Professionals in psychiatry need reflective competence
Authors: Damiaan Denys
Journal: World Psychiatry (2024)

The paper by Stein et al1 provides a comprehensive and timely overview of key theoretical advances in work on philosophy and psychiatry. The authors respond to the grand epistemological questions of psychiatry – the classification debate, the nature of psychiatry, and the mind-body problem – with soft naturalism, pluralism, and 4E cognition, respectively. Though I empathically comply with their considerations, I was surprised by the self-centered view of psychiatry. The authors see psychiatry as a scientific and clinical island in splendid isolation without relationship to society in which it is embedded. Here I address a perspective that takes in account: a) how psychiatry is shaped by forces of society; b) how the above-mentioned topics are influenced by philosophical assumptions held by the global community; and c) why the concept of conceptual competence, in agreement with Stein et al, is indispensable for professionals in psychiatry. Psychiatry is not a stand-alone discipline. It dialogues continuously with other sciences such as pharmacology, neuroscience and psychology. In fact, except for descriptive clinical phenomenology, which has been largely neglected lately, innovation often takes place outside psychiatry, through development of new drugs, new techniques in imaging and genetics, or psychotherapeutic restyling. Artificial intelligence predicts that in the near future substantial innovations in psychiatry may be expected in psychedelic-assisted therapy, neuromodulation (repetitive transcranial magnetic stimulation and deep brain stimulation), and digital personalized psychiatry. On closer inspection, we should even recognize that psychiatry, more than any other medical discipline, is being determined not by science but by society. All psychiatric symptoms are ultimately defined on the background of what is commonly agreed upon as normality. Normality is established not by science but by society. Normal is individual behavior that conforms to the most common behavior. Fluctuations in prevalence of mental disorder across culture and time are not caused by sophisticated adaptations of scientific criteria by experts, but pushed by societal waves. Autism and attention-deficit/hyperactivity disorder have become 100-fold more common due to changing perspectives on education and productivity. Long before misophonia became known in psychiatry and sporadically entered scientific articles, the disease term circulated globally on the Internet between interest groups. Often psychiatry is lagging behind social developments. Only in 1974 did homosexuality disappear as a disorder from the DSM-II, and only in 2019 did conditions related to sexual identity disappear as mental disorders from the ICD-11. We should accept that psychiatry no longer shapes itself. The course and faith of psychiatry is not determined by psychiatrists or philosophers, but by socio-economic variations fueled by influencers on social media. The current and ongoing identity crisis in psychiatry is due to the yet-to-be-embedded realization that psychiatry as a scientific discipline has lost control of itself, sadly popularized by the universal theme of mental well-being. Normality has profoundly changed. Whereas for a long time "mental health" was the norm, now "mental well-being" is paramount. Every self-respecting institution, from companies to universities, appoints "well-being officers". Mental health refers to the absence of mental illness. Mental well-being refers to the presence of favorable conditions, including experiencing positive emotions, maintaining relationships, and feeling meaningful in life. Mental well-being includes feeling good in your own skin, being resilient and able to enjoy life. In view of the "norm" of mental well-being, every person has become a potential patient. Mental disorders are reported to be highly prevalent. Around 1-in-7 people have one or more mental disorders. In 2020, rates of depression and anxiety have climbed globally by more than 25%. This increased rate of mental disorders is not due to changes of perspectives in psychiatry, but of social processes reflecting philosophical values. Once you are born in this world, you are expected to actualize yourself as an individual autonomous person, i.e. an absolute authentic and perfectly self-determining subject. We are all brought up with the assumption that individual freedom is the highest attainable thing in life. The Western ideal of human being is the autonomous person who thrives best in the greatest freedom, surrounded by the greatest convenience, and striving for absolute self-determination and maximum self-actualization. Each step towards greater individual autonomy takes us higher up the evolutionary ladder, further away from the animal instinct. The Western ideal of unlimited autonomy has been globalized in line with consumerism and technologism. Unfortunately, most people fail to comply with that ideal. First, the ideal is either unattainable or untenable. Second, the constant bombardment with social commands to self-maximize, to become ourselves, and to prove that we are worth it, makes people feel stressed, exhausted, traumatized, burn-out, lonely, useless and meaningless. Third, though people suffer because they cannot meet the high demands of a society that values the absolute ideal of individual autonomy, this society does not allow mental suffering. Failure is no option. Individual autonomy dictates that we need to be successful; that we are always in control and feel happy. Since mental suffering is unacceptable, mental distress is allowed only as a psychiatric disorder for which we carry no individual responsibility and are not to blame. Mental disorders are not spiking because more patients are developing psychiatric diseases, but because the ideal of individual autonomy has become the standard of normality across the globe. It is no coincidence that anxiety and depression are the most common mental disorders. They express our failure in attempting to fulfil the impossible demand of individual autonomy. We are more anxious not because our world has become more dangerous – on the contrary it has become safer – but because our desire for control is out of proportion. We are more depressed not because our lives are hopeless and meaningless – the opposite is actually true – but because we are confronted with too many choices, we are set up for unrealistically high expectations, and blame ourselves for any and all failures. I was delighted to read about "conceptual competence" in Stein et al's paper. I want to go one step further. The competence of a psychiatrist should include three different skills: professional competence, or the theoretical knowledge and training to practice your profession; experiential competence, or the clinical expertise through years of contact with patients or clients; and reflective competence, or the ability to reflect on your profession, the specific role you hold in it, and how they are affected by society. Reflective competence is the transformative awareness of how conceptual assumptions in society shape clinical care. The philosophical presuppositions of health and illness, mind and body, normal and abnormal are constantly changing in a globalized and digital world. Imperceptibly, they determine the validity of diagnosis and treatment. That is why thinking about our profession is part of the basic skills of every professional. Just as a jeweler not only designs jewelry but also calculates gold prices, a psychiatrist takes into account society's view of mental suffering in addition to what emerges from his/her contact with patients. Following the crisis in psychiatry, colleagues called for "a fundamental rethinking of the creation and training of psychiatric knowledge"2. A survey found that 65.2% of mental health professionals struggle with conceptual and philosophical questions related to their profession, and only 4.3% feel that training adequately prepared them to face this intellectual challenge3. Is it the task of psychiatry to reflect, beyond psychopathology of individuals, about philosophical values of modern societies? But, then again, do we have a choice?