Teaching critical thinking in psychiatric training: a role for the social sciences.

Abstract

In 1969, a psychiatric resident admitted a young woman who confessed to her doctor that, “twenty-percent of the time I see reality, and the rest of the time I am in my dream world.” Six months later, near the end of her treatment with antipsychotic medications and psychotherapy, her resident summarized how he understood her illness: There is no question that the psychosis continues…Yet, within the overall personality there is… an ego-adaptive, coping, observing, trying to judge—albeit from a weak, uncertain and tenuous position…[often] overwhelmed in the face of inner chaos and psychosis. But there are islands of strength within the psychotic seas, and when the seas diminish, seemingly of their own accord, one can see these islands more clearly than ever before…One can only wonder if all these islands are not somehow connected beneath the sea, and if so, how does one continue to raise the land mass, that is, capacity to cope and adapt above the level of the waters of the raging impulses of her psychosis. Compare this record to one written nearly 40 years later at the same institution. Here, a psychiatric resident describes the hospital course of a man with the identical diagnosis as the woman: This is a 25 yo Hispanic male with a past psych hx of schizophrenia who brought himself to the ER with the chief complaint of command AH telling him to hurt himself and hurt his brother. ….Pt also endorsed depressed mood, decreased appetite, and insomnia. He did not have any other active SI or HI. Pt admitted that he had been off his psychotropic medications for the past 30 days.…Pt was restarted on his previous medications. On day 2, pt reported feeling improved after treatment. He denied having suicidal thoughts or homicidal thoughts. His AH frequency decreased. On day 3, pt reported improved mood, denied suicidal or homicidal thoughts. Case manager contacted the patient's brother, who stated that pt didn't get along with his family members and family members would not be willing to provide housing. The patient agreed to be discharged to a shelter. The two patients experienced nearly identical troubles, including failure to live independently, a paucity of social relationships, and persistent psychosis. In the first case, the resident took little interest in the patient's symptoms (despite the fact that antipsychotic medications had been in widespread use for over 15 years) and spent many hours learning about her life outside of the hospital and her inner psychological world. The second resident dearly cared about the patient's symptoms and viewed them as unrelated to the scarcity and loneliness that characterized his social life. These divergent representations of the patient with schizophrenia reflect dramatic changes in the social, cultural, and scientific contexts in which psychiatry is practiced. Much of what we do as clinicians is not a consequence of the natural world but, instead, results from our contingent social and cultural context and, as such, deserves critical scrutiny. Historical and anthropological approaches provide tools with which psychiatrists-in-training can reckon with the clinical challenges raised by a complex world. For the last three years, the authors have conducted a course on the social sciences and psychiatry for second-year psychiatric residents with these aims in mind. Through lectures, readings, and homework, the course engages residents in discussions about the psychiatric task. Social science is taught not as a set of abstract theories, but as a set of tools with which to be thoughtful about the responsibilities, complexities, and uncertainties of clinical work. The aim is to teach residents to critically engage the knowledge they use as psychiatrists and to make an intellectual investment in the future of their profession. This article describes the conceptual foundation of the course, its structure, and impact.