Abstract
Keywords
It is widely held that the humanities are as important as the sciences in psychiatry.[1] However, Turner argues that with the increasing influence of biological psychiatry, psychiatry as a discipline will be extricated from the humanities.[2] Turner states that biological psychiatrists, who might be viewed as the ‘scientists’ of psychiatry, aim to take the humanity out of the humanities, meaning the humanity out of psychiatry.[3] Harland et al. counter-argue that both the humanistic and biological aspects of psychiatry are fundamental and of equal importance to the discipline.[4] Is psychiatry located, then, in the humanities or in the sciences? In the present study, we posed the question, ‘Is psychiatry an art or a science?’ to a group of consultant psychiatrists and trainees. We consider their answers, what they mean by ‘art’ and ‘science’, and discuss the implications of these for the profession.
METHOD
With approval from the University of Adelaide Human Ethics Research Committee, trainee psychiatrists and their supervisors, working in one geographic area in South Australia, were contacted by the first author and asked to participate in an audiotaped, semistructured interview covering a number of different areas pertaining to the teaching and learning of psychiatry. One area that was explored, on which we report in the present paper, requested a response to the question, ‘Is psychiatry an art or a science?’ Eleven supervisors and nine trainees were asked to respond to the question, and all provided answers. No further supervisors or trainees were asked the question because saturation of data was achieved. Supervisors' experience ranged from 1year to over 20 years. Seven supervisors were male. Trainees, of whom five were male, were in their first through to the fifth year of the 5 year training programme.
The first author transcribed the interviews, and responses to the prompt question were isolated from the rest of the data and analysed using a modified framework approach.[5] This process involves immersion in the raw data, through listening to the interviews, transcribing them, and reading and re-reading the transcripts until familiarity with the data is achieved. Second, key issues and concepts within the interview data are identified, and the relationships between the themes established. The first author conducted the initial step of the analysis, and then the first and second authors engaged in the subsequent step, first independently then discussing resultant themes to come to a consensus.
RESULTS
Persistent themes emerged from analysis of the interviews. These themes were that art and science could be distinguished from each other, that psychiatry as a discipline was difficult to define, and that psychiatry demands a broader range of skills than other medical specialties. The position of the discipline of psychology in relation to psychiatry was a further theme that emerged. Generally speaking, the overall tone of responses from supervisors tended towards a greater cynicism regarding the ‘science’ of psychiatry, when compared with those of trainees. Several trainees considered whether psychiatry was art or science in view of their assessment process, which was an issue not considered by the assessors (the supervisors).
Differences between art and science
A number of participants stated that psychiatry is both art and science, but explained that the two aspects were different. They placed a variety of concepts under the rubric of art, and distinguished them from what they considered to be properly scientific. Art was ‘social science’, ‘clinical skills’, ‘rapport’, ‘dealing with patients’, ‘music’, ‘background knowledge’, ‘philosophy’, ‘conceptualization’, ‘humanities’, ‘literature’, ‘culture’, ‘psychotherapy’ and ‘ambiguity’.
