Diversity in Psychiatry: Or, Why Did We Become Psychiatrists?

Why did 40,000 or more American physicians, as well as many other doctors throughout the world, choose to become psychiatrists? We are among the largest of the medical specialties. Why are we not cardiologists, radiologists, surgeons, or pathologists? We psychiatrists also come in many types and flavors, as indicated by the theme chosen for this year’s annual APA meeting. This theme, Mind Meets Brain: Integrating Psychiatry, Psychoanalysis, and Neuroscience, emphasizes the convergence of our diverse perspectives. Our diversity is also reflected in the varied articles in this issue of the Journal, which range in content from dementia to personality disorders, and in methods from vulnerability loci for alcoholism on chromosome 1 to a single case study of Emily Dickinson’s patterns of creativity. What unites our diverse specialty?

I haven’t interviewed every psychiatrist in the world, but I have known enough to risk venturing an answer.

I think most of us became psychiatrists because we are interested in what makes human beings tick. We chose psychiatry because we want to understand the human mind and spirit as well as the human brain. We chose to join a very clinical specialty because we are interested in people and we like to work with them as individual people. We like to think about them within the context of the social matrix in which they live, to skillfully elicit a “life narrative” that summarizes their past and current experiences, and to use that information in order to understand how their symptoms arise and can be treated. Every person whom we encounter is a new adventure, a new voyage of discovery, a new life story, a new person. Although some patterns generalize across individuals, each patient is unique. This is what makes psychiatry challenging, intellectually rich, complex, and even enjoyable—despite the fact that we often care for people who suffer intensely and for whom we wish we could offer even more help. We are privileged to explore the most private and personal aspects of people’s lives and to try to help them become healthier.

Our specialty was created by a group of people who espoused this vision. During the 18th century, under the influence of the humanistic ideals of the Enlightenment, physicians identified themselves as specialists in caring for the mentally ill because they believed in the importance and dignity of the individual human beings. This group of specialists in mental illness eventually became known as psychiatrists, or “healers of the mind/spirit.” The descriptions of their early efforts to understand disturbances of the mind make fascinating reading. They can be traced in the writings of Philippe Pinel, William Tuke, Vincenzo Chiarugi, Benjamin Rush, Amariah Brigham, and many others. For example, in one of the first issues of what is now the American Journal of Psychiatry (October 1844), Amariah Brigham wrote,

Brigham, the first editor of the Journal, wrote extensively about the value of “moral treatment,” the forerunner of modern psychotherapies, for providing individualized and humanistic care for the mentally ill. We have progressed in the sophistication of our neuroscience and our psychotherapies, but our core conceptual structure was clearly foreshadowed in the early writings that led to the founding of psychiatry as a specialty.

Unfortunately, our fast-moving cyberworld threatens to separate us from our roots and to tempt us to forget our origins. Many of us are besieged by injunctions to interview and diagnose patients as quickly as possible, and sometimes even to eliminate our “old-fashioned” and “inefficient” narrative records that summarize present illness and past history, replacing them with checklists of diagnostic criteria and symptom ratings. Many of us are being pressured to see ourselves as psychopharmacologists who prescribe medications to treat “brain diseases,” at the expense of forgetting that the mind and person may need treatment with psychotherapy as well. Many of us feel overwhelmed by the pace at which the neuroscientific basis of psychiatry is growing, and threatened by the possibility that we cannot keep up or learn enough to practice well. The technicalities of dopamine receptors, lod scores, in situ hybridization, thalamic nuclei, and signal transduction seem both irrelevant to the individual person whom we treat and also beyond our purview or intellectual grasp.

Let’s face it. To meet the demands of current practice, we are being asked to do a lot, to learn a lot, and to do it faster…at the same time that economic and social forces are asking us to do less with our patients because we have to do it faster. We are confronting the risk that psychiatry may slowly lose its identity as the most humanistic of the medical specialties.

What is the solution?

As a group, we must continue to articulate the importance of a comprehensive and integrated view of psychiatric care for our patients—to stress that it must be individualized even if standardized in some ways, to emphasize that it must sometimes include both medications and psychosocial interventions, and to make it clear that integrated care is advocated for the benefit of individual patients and society as a whole. We must continue to educate decision makers and lawmakers about the complexity and the value of high-quality psychiatric care in the 21st century. And we must put our minds where our mouths are. If we wish to educate others, we must also educate ourselves. Each individual clinician must continue to grow and to learn in order to integrate the many positive aspects of our growing knowledge base. Psychiatry is changing and maturing, and most of the changes are for the good. We now know a lot more about what went wrong in Amariah Brigham’s watch! We understand how medications work, thanks to a strong base in neuroscience, and we are developing a similar basis of understanding for the various types of psychotherapy. The Journal is committed to helping with this endeavor by giving our readers a varied fare of educational materials that reflect the diversity of psychiatry, and its roots in both science and humanism, as evidenced by the contents of this May issue.

Sometimes we are so busy with each day’s activities that we don’t remember why those activities are occurring. We may not even remember why we are doing them in the first place—why we chose to become psychiatrists. May, the month of our annual meeting, should become a good time for all of us to pause and reflect on who we are, what we do, and what constructs and values we share with one another, despite our individual differences. Our unique contribution to medicine is our ability to evaluate the mental functions and dysfunctions of individual people who seek treatment for a variety of symptoms and complaints, in the context of their past history and their present interpersonal, social, economic, and family environment. We must retain this unique contribution. This is what each of our patients—whatever his or her problem—expects of us. Each of us, in whatever way we can, must fight against a variety of perverse ideas that denigrate or diminish this unique contribution: that a history can be obtained by a computerized checklist, or that recording a narrative history is a waste of time, or that the practice of psychiatry should be limited to prescribing medications, or any of the other injunctions that threaten to dehumanize or destroy the essence of psychiatric practice.

Writing this editorial is my own small effort in the battle we must all fight to preserve the humanistic essence of psychiatry. I urge others to make an effort as well, each within his or her individual context. Working collectively within this shared vision, we may make a difference.