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The Perspectives of Psychiatry, 2nd ed.
Am J Psychiatry 2000;157:141-141.
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St. Louis, Mo.

by Paul R. McHugh, Phillip R. Slavney. Baltimore, Johns Hopkins University Press, 1998, 375 pp., $35.00.

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The first edition of this book was published in 1983. This second edition is about twice as large as the first and, naturally, provides a good deal more information and discussion by the authors.

The authors’ intention was not to write a textbook of psychiatry but to identify and discuss various viewpoints, hence perspectives, concerning psychiatry, psychiatric illnesses, and the many ideas and approaches to these subjects that have been offered over the last 100 years or more. Needless to say, given the background and experience of the two authors, their efforts have proven to be successful. The reader can expect to consider a wide range of important philosophical, historical, and practical issues that all psychiatrists and many other physicians find important and interesting, although puzzling.

The first two paragraphs in the preface to this edition set out the authors’ intentions. The original version of this book (which served as a blueprint for our teaching and research in psychiatry at Johns Hopkins University School of Medicine) surveyed the sources, principles, and disciplinary history on which psychiatrists base diagnoses and treatments. We held that students with knowledge of the basic patterns and constituent elements of psychiatric reasoning could more easily absorb the details of the discipline, judge proposals from its practitioners, and grasp the problems presented by patients.

This second edition expands on our original effort to describe psychiatric thought—written now after our department has matured and after more than a decade of comments, criticisms, and questions about the book’s thesis and specific components. We have revised those portions of the text that proved obscure and have added new chapters to illustrate our ideas.

I believe that the authors have done an excellent job, even though there are points with which to disagree, and I am very sympathetic to their overall goals and success in setting these points out clearly and interestingly.

One of the most interesting chapters is entitled "Factionalism: The Other Source of Disarray in Psychiatry." The authors begin the chapter as follows:

If the mind-brain issue is the first and most fundamental problem facing psychiatrists, then the longstanding factionalism dividing psychiatric practitioners into party-like blocs, or "camps," according to their beliefs about mental disorder is the second—and perhaps the more distracting—issue obstructing progress. Over the last hundred years, psychiatry has spawned many schools, or denominations, within its ranks. The result is that psychiatry is the only discipline in medicine in which it seems appropriate, even logical, to ask of a practitioner his or her "orientation" or "philosophy." Such questions denote that a professional identity is not sustained from one psychiatrist to another in the way, for example, it is sustained from one surgeon to the next.

Later in the chapter the authors state,

We hold and teach that psychiatric factionalism is actually an aspect of the more general divisiveness over truth and human nature that has emerged over the last 200 years in Western thought. Because we also believe that the same reasoning circumventing the mind-brain problem (and described in the prior chapter) will help transcend factionalism, we now provide a brief discursion into factionalism’s historical background—into the separate sources of ideas behind psychiatry’s denominations—so as to demonstrate how these problems came about.

Briefly, we see factionalism as derived from three major themes in Western thought that have affected psychiatry since the work of René Descartes in the seventeenth century. We shall refer to them as the modern, postmodern, and antimodern ideas and expand on them in the text that follows. Crucially, each has its own background, its own set of leading historical figures, and its own contributions to intellectual history in general and to psychiatry in particular.

Although, as will be apparent, they are at a fundamental level at odds with one another, no one of them has overthrown the others. Rather, they coexist competitively to this day, have strong champions, and contribute mightily to the denominations of psychiatry. Any proposal that hopes to unite the reasoning and practice of psychiatry in order to provide its practitioners with a common foundation and a professional identity must understand these ideas and know what each has to bestow.

These quotations give a vivid sense of the thinking underlying this book, and the authors’ approach is stimulating and often provocative. Readers will undoubtedly respond differently to the ideas presented, sometimes easily agreeing with them and sometimes strongly disagreeing. Few books can do more.




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