One respondent stated:
I think it requires a certain amount ofabstract thought, more so than other disciplines of medicine, so in that sense it's an art. (Supervisor 8) Psychiatry is a failed science. To be a psychiatrist you need a humanist mind. It is a failed science because there is no theoretical foundation in psychiatry. There is no paradigm, no accepted universal theory. (Supervisor 5)
Discipline of psychiatry is difficult to define
Participants expressed the view that psychiatry as a discipline was difficult to define, or could only be vaguely defined. This difficultly was pointed out by appealing to the idea that psychiatry could only be explained through a contrast of one or more dyads; art/science, trade/ practice, and clinical model/personal skill. Illustrating this point, one respondent remarked:
Ithink psychiatry is one ofthose areas ofmedicine where Ithink, ifyou just explain it as science… Ithink you lose a lot of the nuances of psychiatry, particularly the more sort of psychodynamic aspects of psychiatry. And you know, it is one of those more greyer areas of medicine, where, you know, there's not necessarily a right or wrong answer. (Trainee 8)
Psychiatry demands a broader or different range of skills to other medical specialties
When participants compared their understandings of psychiatry with other medical specialties, they contrasted psychiatry by explaining how the range of skills required of the psychiatrist was broader. The following quote encapsulates this way of thinking:
I think there is a real art to being a psychiatrist… And the clinical skills, learning and developing clinical skills, developing the process of interviewing, that's an art. I'm sure it is. Because there are good psychiatrists, excellent psychiatrists who can develop rapport with patients so easily, and that's the art behind it, connecting with the person because then you're able to extrapolate all the information that you need, and the science bit is knowing what to ask. So Ido think it's both. But Iwouldn't want to lose either ofit, Icertainly wouldn't want to lose the art of it, because I think that's something which distinguishes us from some of our other colleagues. (Supervisor 6)
Position of psychology to psychiatry
Supervisors and trainees spoke about psychology as a discipline and expressed concern that it is not integrated with psychiatry in training or practice:
And there's not enough, you know, kind of social science in psychiatry. You know, psych-iatry is so absent of psychology at times, that it's quite, it's quite bizarre really, that you know, when I talk to registrars about normal emotions, they know nothing about it. They're not interested in sadness and anger and happiness and those kind of things, they say ‘what's that about, that's not psychiatry’. (Supervisor 3) There is a disturbing trend in psychiatry at the moment to hear ‘this is all about biology, you don't need to get into that psychological crap’. (Trainee 9)
Trainees' and supervisors' views
Trainees tended to answer confidently that psychiatry is a combination of both art and science, and discussed their reasons around this assertion. Some supervisors were more cynical about the science of psychiatry:
It's not a physical science, you know, there's a lot of pseudoscience, a lot of what looks on superficial inspection to be the most rigorous science within psychiatry, I'd call pseudoscience. (Supervisor 3)
Assessment process
Trainees considered that the question of the discipline of psychiatry as art or science could be related to their assessment processes. Thus, written examinations such as those with multiple choice and short answer questions assess ‘science’, but essays assess ‘art’. Observed cases were seen as assessing a combination of ‘art and science’. On becoming a psychiatrist, once successfully completing the assessments, those interested in ‘science’ work in research and academia, whereas those who become clinicians engage in ‘art’:
There are some psychiatrists in academia who get obsessed withjournals, with doing research and publishing, and they lose sight of the other stuff. They shouldn't be dismissive. One of the skills necessary in psychiatry is to be able to accept ambiguity. (Trainee 9)
DISCUSSION
Participants in the present study articulated a gulf between biological psychiatry and humanism, as well as the notion that psychiatry encompasses both the humanistic and biological aspects, and that both are important. Their answers are instructive insofar as they reveal implicit assumptions about psychiatry, medicine, science, humanities and art. These have implications for the practice and furthering of knowledge within psychiatry, and we discuss them in turn.
Turner and Harland et al. place psychiatry squarely in the humanities.2–4 The humanities are a group of specialized academic disciplines, such as history or philosophy, where psychiatry is clearly not placed, because it is located within the discipline of medicine.[6] So when psychiatrists say that they are in the ‘humanities’, what do they mean?
From the results of the present study, when psychiatrists say that their profession is a ‘humanity’, as opposed to a ‘science’, or when they say it is a combination of both, it would appear that they are actually talking about the ‘art’ of ‘clinical practice’ as opposed to the ‘science’ of ‘research’. They also make the distinction between the ‘art’ of psychotherapy versus the ‘science’ of biological treatments, but the primary differentiation is between clinical practice and research.
