician and patient from initial encounter through the negotiation process in order to achieve patient satisfaction and compliance with treatment signal a renewed commitment to understanding how to provide optimal care (17-19). Medical and psychiatric anthropology have created a patient-centered ethnomedical model that focuses on the personal and cultural “meaning” of the sickness experience (20), a model that complements the biomedical model and makes it more useful for health care research. Investigations in ego psychology and especially coping and adaptation continue to have important implications; e.g., the latter provide a unifying language for psychiatrists, behavioral scientists, health services researchers, and primary caregivers to analyze the core psychosocial aspects of health care (21). Learning theory with its offspring, behavior therapy, shows increasing applicability for a range of clinical problems (22,23). Sociobiology suggests new approaches for integrating social and biologic aspects in the study and management of deviance (24). The emerging discipline of consultation-liaison psychiatry illustrates the need for critical use of new sources of information: communication theory, clinically applied social science, and medical and neurologic aspects of psychiatry (25).
The Biologic Tradition Kraepelin proposed in the late nineteenth century that to classify psychiatric disturbances as diseases requires an identifiable cerebral pathology and biologic etiology. This ideal has seldom been attained (26). Apart from the psychoses associated with niacin deficiency, syphilis, and temporal lobe epilepsy, the great majority of psychiatric illnesses have not yielded to biologic investigation. There is a conspicuous absence of organized theory in biologic psychiatry. There are, indeed, highly developed models, such as the the catecholamine model of affective disorder and the dopamine model of schizophrenia; and psychopharmacology has grown into an effective empirical clinical science. Although the establishment of a unifying general theory for the biologic aspects of psychopathology would be premature, there is strikingly little attempt even at mid-range theorizing. The results are important empirical data, a diversity of narrowly focused models, and little or no means of translating from one model to another or from one area of psychopathology to another. Further, there is too little collaborative work among biologically and clinically oriented researchers.
The Sociocultural
Tradition
Perhaps the most potent stimulus to sociocultural work in psychiatry in the United States was the federal funding of community mental health in the 1960s; yet the results have been discouraging from the standpoint of psychiatric identity. Although the areas of concern for investigation were clearly defined-the social causes and prevalence of psychiatric disorders, prevention, comprehensive services for large numbers of individuals with diverse social class and ethnic background-the lack of a unified theory or set of approaches has characterized these efforts, Moreover, out of the prodigious amount of work, very little was done with rigor or method to match the challenge or the level of support (4). Bridges between community psychiatry and professional social science have been difficult to build. The persistent influence of dynamic theorizing has irked many social scientists who initially criticized psychiatry and, more recently, have simply ignored it. Now, with crumbling federal financial support and an increased demand for effective care coming from health consumers, the need for practical efficient translation of social-scientific insights looms
Psychiatry’s Identity Crisis
larger for psychiatry and medicine. The present call for more psychiatric input to primary care presents an especially significant occasion either to repeat the excesses of the early community health movement or, hopefully, more cautiously to advance psychiatric concepts and strategies to meet appropriate primary care needs and to evaluate both their success and failure. Similarly, increasing recognition that ethnocentric psychiatry cannot be effective in a world whose population is well more than threefourths non-Western and whose major cultural codes for organizing and communicating experiences are nonpsychologic (and based on markedly divergent values and social structures) presents an opportunity for developing a cross-cultural discipline at all levels of theory, research, and practice. But this opportunity could equally well become a source of future failures and further fragmentation of identity, if inappropriately handled.
The Nature of Critical Rationality Despite psychiatry’s loosely knit, fragmented identity, we believe that a consensus could be achieved concerning the fundamental features of psychiatry. Certainly, it has a clear clinical purpose: to provide the best patient care to patients suffering mental illness or psychosocial concomitants of medical disorders. Further, psychiatry must draw on current relevant knowledge from outside psychiatry, e.g., the biologic, behavioral, and social sciences, in order to accomplish its purpose. Moreover, psychiatry shares with medicine explicit values that guide clinical and research activities, namely, the therapeutic imperative: to help, to prevent, to care, to palliate, and not to harm. Unlike behavioral, social, or biologic science, psychiatry has a mandate to state its problems in a clinically relevant language shared by other clinicians and to develop practical therapeutic interventions (27). There are, however, major barriers to consensus: (a) The fields of psychiatry are not disciplined, sufficiently self-critical of existing paradigms, receptive to new ideas, or rigorously methodical in their approaches to new knowledge; (b) the fields of psychiatry are not organized systematically to introduce, evaluate, and integrate emerging concepts and findings from other disciplines and to reassess existing canons in terms of new developments. In order to effect its purpose and to survive as a profession-in short, to establish its identitypsychiatry needs to overcome these barriers. We propose one potential solution to these diffi-
culties, which may appear at first glance deceptively simple: We suggest a systematically critical approach toward knowledge, an approach we shall call critical rationality. Such an approach is needed if psychiatry is to discipline itself and routinely to evaluate and integrate knowledge systematically; if it is, in short, to become a more rigorous human science. Also, it may aid psychiatrists to understand and respond effectively to the anti-intellectualism, irrationality, and antiscientific interests currently flourishing. Other approaches may also be appropriate, but like this one, they must be made explicit in order to be properly evaluated. In proposing critical rationality, we wish to emphasize two component concepts, critical and rationality. Most psychiatrists are rational; rationality alone, however, is not sufficient. We wish to stress that several different meanings of the term “critical” need to be linked strategically to the concept of rationality in order to build the requisite comprehensive approach. First, critical refers to and emphasizes the reflexive character of rationality. In order to prevent stagnation, psychiatrists and trainees must scrutinize critically the limits and potential of their own methods and knowledge. For example, although psychoanalysis is a rational theory, there have been few attempts among its devotees to commit themselves to a critical stance. The result has been stagnation as well as inability to separate what is scientifically valid from what is speculative and intuitive. Second, critical emphasizes the constructive quality of rationality: the motivation to make explicit the merits and faults of new ideas or established ones. For instance, the critical examination of the concept of transference in the light of current knowledge of psychoanalysis, social science, and learning theory should produce valuable new ideas potentially translatable into clinical practice. Third, critical calls for what Polanyi and Prosch (28) refer to as the analysis of tacit (or personal) knowledge; that is, examining the tacit subsidiaries we make use of to move from pieces of unintegrated (and usually unexamined) knowledge to more or less explicit knowledge. Much of the time, this integration is ad hoc and unanalyzed. Although this may be less of a problem in research, it is characteristic of clinical decisions: “My gut reaction is that this patient is schizophrenic.” Critical rationality in psychiatry, in this instance, might make the study of clinical judgment a major avenue of research as well as a pedagogic vehicle for teaching future clinicians (29, 30).
