Psychiatry and its discontents: Foxes,hedgehogs and non-experts

‘The fox knows many things, but the hedgehog knows one big thing’.

Archilochus, quoted by Isaiah Berlin in ‘The Hedgehog and the Fox’.

More than any branch of medicine, psychiatry is subject to relentless and often ill-informed criticism. There can be few psychiatrists who have not had to endure a critical diatribe from a person with limited expertise on psychiatry. Such criticism occurs in the context what has been described as ‘The Death of Expertise’: a collapse of the acceptance of the distinction between those with knowledge and skills in a domain and those without knowledge or skill (Nichols, 2017). The loss of acknowledgement of the role of expertise in public discourse is deeply troubling: it has a flattening effect such that people simply assert that they are an expert whether qualified or not (Nichols, 2017). Psychiatry has been particularly subject to such criticism by those lacking in expertise, but we assert that psychiatrists can, and should, engage in public discourse.

Psychiatric expertise is broad and deep, having been founded on general medical education and physician training, as well as specialised training in assessment, diagnosis, medical, pharmacological and psychological therapy (Bhugra et al., 2015). This expertise encompasses the following features: providing evidence-based care for patients; managing complexity and severity of illness; assessing and managing risk; teaching and training; research and innovation; advocacy; clinical leadership and engaging on provision of public mental health (Bhugra et al., 2015). Based on these comprehensive skills and knowledge, we adapt Tetlock’s (2006) metaphorical characterization from political expertise research of the psychiatrist-expert as a fox, as one that knows many things, as opposed to narrower disciplinary experts, typified as hedgehog, such as psychology, pharmacy or cognate fields. Fox-like thinkers display the ability to think with integrative complexity, more openness to dissonant counterfactuals, leading to better belief updating and better forecasting (Tetlock, 2006). For the analogously difficult field of political forecasting, fox-like experts generally outperformed hedgehog-like experts (Tetlock, 2006), and we expect that psychiatrists should perform similarly in comparison to non-experts in psychiatry. As thus conceptualised, we suggest that the fox-like broad spectrum expertise of psychiatrists can and should outperform the narrow band expertise of hedgehog-like experts and non-experts.

The discontent of challengers to psychiatric expertise

The psychiatric profession faces challenges to expertise from patient discontent, professional rivalry, a negative public image (Katschnig, 2010), consumerism, egalitarianism and political currents (De Waal et al., 2009). We sketch out the landscape of the challengers, often narrow expertise hedgehog-like thinkers or those lacking expertise, before offering advice on engagement in discourse.

As Orwell demonstrated in his book ‘1984’, language can define possible discourse. It has been observed that changes in modern psychiatric nomenclature signify the shifts in the public and institutional views of psychiatrists from ‘doctors’ to ‘professionals’; ‘patients’ to ‘clients’ and ‘psychiatrist’ to ‘mental health specialist’ (Bhugra et al., 2015). Also our professional language of diagnosis, investigation and treatment has been observed to be misappropriated by non-expert media and other commentators, especially in the context of anti-elitist and anti-scientific cultural trends against our assertion of expertise (De Waal et al., 2009).

Patients may seek a less paternalistic relationship with a psychiatrist who offers ‘choice’ and facilitation, following a consumerist ethic eschewing expertise and in the context of egalitarianism (De Waal et al., 2009). However, ‘ …the patient is definitely the expert on how illness affects their life, but it is the psychiatrist that is the expert on the illness itself’ (De Waal et al., 2009: 665). Self-help and consumer non-governmental organisations, as well as politicians, lacking expertise, may also establish parallel care services devoid of psychiatric expertise.

General practitioners (GPs), doctors who practice alternative medicine, and neurologists may again claim varying degrees of hedgehog-like mental health expertise (Katschnig, 2010). In a misconstrued understanding of the role of pharmacotherapy and the need for medical expertise, psychologists and pharmacists have lobbied in Australia for prescribing rights, including for psychiatric medications. Psychologists and pharmacists may thus potentially challenge to role substitute as experts for psychological therapy and/or pharmacotherapy. However, based on the broad fox-like expertise of psychiatrists in medicine, psychological therapy, social sciences and collaborative health care (Bhugra et al., 2015), we assert that psychiatric expertise is deeper and broader than that of these other hedgehog-like professional groups.

Psychiatry often does not have the respect and social prestige accorded to other medical specialities, especially in the context of the damagingly negative image of psychiatry and psychiatrists (Katschnig, 2010). This negative image may arise from the lack of expertise of hedgehog-like or non-experts in the medical profession, media, the arts and society.

Challenging psychiatry’s discontents

The psychiatric profession serves persons with mental illness by providing expert medical care. Accordingly, psychiatrists can, and should, assert their expertise in contributing to public discourse in relation to mental health (De Waal et al., 2009). Psychiatric expertise should not be ceded to unqualified criticism of non-experts, or narrowly qualified hedgehog-experts, no matter how aggressively asserted. Based on their broad fox-like interdisciplinary expertise, psychiatrists should identify the weaknesses in knowledge, skill and argument that non-expert critics demonstrate, especially since such critics are unable to recognise their lack of expertise (Nichols, 2017). Indeed, as Nichols observed, non-experts may respond to challenges of their views with vehemence, and thus discourage debate. However, psychiatrists should still engage in public discourse regarding matters of psychiatric expertise such as, but not limited to, aetiology, pathogenesis and diagnosis of mental illness, new research findings, as well as its treatment.

In addition to the fox-like expertise of broad psychiatric training and skills, development of specific skills in engaging in public discourse will necessarily require practice and feedback. The development of such skills can be considered complementary to those that we engage in understanding, engaging and collaborating in care of our patients. Practical steps for psychiatrists to develop skills to engage in discourse include:

• Developing skills in public speaking (e.g. www.rostrum.com.au);

• Developing skills in preparing arguments (e.g. www.coursera.org/learn/understanding-arguments);

• Undertaking media training to improve skills in presentation of psychiatric views (although evolving social media requires circumspection);

• Volunteering to participate to provide policy advice to governments and non-governmental bodies on psychiatric matters via the RANZCP or AMA;

• Volunteering for media appearances via the RANZCP or AMA;

• Writing educational articles for the public and profession on topics of psychiatric expertise (e.g. debate, opinion or clinical updates for the ANZJP, Australasian Psychiatry and news media).

While engaging in public discourse, psychiatrists must ultimately be open to responding to well-informed and reasoned argument. As Lord Keynes observed: ‘When the facts change, I change my mind. What do you do, sir?’ Psychiatrists, necessarily enduring the barbs of hedgehogs and the amateur observations of non-experts, can and should engage in the rough and tumble of public discourse, precisely because they know that of which they speak. In this way, psychiatry can address its discontents, dispelling misinformed illusions with expert, reasoned arguments.

‘One thing only do I know for certain and that is that man’s judgments of value follow directly his wishes for happiness-that, accordingly, they are an attempt to support his illusions with arguments’. (p. 111)

– Sigmund Freud, Civilization and Its Discontents.