Psychiatry—Art, Science, Both or Neither?
Before I had any real experience in psychiatry, I saw it as more of an art than a science. It stood out in comparison to other medical specialties as a practice driven primarily by intuition, empathy, abstraction—and chain-smoking—rather than concrete facts or empirical observation. I imagined assessing the human mind to be more like analyzing the themes within a piece of art: something as fascinating as it is utterly subjective. However, as I have read more about psychiatry, and gained more clinical experience, my view has changed. No other specialty demands the same amount of cognitive flexibility from its practitioners, who must juggle the subjective experience and psychosocial realities of their patients, and the establishment and maintenance of therapeutic relationships, with an understanding that the behaviour, emotion, and internal experiences (of their patients, as well as themselves) arise from, and are constantly influenced by, the structural and neurochemical dynamics of the brain.
As a field, psychiatry has gone through many phases over the last century, with standards for practice ranging from the opinion of the local exorcist, to the philosophical writings of tweed-jacketed, snuff-snorting homophobes, to all those irreplicable LSD-fueled cognitive-behavioural experiments in the 1970s, which are far more fun to consider than the profound tragedy incurred by the widespread use of unsubstantiated treatments—such as frontal lobotomy.
With the advent of neuroleptics, the field has steadily moved in the direction of psychopharmacology, though with a more modern push to acknowledge the “bigger picture” rather than relying solely on pharmaceuticals—e.g., the biopsychosocial model. Over time, the emphasis of clinical psychiatry has shifted towards standardized guidelines, based on the highest quality evidence available. Diagnostic criteria and treatment methods have been refined through observation, data collection, statistical analysis, and replication of findings. Advances in molecular pharmacology and functional neuroscience have given us more insight into the biological underpinnings of conditions like schizophrenia, bipolar disorder, depression, and OCD, guiding treatments that are safer and more targeted than ever before. In this sense, modern psychiatry is as scientific as any other branch of medicine. And yet… it still stands out. Why?
According to neuroscience, cognitive-behavioural and psychological phenomena represent the output of an electrical organ—just as the heart generates mechanical force. However, the brain is less like a pump than a highly complicated orchestra, made up of innumerable groups of neurons, all frantically processing tiny electrochemical inputs and outputs to the rhythm of thermodynamics. Every person you encounter in this life represents the sum total of innumerable local field potentials, and phenomena such as feeling, memory, and movement are the multi-overtonic harmonies of hundreds of synchronized choirs. It is here that the “art” of psychiatry is found: in the maintenance of an unlearnable, biological instrument, that—thankfully—plays itself.
With the right equipment, we can visualize brain activity in real time, as tracings of electrical current on a graph that change predictably—in rate, rhythm, and amplitude—in response to different drugs. It sounds a bit Brave New World, but given what we know, wouldn’t it make sense to just get it over with, and collectively spend a few billion dollars to have psychiatry condensed into a set of pharmacological algorithms, so that we can have ChatGPT automatically calculate the perfect drug cocktail for any individual, finally ending the issue of suboptimal neuronal collusion?
Even if something like that were feasible, one simply needs to spend ten minutes reading about the history of psychiatry (or step foot on a psychiatric ward) to understand why this wouldn’t go well. For one, every time we think we have the brain sussed, another hundred graduate students earn PhDs by pointing out that we do not, in fact, have it sussed—cue another decade of rigorous debate, as waves of key publications rise and fall (amid allegations of p-hacking). As for my second point—which I probably should have led with—’brain activity-based algorithmic psychopharmacology’ misses the whole point of psychiatry.
Psychiatry (and arguably, medicine in general) does not simply deal with the physical processes of the brain or body, but also what arises from those processes. More specifically, ‘who’ arises—see Osler et al. While we are all entitled to our personal spiritual beliefs, modern psychiatrists (and indeed neurologists and neurosurgeons) must be prepared to acknowledge the existence of the ‘neurological soul’—a phrase enjoyed by the late neurologist Oliver Sacks, which refers to the idea that an individual’s subjective experience, or ‘personhood’, and the expression thereof, is permitted in whole by the structure and physiology of their nervous system, irrespective of how or where exactly the basis for this ‘soul’ arises.
Accepting this idea means that any attempts to change, or modulate, the structure or function of the brain must be done in a manner that is supremely respectful of the patient’s values, priorities, and self-concept, in addition to their close relationships, cultural context, and quality of life. In this sense, psychiatrists must be more like sound technicians, stage managers, or audio engineers than, for instance, conductors.
Maybe the setlist isn’t your cup of tea. Maybe you find the overuse of leitmotif a little grating. But even if you bought the tickets, you don’t get any say over the music. The role of a psychiatrist is to ensure that the instruments are all in tune, the right microphones are ‘hot’, and that the levels are mixed in such a way that the drums don’t drown out the cello. Perhaps I’m getting a bit lost in the allegory here, but my point is that the beauty of psychiatry lies in the mixing, mastering, and equalization of neurochemistry, so that the music is not lost to the idiosyncrasy of its synthesis—the inherently underappreciated craft of pulling signal out of noise. And then, if all goes well, that music will be stable enough to consider seeing a psychologist.
In conclusion, art and science are blended indistinguishably within the field of psychiatry, and this dual nature makes it a uniquely challenging specialty. Just as cells can’t be perceived without a microscope, thoughts and feelings can only be studied through the lenses of behaviour, language, or self-expression. It is the job of the psychiatrist to master the use of these lenses—an art which demands empathy, intuition, and the ability to genuinely connect with others, in addition to however many years of study are required before you can remember (and pronounce) the names of all those damned antidepressants.