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Fourth, critical refers to the normative thrust of rationality. It would promote awareness of the consequences of rational scientific endeavor. Such awareness can orient psychiatrists to the ethical, social, and political implications of their work. Psychosurgery for prisoners, the excessive use of civil commitment procedures, the abortion problem, “new” psychotherapies, and labeling people psychiatrically ill for social and political reasons all call for a critical rational appraisal. Critical rationality thus represents a methodology rather than a body of knowledge. It is a systematic approach to theory, clinical problems, research findings, and implications which should be part of the training of new psychiatrists and,basic to the practice and teaching of psychiatry, if it is to be regarded as a human science. Although some might contend that critical rationality simply embodies the values of “good science, ” we observe that at present, psychiatry neither explicitly inculcates such an approach nor assumes its routine application in practice and academic work.
The Uses of Critical Rationality One obvious example of the usefulness of the critical rational approach in psychiatry relates to training. We would argue that this approach has ramifications for the curriculum and training process of psychiatric residents. First, let us suggest comparisons between a traditional approach and the one that we propose. The traditional approach to psychiatric training has the following characteristics: (a) There is a lack of general explicit goals for training. Is the young psychiatrist to be trained to become a biologic researcher, a psychotherapist, or an administrator? What constitutes the “core curriculum” or essential knowledge? Should training be diversified or focused on one viewpoint? There is no consensus on these matters. Hence, we have training tracks, generalist programs, and what is paraded before residents as eclecticism. (b) Another characteristic of this approach is an implicit de-emphasis of methodic, rigorous, and critical approaches to knowledge. (c) The great bulk of teaching time is focused on supervision-usually of psychotherapy (most often some variant of current dynamic theory, but also behavior therapy). Relatively little time is devoted to in-depth exploration of major relevant disciplines, e.g., neurosciences, psychology, medical aspects of psychiatry. Thus, traditional training has the character more of appren170
ticeship than of disciplined graduate scholarship. (d) As a result of both unclear goals and a relative disinterest in rigorous approaches to knowledge, there is a tendency to rely every year on an unimaginative curriculum. As an alternative, a critical rational approach to the issues of training might have a clearer vision: (a) The formation of explicit goals for all training experiences: 1. to develop a critical attitude toward evaluation of information 2. to introduce a variety of relevant subject areas 3. to achieve an in-depth understanding of the subject areas, in order to recognize the limits and potentials of the knowledge and disciplines presented 4. to foster the development of integrative approaches, utilizing intra- and interdisciplinary contributions in concepts and methods new knowledge and ap5. to translate proaches into practical strategies directly applicable to patient care. (b) Instead of a de-emphasis of method, there would be a clear commitment to teach residents a critical rational approach as a means for assimilating, organizing, and evaluating psychiatric ideas and relevant knowledge from related fields. At the outset, the ground rules for rational discourse in the presentation of patients and ideas would be taught. (c) Instead of apprenticeship, the model for teaching would be more flexible-to use as many techniques as needed (including supervision) to promote each resident’s achievement of professional competence. But a graduate studies environment would be emphasized. (d) And finally, instead of traditional subjects, the curriculum would attempt to present systematically a variety of disciplines deemed basic to psychiatry’s needs and taught from the standpoint of their relevance to specific issues in psychiatry: These might include biomedical subjects (the neurosciences, epidemiology, genetics, psychopharmacology); behavioral sciences (cognitive, developmental, and personality psychology, learning theory, psychophysiology); social sciences (medical sociology and anthropology, social psychology); communication sciences; and
Psychiatry’s Identity Crisis
humanities (ethics, philosophy of science, tory of psychiatric ideas and institutions).
