Thursday, April 12, 2018

What’s happened to Harvard psychiatry?

Theo Manschrek and Arthur Kleinman in their introduction to a 1977 book, Renewal in psychiatry, that I have mentioned before (see previous post), decried the “current deficiency of critical rationality in psychiatry” (p.1). They wrote these words soon after they started training in psychiatry, but I think they still apply today.

They also edited their book to honour Leon Eisenberg (who I have mentioned in another previous post). Their contribution was written from “strong backgrounds in clinical medicine” (p.2). They recognised “how ubiquitous within psychiatry the practices of uncritical thinking and inattention to methodological issues are” (p.2). People after my own heart!

They divided the state of psychiatry at the time into what they labelled the semicritical and hubris positions. The first is what I have called the atheoretical, eclectic position, for example adopted by Anthony Clare after the anti-psychiatry debate (see previous post). It’s a consensus position taken by mainstream psychiatrists, such as Simon Wessely (see another previous post). It’s sometimes called the biopsychosocial model by its advocates, but this is not fully understanding what George Engel meant when he said there was a need for a new medical model (see another previous post). Manshreck & Kleinman say that the semi-critical position “fails to see the limitations of the medical model in clinical medicine ... and, thus, does not push its critique far enough” (p.7).

The hubris position is what I tend to call the biomedical model. This is a more dogmatic position, which Engel reacted against to produce his biopsychosocial model (see copy of my talk). More recently it has been called a ‘remedicalised psychiatry’ (see another previous post). Manschrek and Kleinman “see this position as very dangerous” (p.7). It’s interesting their book was published in 1977, the same year as Engel’s paper in Science. There is, therefore, no cross referencing. Both propose a new way forward and this is set in the context of what they see as the more radical critique of authors such as Thomas Szasz.

Quoting Callway (1975), Manschrek & Kleinman say that “psychiatry needs to tidy up the mess left by its snake oil salesmen” (p.8) and conclude that “special psychiatric techniques ... have sold themselves too well” (p.8). To discover the ”roots and consequences of this crisis” (p.9), they do an excellent examination of the clinical, biological and sociocultural traditions within psychiatry at the time.

Interestingly they saw psychiatry then as in the same state as the origins of psychology with William James. They found that ”much is amiss in psychiatry” (p.22). From their point of view, psychiatry needed a firmer foundation. They recognised the “barriers to the realisation of this consensus“ (p.22) and their solution was that “psychiatrists employ a critical stance toward knowledge” (p.33). I couldn’t agree more.

Manschrek & Kleinman promoted critical rationality as a “tool that ... can go far to discipline the fields of psychiatry” (p.29). Of course, a truly scientific perspective should start from the null hypothesis, even though most so-called scientific research speculates beyond the evidence (for example, see my comments about cannabis and psychosis (see previous post) and/or tobacco and psychosis - see eg. another previous post). Manschrek & Kleinman encouraged explicit goals for training (eg. see previous post) with an emphasis on method. As they said, “rationality alone is not a sufficient answer” (p. 23). I have also looked at the definition of ’critical’ (eg. see powerpoint slide).

What is of interest is what happened to Manschrek & Kleinman's perspective. As is known, Arthur Kleinman went on to become central to integrating anthropology with medicine and psychiatry (see previous posts linking to two of Kleinman's classic books: Rethinking psychiatry and The illness narratives). But what about Theo Manschrek? He was, after all, the first author of this chapter. I suspect he got taken up with neo-Krapelinianism (see eg. my book chapter). I may be wrong but it would be interesting to find out, because the need for a critical rationality in psychiatry is even more pressing now than it was then (eg. see another previous post).

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