This tension between practice as art and research as science is echoed in the allied profession of clinical psychology, which variously places itself as a humanity and a science.[7] Psychology follows the ‘science-practitioner’ (S-P) model, which was adopted in the 1950s.[8] The S-P model values the simultaneous contributions ofboth science training and clinical practice training in professional education. Stricker summarizes the main philosophy of the model as follows:[8]
It does not favor [science training over practice training or vice versa] and recognizes that few psychologists will be expert in both, but hopes that, whichever area of endeavor the psychologist chooses, the influence of the other aspect of training will be evident. It would be inconsistent with the S-P model for a scientifically oriented psychologist to speak disdainfully of the practitioner or for the practice-oriented psychologist to disparage the contributions of science to practice. (p. 1277)
In the present study, participants saw psychiatry as different to other areas in medicine, in that they perceived the skills needed in psychiatry as being more broad and ‘artistic’. Interestingly, the humanities are now incorporated within numerous undergraduate and some postgraduate medical curricula across the world, and in 2003 AcademicMedicine devoted an edition of the journal to the Medical Humanities in medical education. Disciplines offered to students of medicine include history, philosophy, dance, drama, anthropology, psychology, sociology, religious studies, linguistics, art and literary studies. The core aim behind the inclusion of the humanities in medical schools is to encourage reflective learning and thus increase empathy for patients. Reflective learning goals include a consideration of the student's and the patient's values, culture, education, environment, beliefs, socioeconomic status, profession, and ‘inherent paradoxes’.[10] Additional aims include the development of critical thought and writing skills, personal development, a facilitation of interdisciplinary and multiprofessional approaches and a holistic approach to patient care. The point to be made here is that all of medicine is considered to be ‘humanistic’;[11] psychiatry is not seen to be especially more or less so than any other branch of medicine. However, the psychiatrists and trainee psychiatrists in the present study clearly do not see it this way. Possibly, there is a compensatory mechanism at work here; charges made bypeople within and outside psychiatry, that it lacks ‘science’ or is based on ‘pseudoscience’, can be countered with the claim that, importantly, psychiatry is an ‘art’.
The lack ofintegration with psychology is an interesting issue. Historically, psychiatry and clinical psychology have had a strained relationship, for various ideological, political and ‘turf’ reasons. Nevertheless, psychology has a great deal to offer psychiatry, and greater collaboration between the two professions would benefit both the ‘art’ and ‘science’ of each.
The greater cynicism of supervisors regarding psychiatry as science as compared with their trainees may be a function of experience, or may be the result of professional ‘burn-out’. From the results of the present study, the reasons for this can only be speculative. However, whatever the reasons, it is of concern, because this attitude may be relayed to trainees, and discourage them from engaging in research, if the message is that problems in psychiatry cannot be validly examined through empirical or other scholarly activity because it is too ‘grey’ an area.
Trainees' thoughts about the art and science of psychiatry translated to their views oftheir assessment methods. ‘Science’ is assessed through multiple choice and short answer questions, assessment methods for which there is a ‘right or wrong’ answer. Essays, which cannot be marked ‘right or wrong’, but are judged on the quality and expression of the argument, assess ‘art’. Clinical examinations, where the trainee is observed with a patient and then answers questions about why they have made certain decisions, assesses both ‘science’ and ‘art’. The perception that psychiatrists interested in ‘science’ work in academia and conduct research, whereas those who prefer ‘art’ become clinicians, further highlights the undesirable divide between the scientist and the practitioner that exists in psychiatry.
In conclusion, on the basis of the views of a group of consultant psychiatrists and their trainees, we argue that psychiatry is both the art of clinical practice and the science of research into illness and disease, and that the former is what psychiatrists are talking about when they consider their profession as a ‘humanity’. This division is counter-productive to the profession, and we suggest that lessons may be learned from the S-P model that dominatesclinical psychology, a discipline with which collaboration may be fruitful in furthering the art and science of psychiatry. Psychiatry is not necessarily any more or less of a humanity than other areas of medicine, which have the same application–science divisions, although psychiatrists themselves do consider their field as different to the other specialities. The perpetuation of the gap between clinical practice and scientific research may be continued with supervisors' cynicism regarding the state of psychiatric research and its validity as a science, and trainees' perceptions that assessments and career paths can be categorized as ‘art’ or ‘science’.
Footnotes
Acknowledgements
We thank Professor Philippa Hay for her thoughtful comments on a draft ofthis manuscript, and the South Australian Psychiatry Training Committee(SAPTC) for providing a digital tape recorder to the first author for this research.