his-
Let us elaborate this proposal for a general curriculum with respect to training residents in psychotherapy. Teaching would be organized to conform to the general goals outlined above. The format might be a seminar, supplemented by supervised psychotherapy experiences. Initially, residents would be introduced to relevant materials from directly related basic subject areas: linguistics, communication theory, social psychology, social anthropologic studies of the healing relationship, learning theory, psychodynamic theory of transference, and so on. The various psychotherapy schools could be presented systematically with attention to the scientific bases of each. A detailed examination of the literature on psychotherapy research of all persuasions from analytic therapy to techniques of behavioral control (e.g., propaganda, brainwashing, “deprogramming,” and so forth) would be useful for these purposes. Residents could review the established facts, the key questions generating research, and, perhaps most important, what is not known. Building on these foundations, residents could then critically appraise in the seminar and in supervisory sessions their own experiences in providing psychotherapy to patients. In such a seminar, residents could begin developing integrated frameworks to evaluate and compare psychotherapies. In learning how to apply techniques such as behavior therapy, hypnosis, or psychodynamic therapy in individual or group psychotherapy, residents might wish to determine the assumptions and efficacies of these techniques and clarify their similarities and differences. Knowledge of social psychology and sociocultural factors relevant to the doctor-patient relationship might increase therapeutic effectiveness by making explicit the factors influencing patient compliance and satisfaction. Or, as Lazare et al. (31) have recently done, residents might turn to studies of diplomacy, labor relations, and collective bargaining to draw important information and concepts to learn about the process of negotiating treatment plans with patients. The fact that we do not possess clear clinical guidelines to determine the indications and contraindications for psychotherapeutic interventions illustrates that such training, based on a critical rational heuristic approach, might prove useful for continuing psychiatric education as well. An obvious application of critical rationality is in
the development of effective means of overcoming disciplinary barriers to ensure the flow of relevant knowledge into psychiatry. A mechanism for systematic translation, application, and evaluation of knowledge from other fields to psychiatry would be an invaluable tool. This mechanism might conform to the following paradigm (following and extending that of Nida (32)): (a) elicitation of new knowledge from another field; (b) its analysis in terms of that field; (c) its translation from the concepts of that field into relevant models in the language of a particular field of psychiatry; (d) its reconstruction in terms of related concepts in that specific field and in other fields of psychiatry; and (e) feedback based on evaluating the results of its actual application to particular clinical and research problems in psychiatry, which will change that knowledge for this specific field of psychiatry, psychiatry in general, and the extrapsychiatric discipline from which it is derived. Such a translational paradigm might be a means of systematically translating among the different fields in psychiatry and thus generating a framework for integrating those new quite separate systems of psychiatric knowledge, i.e., the “special psychiatries” (33). An example may make this instance of a critical rational approach more concrete. Suppose we wish to apply the concept of the sick role from medical sociology to psychiatric illness. Generally, such applications are made unsystematically on an ad hoc basis. The mechanism proposed above-the product of a critical rational approach-could be systematically applied to this interdisciplinary transfer. That mechanism calls for analyzing what the sick role means in sociology, then translating it into a specific conceptual domain in psychiatry, such as psychopathologic concepts about hysteria or somatization, or psychodynamic concepts about secondary gain and its determinants, or crosscultural psychiatric concepts about how the same psychiatric disorder might be perceived differently and even experienced differently by different ethnic groups. That means, in part, defining the sick role and conflicts in labeling and sanctioning particular kinds of psychiatric sick roles as notions that might be used to reconstruct psychiatric theory about somatization, hysteria, and hypochondriasis with secondary gain (17). The next step would be to apply a clinical understanding of the sick role as a practical strategy for the clinical management of a prticular problem such as several commonly encountered in consultation psychiatry: chronic functional sickness, malingering, and factitious disease. The results of
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this application should be evaluated with regard to their validity and benefit (heuristic or clinical) compared with previous psychiatric concepts. Finally, this evaluation based on a specific application would “feed back” to social science to refine further what needed to be clarified or elaborated in order to make the sick role concept more useful to psychiatry and to provide a more discriminating distinction between medical and psychiatric sick roles. The end result would almost certainly facilitate the learning and practice of consultation psychiatry by residents. Along the lines of this translational paradigm, for example, communication theory models of dyadic communication might be transferred into studies of doctor-patient interactions. The same kind of approach might be useful for translating concepts from genetics and population science into the study of familial transmission of psychiatric disorder, or from cognitive psychology into the study of schizophrenic thought disorder. One simple illustration of critical rationality applied to psychiatry might be the rigorous elaboration of the medical anthropologic distinction between disease and illness, in which the concept of disease stands for a primary malfunctioning of the biologic and/or psychologic processes, whereas the concept of illness stands for psychosocial and cultural reactions to disease (34). Using this dichotomy, we might review diagnostic categories to see where this conceptual distinction would be beneficial in thinking about and treating psychiatric disorders. We know that acute disease can occur in the absence of illness (e.g., acute intoxications). Chronic disease, on the other hand, is always accompanied by illness, which usually provides the major issues for clinical management. Indeed, illness may be fulminant when disease grows quiescent. Perhaps malingering, alcoholism, and drug abuse could be regarded as illnesses in the absence of disease. The value of the distinction is that it bears on a major issue in clinical care: Medical technology usually treats disease, not illness; communication and “caring” aspects of doctor-patient relationships usually treat illness rather than disease. Psychotherapy can affect disease, but its primary impact is on illness. Most dissatisfaction with modern health care indicates ineffective or absent treatment of illness. This critical rational elaboration of a useful dichotomy suggests models and a language for responding to routine psychosocial problems in medical care (lack of compliance, patient dissatisfaction, medical-legal actions) that are as prevalent as in psychiatric practice. It offers practi172
cal, integrative possibilities for psychiatrists to work more closely with other primary care practitioners. We might argue from this perspective that psychiatric consultation often is called upon to augment medical care devoted entirely to disease by treating illness. Limits of space do not allow us to demonstrate how this model can be applied to actual cases, but this distinction discloses potentially powerful clinical consequences. For example, should the treatment of disease-illness be separated into two distinct clinical functions with distinct health professional roles (e.g., doctor and nurse, or general medical doctor and psychiatrist); or should an attempt be made to reunify these traditionally integrated functions in the role of physician? This is a problem for a critical rational approach in psychiatry which needs to be more fully elaborated (35). Dyslexia is an example of a problem cutting across psychiatry, pediatrics, neurology, psychology, and education that would derive conceptual and applied clinical benefits from a critical rational appraisal. And we would suggest that psychiatry has numerous clinical problems that call for a critical rational analysis.
