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Dr Robert Harland and Dr Gareth Owen
specialist registrars at the Maudsley Hospital in London, clinical researchers at the Institute of Psychiatry, and members of the Maudsley Philosophy Group

One of the biggest challenges in psychiatry is attracting and retaining good nurses and doctors. One reason is an unfortunate malaise that is affecting the discipline and that possibly suggests a disconnection between the research academy, politics and national guidelines, as well as working clinicians and their patient’s psychiatric problems.

As a trainee in psychiatry, epidemiology points to environmental and hereditary factors as aetiologically important. But the effects sizes are small and can’t yet take us beyond population risk statistics to the individual. Despite huge technological advances in neuro-imaging, genetics, pharmacology and epidemiology, the results in psychiatry remain conflicted. The benefits of imaging or genotyping our patients are very moot and modern drugs in contrast to older compounds have advocates as well as detractors.

In psychology ever more data from psychological batteries and randomised controlled trials of short-term manualised therapies promise improved mental health. But these optimistic outcomes only partially transfer to the real world clinics and have unknown side effects when expanded to a large scale.

The best trainees are attracted to psychiatry not just because of new avenues of research in neuroscience, psychology, or even their own experience, or family experience, of mental illness. They are attracted because there is something wondrous about psychiatry. Historically psychiatry was a strong conceptual field, using psychopathology as a source of insights into what it is to be human – for answers to that classic question ‘what is man?’ Immanuel Kant, Karl Jaspers, Sigmund Freud and Michel Foucault all stand in this field. Remembering this seems particularly pertinent at a time when we have lost confidence in what our human nature is and what our shared values can be. This has become a global issue. It isn’t just psychiatry’s issue.

A huge challenge to psychiatry is to not only use concepts from other sciences, but to regain confidence in its own philosophical and phenomenological heritage. A conceptual reinvigoration of the subject is likely to put in perspective the shortcomings of laboratory science and clinical psychology and reconnect with the everyday experiences, problems and challenges of patients and their clinicians. Not only will this increase the chance that clinicians will want to spend a lifetime working in psychiatry, but they will also be better able to make relevant and humane contributions to the wider societal problems that psychopathology often reflects.

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