Psychiatry: a specialized profession or a medical specialty?

The paper by Heinz Katschnig is a thoughtful description of the challenges faced by psychiatrists worldwide, providing an interesting opportunity to reflect upon what the profession really means. The dilemma may be put through the following question: if psychiatry (and psychiatrists) are the solution, which is in fact the problem? The “eliminative procedure” should lead us to question what would happen if the psychiatric profession disappears. Would health of the populations deteriorate? Would people suffer more? Would anyone notice that we do not have psychiatrists anymore? All these are hard questions. They are hard to pose and hard to answer. A profession is an institutionalized response to a social demand. A demand is not simply a need or a wish. It is a need or a wish consciously perceived by people and for whose satisfaction they are willing to pay, i.e., to provide practitioners with honor (honoraria), money, prestige, power or love. It is important to stress that the perceived need or desire lies in the people and not in the providers of the services 1. One of the most unfortunate developments of postmodernist societies consists in the development of expertocracies, that is, groups of experts who believe that progress and advancement rely exclusively on their own needs and interests. Sometimes, this development leads to ignore the original demand which created the expertise. Experts are concerned with the improvement of their knowledge base, refer to their peers for approval and acceptance and contend to know the real needs of people without confronting changing realities. The typical paternalism of the medical profession, characterized by beneficence without autonomy, is a rough form of expertocratic thinking based on the idea that “doctors know best”. The fact that psychiatrists are criticized is a warning that the profession should review the fundaments of its alleged power and influence on human affairs. As many other knowledge-based professions, the cognitive side of this knowledge has been considered the basis of professional power for psychiatrists. However, in terms of specialized information, current psychiatry could be subsumed under neurology, psychology, social work, or policy making. Searching for power in the knowledge base is not appropriate, or it has not been appropriate considering the results. The fashionable “evidence-based” practice does not apply to many psychiatric practices in diagnosis, treatment, or prevention. The many aspects of a seemingly heterogeneous profession, ranging from Bohemian speculation to hardcore empirical research, do not find a reasonable harmonization within individual practice of psychiatrists. In order to honor all the heterogeneous discourses constituting the historical knowledge base, they should resemble “Renaissance men” and this is seldom the case, particularly in an era of state-controlled or market-driven practice 2. If anything, what needs to be done is to reformulate the actual demand for a profession comprising so many disparate discourses and so different practices. This reformulation can only be done on the basis of a dispassionate analysis of what people really demand and what current health care systems permit. However, the defense of the psychiatric profession nowadays cannot be based exclusively on the knowledge base, contested by other professions and limited by laws, regulations, and pressure groups within society. As a proposal, I strongly believe that what people may really appreciate, and thus may justify an expert role of the kind psychiatrists might be able to provide, is not so much “evidence-based” practice as “value-based” integration of discourses and knowledge 3. The psychiatrist could represent that kind of general harmonizer of information that uses it in a prudent form and can be a counselor, a therapist and a health promoter without colliding with physicians, psychologists, lawyers, or social workers. From competition to integration, going through the intermediate stage of cooperation, psychiatrists could be the systemic organizers of health care and research and not insist to remain one among many medical specialties which, by necessity, could render its claims irrelevant. Psychiatry should become a specialized profession, solving the problems of integrality of approach and human relevance that no other prudent expert could provide. This, of course, might mean reorienting teaching, training, and practice, but is based on a perception of real demand and a response to the challenges now being uncovered and discussed 4.