Implications Psychiatry needs a common language and procedure for assessing psychopathology. Psychiatry also needs a routine method for approaching the enormous body of materials in relevant disciplines. Psychiatry further needs a clear statement of the intellectual and human values on which it rests. In effect, what is required is agreement on a method that is scientific and humane, that bridges biologic, behavioral, and social science, and that will prevent obscurantism, romanticism, dogmaticism, and the confusion that currently abounds. To provide for these needs requires a new discipline based on an old approach-critical rationality. Other academic fields already benefit from the strength of explicit and rigorous approaches to fact and theory; in many clinical fields, more implicit methods operate. In psychiatry, however, no unified approach is clearly visible. Despite our suspicion that at least some will protest the need for critical rationality, we see such an approach as necessary for the resolution of the problems of knowledge plaguing psychiatry. We feel that the identity crisis in psychiatry cannot be solved by present approaches. Psychiatry should discipline itself, hopefully through a critical
Psychiatry’s
rational process; its identity will emerge context of more effective function.
in the
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Direcf r@nt
requests fo:
Theo C. Manschreck, M.D. Department of Psychiatry Massachusetts General Hospital Fruit St. Boston, MA 02114
173
Psychiatry
Program,
Department
of Psychiatry,
Harvard Medical School,
Arthur M. Kleinman, M.D., M.A. Professor and Head, Division of Social and Cross-Cultural Psychiatry, Department of Psychiafy Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington
Abstract: Psychiatry has several partial identities reflecting its biologic, psychoanalytic, and social subspecialties. It has, however, no encompassing professional identity. This identity requires three features: (a) a common language and procedurefor assessing psychopathology, (b) a common method for evaluation and use of knowledge from outside psychiatry, and (c) a common set of values regarding clinical and research activities. The authors discuss the clinical, biologic, and sociocultural psychiatric traditions to identify the roots and consequences of psychiatry’s fragmented state. Psychiatry’s identity problems cannot be solved by ignoring them or simply becoming more “medical.” Rather, the authors propose a remedy--critical rationality-to help resolve the crisis. Critical rationality requires a disciplined approach to psychiatric knowledge that underscores the necessity of methodologic rigor, practicality, and mid-range theorizing (rationality); and the equal necessity for systematic self-criticism, reform, self-awareness, and attention to the ethical dimensions in teaching, practice, and research (critical).
In recent years, thoughtful individuals throughout psychiatry have commented on the “identity crisis” facing the psychiatric profession (l-3). What is psychiatry, what are its responsibilities, what is it best suited to do, where is it going? These questions reflect persistent concern. The reasons are several. First, psychiatry’s domain has extended well beyond the insane asylums characteristic of the late nineteenth century. Psychiatry today finds itself involved in wide areas of human activity-from politics and death to the search for fulfillment in work and sex. 166 ISSN 0163-8343179M20166-081$02.25
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Second, psychiatry’s knowledge base has remained small compared with that of other medical specialties and has not expanded as hoped for. Too few psychiatrists are engaged in research; too little money is being spent to prepare younger investigators for the demands of psychiatry’s growth (4). Third, the traditional sources of psychiatric identity-psychoanalytic theory on the one hand and medical descriptive psychiatry on the otherhave come under attack. The persisting absence of rigorous and empirical testing of psychoanalytic theory (5, 6) has alienated behavioral scientists and nonpsychiatrist physicians to the point that, increasingly, psychiatry is either ignored or denigrated. And medical descriptive psychiatry has its critics among the social labeling theorists (7) and from some within psychiatry (8, 9). The questioning also persists because the major responses are unsatisfactory (1, 10). One position maintains that what psychiatry faces now is not an identity crisis but a “phase” of opportunity and change. The psychiatrists in this camp are less medically oriented. They deemphasize disease formulations of mental disorders, biologic models of behavior, and somatic treatments and tend to emphasize psychosocial aspects of psychiatric disturbance, “functional” etiology, and psychotherapy. The other position is characteristic of those psychiatrists who see themselves primarily as physicians. Those in this camp consider medicine (2) to be the wellspring of psychiatry. They deplore those trends that deemphasize traditional interests in
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Psychiatry’s Identity Crisis
mental illness, and they encourage a toughminded skepticism among their students (10, 11). Psychiatrists, the argument goes, should be more disease oriented. Neither position provides an adequate solution. Certainly, psychiatry has drifted to a point where its knowledge base can scarcely support the demands made upon it. But the identity problem in psychiatry calls for more than optimistic platitudes or pessimistic retrenchment. Let us consider an alternative viewpoint. There is nothing intrinsically wrong with pursuing special interests in psychotherapy, psychopathology, psychobiology, or even crime and social change. The problem is that each of these separate areas of psychiatric activity has developed within narrowly conceived frames of reference. Psychiatry has, in fact, multiple partial identities, each of which has its own rules, terminology, data, and a theoretical overgrowth that has obscured its empirical foundations. Because we do not have a generally agreed upon field theory that integrates these approaches (nor is one likely to emerge in the near future), communication among psychiatrists with different identities has been difficult. Hence, we have the “special psychiatries” : the psychoanalytic, biologic, social, and community. Despite their diversity, Callaway (12) has pointed to one common feature: “intellectual tunnel vision.” Psychiatry has become an undisciplined discipline, unable to capitalize on potential intra- and interdisciplinary research and to respond to increasing demands for psychiatric services. This is the crisis in psychiatry: There is an urgent need to define a general identity anew. A definition would prove a reasonable basis on which to reexamine the specialized endeavors now regarded as part of the profession, to determine their appropriateness and limitations, and to improve the teaching and learning of psychiatry. A general or encompassing identity in psychiatry requires at least three features: (a) a common language and procedure for assessing psychopathology, (b) a common method for evaluation and use of knowledge from outside psychiatry, and (c) a common set of values regarding clinical and research activities. The unifying attribute of these features is a methodologic discipline for psychiatry. Presently, the measures, principles, and values with which we approach problems and examine ideas are neither clear nor consistent. Let us examine the major traditions in psychiatry in order to identify the reasons that psychiatry has lost a sense of identity. Thereaf-
ter, we propose a critical rational approach for psychiatry as a potential means to remedy its current lack of definition.
