Towards a hermeneutic shift in psychiatry.

Abstract

Psychiatry is currently going through a crisis of confidence (1). Some medical commentators have even questioned the very credibility of the profession (2). There are many indicators of this crisis. For example, leading up to the launch of DSM-5 by the American Psychiatric Association last year, the chairperson of the DSM-IV task force raised serious questions about the validity of the whole DSM process (3), echoing earlier criticisms by the chairperson of the DSM-III (4). It is clear that psychiatry has been a particular target of the marketing strategies of the pharmaceutical industry (5), strategies that have led to the corruption of evidence-based medicine in general (6). Much-heralded advances in antipsychotic psychopharmacology are now revealed as “spurious” (7). Academic psychiatry's attempt to transform itself into a sort of “applied neuroscience” (8) has consumed enormous resources but delivered very little for patients. A. Kleinman has called it an “extraordinary failure” and stated that “academic psychiatry has become more or less irrelevant to clinical practice” (9). In the U.S., where the practice of psychiatry has been most dominated by the DSM, neuroscience and the pharmaceutical industry, clinical work has become equated with the prescription of drugs. The New York Times carried a story in 2011 in which a psychiatrist spoke of having to train himself not to get too close to his patients and “not to get too interested in their problems” (10). Our discipline is in trouble. There are several dimensions to the current crisis, but one of the most important difficulties is around the perennial question of what is an appropriate epistemology for psychiatry. What sort of knowledge can we have with regard to mental illness and what sort of expertise is possible? The current technological paradigm that dominates psychiatric thought (11) is based on the idea that episodes of mental illness arise from abnormalities in specific neural, or psychological, pathways or processes. Furthermore, it assumes that these can be grasped with the same sort of de-contextualized, causal logic that is used to explain problems of the liver or lungs. The authority of psychiatry and the power invested in it are often justified on the basis that it possesses, or is on the way to possess, a science that can predict outcomes, based on an accurate map of the underlying processes (12). Therefore, debates about epistemology are not simply an intellectual exercise. Many psychiatrists feel that they cannot be “real doctors” unless their discipline is grounded in the natural science epistemology that guides the rest of medicine. In this short discussion, I do not intend to engage with the wider ethical and political dimensions of the current crisis; rather I simply wish to make the case that natural science methods reach their limits in the territory of mental health and illness. This is largely a territory of meanings, values and relationships, an assertion now supported by a large body of empirical evidence about how psychiatric interventions actually work (11). I argue that, if we are to be truly “evidence-based” in our discipline, we need a radical rethinking of our guiding epistemology: a move from reductionism to hermeneutics.