Psychiatry today is torn by opposing sensibilities. Is it primarily a science of brain functioning or primarily an art of understanding the human mind in its social and cultural context? Competing conceptions of mental illness as amenable to scientific explanation or as deeply complex and beyond the reach of empirical study have left the field conceptually divided between science and humanism. In Healing Psychiatry David Brendel takes a novel approach to this stubborn problem. Drawing on the classical American pragmatism of Charles Sanders Peirce, William James, and John Dewey, as well as contemporary work of pragmatic bioethicists, Brendel proposes a "clinical pragmatism" that synthesizes scientific and humanistic approaches to mental health care. Psychiatry, he argues, must integrate scientific and humanistic models by emphasizing the practical, pluralistic, participatory, and provisional aspects of clinical diagnosis and treatment. Psychiatrists need to have the skill and flexibility to use scientific and humanistic approaches in a collaborative, open-ended clinical process; they must recognize the complexity of human suffering even as they strive for scientific rigor. This is the only way, he writes, that psychiatry can heal its conceptual rift and the emotional wounds of its patients.
Healing Psychiatry explores these issues from both clinical and theoretical standpoints and uses case histories to support its basic argument. Brendel calls for an open-minded and flexible yet scientifically informed approach to understanding, diagnosing, and treating mental disorders. And he considers the future of psychiatry, applying the principles of clinical pragmatism to a broad range of ethical concerns in psychiatric training and research.
In his 1983 treatise, The Reflective Practitioner, philosopher Donald Schon explained that many professionals negotiate a tricky landscape between a high ground of theoretical questions and a swampy lowland of messy, real-life situations. The quandary is that the issues of the high ground, though easy to resolve, are relatively unimportant to most people, whereas the swamp involves matters of deep human concern. Should the practitioner remain safe or descend instead into the soup to help real people in real need? Psychiatrists struggle with such tension daily. Practicing their profession requires theory and diagnostic definition, yet reaching a patient requires an emotional bond between the two individuals. David Brendel, an assistant professor of psychiatry at Harvard Medical School who has academic training in philosophy, explores the complexity of this tension and how it vexes modern mental health care. "The disorder in twenty-first-century psychiatry is all about the search to integrate human values," Brendel writes. "With no objective moral or conceptual compass to orient today’s practitioner, the world of clinical psychiatry remains messy and ill-defined." Despite increasing precision in biological psychiatry, he adds, "inherent limitations" of such approaches often lead to treatment shortfalls when faced with "complex and unpredictable human behavior." Part of the solution, Brendel advises his colleagues, is to invoke a pragmatic approach espoused by the classical American philosophers William James and John Dewey. Together James and Dewey cultivated an eclectic and variegated view of scientific inquiry and discourse that aims for practical consequences for ordinary people. They emphasized the need to remain open-minded when interpreting scientific results, which always arise in a social context that shapes the nature and use of new findings. Along similar lines, Brendel advocates a "clinical pragmatism" that, for example, favors practical results over cumbersome psychological theories, decries moralistic decisions devoid of patient input, and steers clear of attributing greater certainty to clinical interpretations than may actually exist. Fleshing out his pragmatist views, he interweaves case studies with philosophical discourse and vivifies theories with clinical tales. Brendel highlights his message with a New Yorker cartoon captioned "Richard the Pragmatist," in which the king proclaims: "My kingdom for a newer, stabler, more centrally located kingdom!" So, too, for the workaday practitioner, struggling to treat a patient afflicted with recurring depression or anxiety.
Richard Lipkin