The Clinical Tradition Until recently, Freud and Meyer have had dominant influence on clinical training and practice in the United States. Now, Kraepelin’s views on psychiatric diagnosis and disease have gained increasing influence on the mainstream of American psychiatry.
Freudian and Meyerian Tradition Freud developed a brilliant closed system of psychologic theory, a promising attempt to explain behavior, which linked motivation, unconscious The inexperience, and emotional development. vention of the psychoanalytic treatment technique for psychologic problems refractory to simple reassurance initiated a new clinical era that conspicuously lacked a strong research tradition. This is particularly noteworthy because of the experimental quality of the initial analytic investigations and the tentative nature of the formulations Freud put forth (5). At Johns Hopkins, Adolf Meyer proposed ideas similar to those of Freud, stressing life history as crucial in the production of mental disturbance. His work eventually expanded under the influence of Harry Stack Sullivan’s concern for the interpersonal dimension of psychology into the first truly American school of psychiatry. The traditions fostered by Freud and Meyer have had an important humanizing effect on medicine. Rather than merely categorizing difficulties that patients present, under the influence of these traditions, practitioners have learned to listen and try to understand the suffering of their patients, have treated personal biography as an essential aspect of illness, and have recognized the important clinical implications that result from the meaning that symptoms and treatments hold for the patient.
Kraepelinian
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Emil Kraepelin pioneered in efforts to classify medical psychiatric illnesses. His work became a standard for clarity in the description of psychopathology. Research into natural history, genetics, 167
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and the neuropathology of psychiatric entities flourished. Kraepelin, however, like Freud and Meyer, must be criticized for a lack of openness to alternative views. Kraepelin clearly linked himself to nineteenth century medicine, its methods, assumptions, and limitations. The search for biologic causes became a passionate bias. Kraepelin has only recently become influential in American psychiatry. One consequence of his influence has been renewed interest in diagnosis. Over the past 30 or so years, studies of diagnosis have frequently demonstrated the drawbacks of current nosology and the unreliability of psychiatric ratings of psychopathology when carried out by clinicians who have been given little systematic training (13, 14). The importance of phenomenologic diagnosis shrinks to the extent one believes that the key issues are psychodynamic; far greater value is attached to clarifying early relationships and the impact of developmental crises. Although the picture of clinical psychiatry we have painted appears gloomy, there are reasons for optimism. Through research in psychopathology, real progress has been made in the development of common language and standardized clinical procedures (10, 15, 16). Interdisciplinary attempts to study the interaction of physician and patient from initial encounter through the negotiation process in order to achieve patient satisfaction and compliance with treatment signal a renewed commitment to understanding how to provide optimal care (17-19). Medical and psychiatric anthropology have created a patient-centered ethnomedical model that focuses on the personal and cultural “meaning” of the sickness experience (20), a model that complements the biomedical model and makes it more useful for health care research. Investigations in ego psychology and especially coping and adaptation continue to have important implications; e.g., the latter provide a unifying language for psychiatrists, behavioral scientists, health services researchers, and primary caregivers to analyze the core psychosocial aspects of health care (21). Learning theory with its offspring, behavior therapy, shows increasing applicability for a range of clinical problems (22,23). Sociobiology suggests new approaches for integrating social and biologic aspects in the study and management of deviance (24). The emerging discipline of consultation-liaison psychiatry illustrates the need for critical use of new sources of information: communication theory, clinically applied social science, and medical and neurologic aspects of psychiatry (25).
The Biologic Tradition Kraepelin proposed in the late nineteenth century that to classify psychiatric disturbances as diseases requires an identifiable cerebral pathology and biologic etiology. This ideal has seldom been attained (26). Apart from the psychoses associated with niacin deficiency, syphilis, and temporal lobe epilepsy, the great majority of psychiatric illnesses have not yielded to biologic investigation. There is a conspicuous absence of organized theory in biologic psychiatry. There are, indeed, highly developed models, such as the the catecholamine model of affective disorder and the dopamine model of schizophrenia; and psychopharmacology has grown into an effective empirical clinical science. Although the establishment of a unifying general theory for the biologic aspects of psychopathology would be premature, there is strikingly little attempt even at mid-range theorizing. The results are important empirical data, a diversity of narrowly focused models, and little or no means of translating from one model to another or from one area of psychopathology to another. Further, there is too little collaborative work among biologically and clinically oriented researchers.
The Sociocultural
Tradition
Perhaps the most potent stimulus to sociocultural work in psychiatry in the United States was the federal funding of community mental health in the 1960s; yet the results have been discouraging from the standpoint of psychiatric identity. Although the areas of concern for investigation were clearly defined-the social causes and prevalence of psychiatric disorders, prevention, comprehensive services for large numbers of individuals with diverse social class and ethnic background-the lack of a unified theory or set of approaches has characterized these efforts, Moreover, out of the prodigious amount of work, very little was done with rigor or method to match the challenge or the level of support (4). Bridges between community psychiatry and professional social science have been difficult to build. The persistent influence of dynamic theorizing has irked many social scientists who initially criticized psychiatry and, more recently, have simply ignored it. Now, with crumbling federal financial support and an increased demand for effective care coming from health consumers, the need for practical efficient translation of social-scientific insights looms
Psychiatry’s Identity Crisis
larger for psychiatry and medicine. The present call for more psychiatric input to primary care presents an especially significant occasion either to repeat the excesses of the early community health movement or, hopefully, more cautiously to advance psychiatric concepts and strategies to meet appropriate primary care needs and to evaluate both their success and failure. Similarly, increasing recognition that ethnocentric psychiatry cannot be effective in a world whose population is well more than threefourths non-Western and whose major cultural codes for organizing and communicating experiences are nonpsychologic (and based on markedly divergent values and social structures) presents an opportunity for developing a cross-cultural discipline at all levels of theory, research, and practice. But this opportunity could equally well become a source of future failures and further fragmentation of identity, if inappropriately handled.
The Nature of Critical Rationality Despite psychiatry’s loosely knit, fragmented identity, we believe that a consensus could be achieved concerning the fundamental features of psychiatry. Certainly, it has a clear clinical purpose: to provide the best patient care to patients suffering mental illness or psychosocial concomitants of medical disorders. Further, psychiatry must draw on current relevant knowledge from outside psychiatry, e.g., the biologic, behavioral, and social sciences, in order to accomplish its purpose. Moreover, psychiatry shares with medicine explicit values that guide clinical and research activities, namely, the therapeutic imperative: to help, to prevent, to care, to palliate, and not to harm. Unlike behavioral, social, or biologic science, psychiatry has a mandate to state its problems in a clinically relevant language shared by other clinicians and to develop practical therapeutic interventions (27). There are, however, major barriers to consensus: (a) The fields of psychiatry are not disciplined, sufficiently self-critical of existing paradigms, receptive to new ideas, or rigorously methodical in their approaches to new knowledge; (b) the fields of psychiatry are not organized systematically to introduce, evaluate, and integrate emerging concepts and findings from other disciplines and to reassess existing canons in terms of new developments. In order to effect its purpose and to survive as a profession-in short, to establish its identitypsychiatry needs to overcome these barriers. We propose one potential solution to these diffi-
culties, which may appear at first glance deceptively simple: We suggest a systematically critical approach toward knowledge, an approach we shall call critical rationality. Such an approach is needed if psychiatry is to discipline itself and routinely to evaluate and integrate knowledge systematically; if it is, in short, to become a more rigorous human science. Also, it may aid psychiatrists to understand and respond effectively to the anti-intellectualism, irrationality, and antiscientific interests currently flourishing. Other approaches may also be appropriate, but like this one, they must be made explicit in order to be properly evaluated. In proposing critical rationality, we wish to emphasize two component concepts, critical and rationality. Most psychiatrists are rational; rationality alone, however, is not sufficient. We wish to stress that several different meanings of the term “critical” need to be linked strategically to the concept of rationality in order to build the requisite comprehensive approach. First, critical refers to and emphasizes the reflexive character of rationality. In order to prevent stagnation, psychiatrists and trainees must scrutinize critically the limits and potential of their own methods and knowledge. For example, although psychoanalysis is a rational theory, there have been few attempts among its devotees to commit themselves to a critical stance. The result has been stagnation as well as inability to separate what is scientifically valid from what is speculative and intuitive. Second, critical emphasizes the constructive quality of rationality: the motivation to make explicit the merits and faults of new ideas or established ones. For instance, the critical examination of the concept of transference in the light of current knowledge of psychoanalysis, social science, and learning theory should produce valuable new ideas potentially translatable into clinical practice. Third, critical calls for what Polanyi and Prosch (28) refer to as the analysis of tacit (or personal) knowledge; that is, examining the tacit subsidiaries we make use of to move from pieces of unintegrated (and usually unexamined) knowledge to more or less explicit knowledge. Much of the time, this integration is ad hoc and unanalyzed. Although this may be less of a problem in research, it is characteristic of clinical decisions: “My gut reaction is that this patient is schizophrenic.” Critical rationality in psychiatry, in this instance, might make the study of clinical judgment a major avenue of research as well as a pedagogic vehicle for teaching future clinicians (29, 30).
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Fourth, critical refers to the normative thrust of rationality. It would promote awareness of the consequences of rational scientific endeavor. Such awareness can orient psychiatrists to the ethical, social, and political implications of their work. Psychosurgery for prisoners, the excessive use of civil commitment procedures, the abortion problem, “new” psychotherapies, and labeling people psychiatrically ill for social and political reasons all call for a critical rational appraisal. Critical rationality thus represents a methodology rather than a body of knowledge. It is a systematic approach to theory, clinical problems, research findings, and implications which should be part of the training of new psychiatrists and,basic to the practice and teaching of psychiatry, if it is to be regarded as a human science. Although some might contend that critical rationality simply embodies the values of “good science, ” we observe that at present, psychiatry neither explicitly inculcates such an approach nor assumes its routine application in practice and academic work.
The Uses of Critical Rationality One obvious example of the usefulness of the critical rational approach in psychiatry relates to training. We would argue that this approach has ramifications for the curriculum and training process of psychiatric residents. First, let us suggest comparisons between a traditional approach and the one that we propose. The traditional approach to psychiatric training has the following characteristics: (a) There is a lack of general explicit goals for training. Is the young psychiatrist to be trained to become a biologic researcher, a psychotherapist, or an administrator? What constitutes the “core curriculum” or essential knowledge? Should training be diversified or focused on one viewpoint? There is no consensus on these matters. Hence, we have training tracks, generalist programs, and what is paraded before residents as eclecticism. (b) Another characteristic of this approach is an implicit de-emphasis of methodic, rigorous, and critical approaches to knowledge. (c) The great bulk of teaching time is focused on supervision-usually of psychotherapy (most often some variant of current dynamic theory, but also behavior therapy). Relatively little time is devoted to in-depth exploration of major relevant disciplines, e.g., neurosciences, psychology, medical aspects of psychiatry. Thus, traditional training has the character more of appren170
ticeship than of disciplined graduate scholarship. (d) As a result of both unclear goals and a relative disinterest in rigorous approaches to knowledge, there is a tendency to rely every year on an unimaginative curriculum. As an alternative, a critical rational approach to the issues of training might have a clearer vision: (a) The formation of explicit goals for all training experiences: 1. to develop a critical attitude toward evaluation of information 2. to introduce a variety of relevant subject areas 3. to achieve an in-depth understanding of the subject areas, in order to recognize the limits and potentials of the knowledge and disciplines presented 4. to foster the development of integrative approaches, utilizing intra- and interdisciplinary contributions in concepts and methods new knowledge and ap5. to translate proaches into practical strategies directly applicable to patient care. (b) Instead of a de-emphasis of method, there would be a clear commitment to teach residents a critical rational approach as a means for assimilating, organizing, and evaluating psychiatric ideas and relevant knowledge from related fields. At the outset, the ground rules for rational discourse in the presentation of patients and ideas would be taught. (c) Instead of apprenticeship, the model for teaching would be more flexible-to use as many techniques as needed (including supervision) to promote each resident’s achievement of professional competence. But a graduate studies environment would be emphasized. (d) And finally, instead of traditional subjects, the curriculum would attempt to present systematically a variety of disciplines deemed basic to psychiatry’s needs and taught from the standpoint of their relevance to specific issues in psychiatry: These might include biomedical subjects (the neurosciences, epidemiology, genetics, psychopharmacology); behavioral sciences (cognitive, developmental, and personality psychology, learning theory, psychophysiology); social sciences (medical sociology and anthropology, social psychology); communication sciences; and
Psychiatry’s Identity Crisis
humanities (ethics, philosophy of science, tory of psychiatric ideas and institutions).
his-
Let us elaborate this proposal for a general curriculum with respect to training residents in psychotherapy. Teaching would be organized to conform to the general goals outlined above. The format might be a seminar, supplemented by supervised psychotherapy experiences. Initially, residents would be introduced to relevant materials from directly related basic subject areas: linguistics, communication theory, social psychology, social anthropologic studies of the healing relationship, learning theory, psychodynamic theory of transference, and so on. The various psychotherapy schools could be presented systematically with attention to the scientific bases of each. A detailed examination of the literature on psychotherapy research of all persuasions from analytic therapy to techniques of behavioral control (e.g., propaganda, brainwashing, “deprogramming,” and so forth) would be useful for these purposes. Residents could review the established facts, the key questions generating research, and, perhaps most important, what is not known. Building on these foundations, residents could then critically appraise in the seminar and in supervisory sessions their own experiences in providing psychotherapy to patients. In such a seminar, residents could begin developing integrated frameworks to evaluate and compare psychotherapies. In learning how to apply techniques such as behavior therapy, hypnosis, or psychodynamic therapy in individual or group psychotherapy, residents might wish to determine the assumptions and efficacies of these techniques and clarify their similarities and differences. Knowledge of social psychology and sociocultural factors relevant to the doctor-patient relationship might increase therapeutic effectiveness by making explicit the factors influencing patient compliance and satisfaction. Or, as Lazare et al. (31) have recently done, residents might turn to studies of diplomacy, labor relations, and collective bargaining to draw important information and concepts to learn about the process of negotiating treatment plans with patients. The fact that we do not possess clear clinical guidelines to determine the indications and contraindications for psychotherapeutic interventions illustrates that such training, based on a critical rational heuristic approach, might prove useful for continuing psychiatric education as well. An obvious application of critical rationality is in
the development of effective means of overcoming disciplinary barriers to ensure the flow of relevant knowledge into psychiatry. A mechanism for systematic translation, application, and evaluation of knowledge from other fields to psychiatry would be an invaluable tool. This mechanism might conform to the following paradigm (following and extending that of Nida (32)): (a) elicitation of new knowledge from another field; (b) its analysis in terms of that field; (c) its translation from the concepts of that field into relevant models in the language of a particular field of psychiatry; (d) its reconstruction in terms of related concepts in that specific field and in other fields of psychiatry; and (e) feedback based on evaluating the results of its actual application to particular clinical and research problems in psychiatry, which will change that knowledge for this specific field of psychiatry, psychiatry in general, and the extrapsychiatric discipline from which it is derived. Such a translational paradigm might be a means of systematically translating among the different fields in psychiatry and thus generating a framework for integrating those new quite separate systems of psychiatric knowledge, i.e., the “special psychiatries” (33). An example may make this instance of a critical rational approach more concrete. Suppose we wish to apply the concept of the sick role from medical sociology to psychiatric illness. Generally, such applications are made unsystematically on an ad hoc basis. The mechanism proposed above-the product of a critical rational approach-could be systematically applied to this interdisciplinary transfer. That mechanism calls for analyzing what the sick role means in sociology, then translating it into a specific conceptual domain in psychiatry, such as psychopathologic concepts about hysteria or somatization, or psychodynamic concepts about secondary gain and its determinants, or crosscultural psychiatric concepts about how the same psychiatric disorder might be perceived differently and even experienced differently by different ethnic groups. That means, in part, defining the sick role and conflicts in labeling and sanctioning particular kinds of psychiatric sick roles as notions that might be used to reconstruct psychiatric theory about somatization, hysteria, and hypochondriasis with secondary gain (17). The next step would be to apply a clinical understanding of the sick role as a practical strategy for the clinical management of a prticular problem such as several commonly encountered in consultation psychiatry: chronic functional sickness, malingering, and factitious disease. The results of
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this application should be evaluated with regard to their validity and benefit (heuristic or clinical) compared with previous psychiatric concepts. Finally, this evaluation based on a specific application would “feed back” to social science to refine further what needed to be clarified or elaborated in order to make the sick role concept more useful to psychiatry and to provide a more discriminating distinction between medical and psychiatric sick roles. The end result would almost certainly facilitate the learning and practice of consultation psychiatry by residents. Along the lines of this translational paradigm, for example, communication theory models of dyadic communication might be transferred into studies of doctor-patient interactions. The same kind of approach might be useful for translating concepts from genetics and population science into the study of familial transmission of psychiatric disorder, or from cognitive psychology into the study of schizophrenic thought disorder. One simple illustration of critical rationality applied to psychiatry might be the rigorous elaboration of the medical anthropologic distinction between disease and illness, in which the concept of disease stands for a primary malfunctioning of the biologic and/or psychologic processes, whereas the concept of illness stands for psychosocial and cultural reactions to disease (34). Using this dichotomy, we might review diagnostic categories to see where this conceptual distinction would be beneficial in thinking about and treating psychiatric disorders. We know that acute disease can occur in the absence of illness (e.g., acute intoxications). Chronic disease, on the other hand, is always accompanied by illness, which usually provides the major issues for clinical management. Indeed, illness may be fulminant when disease grows quiescent. Perhaps malingering, alcoholism, and drug abuse could be regarded as illnesses in the absence of disease. The value of the distinction is that it bears on a major issue in clinical care: Medical technology usually treats disease, not illness; communication and “caring” aspects of doctor-patient relationships usually treat illness rather than disease. Psychotherapy can affect disease, but its primary impact is on illness. Most dissatisfaction with modern health care indicates ineffective or absent treatment of illness. This critical rational elaboration of a useful dichotomy suggests models and a language for responding to routine psychosocial problems in medical care (lack of compliance, patient dissatisfaction, medical-legal actions) that are as prevalent as in psychiatric practice. It offers practi172
cal, integrative possibilities for psychiatrists to work more closely with other primary care practitioners. We might argue from this perspective that psychiatric consultation often is called upon to augment medical care devoted entirely to disease by treating illness. Limits of space do not allow us to demonstrate how this model can be applied to actual cases, but this distinction discloses potentially powerful clinical consequences. For example, should the treatment of disease-illness be separated into two distinct clinical functions with distinct health professional roles (e.g., doctor and nurse, or general medical doctor and psychiatrist); or should an attempt be made to reunify these traditionally integrated functions in the role of physician? This is a problem for a critical rational approach in psychiatry which needs to be more fully elaborated (35). Dyslexia is an example of a problem cutting across psychiatry, pediatrics, neurology, psychology, and education that would derive conceptual and applied clinical benefits from a critical rational appraisal. And we would suggest that psychiatry has numerous clinical problems that call for a critical rational analysis.
Implications Psychiatry needs a common language and procedure for assessing psychopathology. Psychiatry also needs a routine method for approaching the enormous body of materials in relevant disciplines. Psychiatry further needs a clear statement of the intellectual and human values on which it rests. In effect, what is required is agreement on a method that is scientific and humane, that bridges biologic, behavioral, and social science, and that will prevent obscurantism, romanticism, dogmaticism, and the confusion that currently abounds. To provide for these needs requires a new discipline based on an old approach-critical rationality. Other academic fields already benefit from the strength of explicit and rigorous approaches to fact and theory; in many clinical fields, more implicit methods operate. In psychiatry, however, no unified approach is clearly visible. Despite our suspicion that at least some will protest the need for critical rationality, we see such an approach as necessary for the resolution of the problems of knowledge plaguing psychiatry. We feel that the identity crisis in psychiatry cannot be solved by present approaches. Psychiatry should discipline itself, hopefully through a critical
Psychiatry’s
rational process; its identity will emerge context of more effective function.
in the
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