Divergent Fates Article

Excerpts from
Divergent Fates of the Medical Humanities in Psychiatry and Internal Medicine: Should Psychiatry be Rehumanized?
Bret R. Rutherford, M.D., David J. Hellerstein, M.D.
Academic Psychiatry 32:3, May-June 2008

Objective: To determine the degree to which the medical humanities have been integrated into the fields of internal medicine and psychiatry, the authors assessed the presence of medical humanities articles in selected psychiatry and internal medicine journals from 1950 to 2000.

Methods: The journals searched were the three highest-ranking psychiatry and internal medicine journals on the Institute for Scientific Information’s Impact Factor rankings that were published in English and aimed at a clinical audience. Operationalized criteria defining the medical humanities allowed the percentage of text in the selected journals constituting medical humanities to be quantified. Journals were hand searched at 10- year intervals from 1950 to 2000. Mixed effects models were used to describe the change in medical humanities over time.

Results: The percentage of text within psychiatry journals meeting the criteria for medical humanities declined from a peak of 17% in 1970 to a low of 2% in 2000, while the percentage of humanities articles in internal medicine journals roughly doubled from 5% to 11% over the same time period. A linear model increasing over time best fit the medical humanities in the internal medicine journals, while a cubic model decreasing over time best fit the psychiatry humanities data. Humanities articles in medical journals had a greater breadth and diversity than those in psychiatry journals.

Conclusion: Medical humanities publications dramatically decreased over time in psychiatry journals while they more than doubled in internal medicine journals. These data suggest the need for further empirical research and discussion of the potential roles of the humanities in psychiatry.

“In a larger sense, the biological study of mind is more than a scientific inquiry of great promise; it is also an important humanistic endeavor. The biology of mind bridges the sciences— concerned with the natural world—and the humanities— concerned with the meaning of human experience. Insights that come from this new synthesis will not only improve our understanding of psychiatric and neurological disorders, but will also lead to a deeper understanding of ourselves”(1)
–Eric Kandel, M.D.

Exciting progress has been made in psychiatric research over the last 20 years, including the development of new brain imaging techniques, clues into the genetic basis of mental illness, and acceptance of the randomized clinical trial as the means for establishing evidence of treatment efficacy. With these advances, neuroscience has rapidly supplanted psychoanalysis as the dominant force in American psychiatry and has changed the focus of scientific inquiry from mind to brain. This paradigm change is discernible in the papers presented at annual meetings of APA and the brain-image-dominated covers of journals such as The American Journal of Psychiatry.
In contrast, the field of internal medicine has followed a different course. More distant 18th and 19th-century technological advances moved medical practice away from the bedside to the laboratory and reading room (2). The growth of government-sponsored research after World War II resulted in a dramatic increase in medical specialization and mechanization (3). The rise of evidence-based medicine restricted what counted as informative data to population-based numbers, and doctors were perceived to lose their focus on the individual (4). By the 1980s, technological optimism was tempered by concern that doctors seemed unable to recognize the meaning of patients’  experience of illness (5). A schism formed between the biomedical sciences and the humanities disciplines such as philosophy, anthropology, and literature, which fed perceptions of a harmful medical reductionism (6). Patients alienated by this reductionistic model of scientific medicine often opted for nonevidence based treatments which could actually be harmful (7).
In response to this growing crisis, some internal medicine physicians turned to the humanities in an attempt to refocus attention on patients’ experience of illness and doctors’ experience of caring for them (8). A new discipline, the medical humanities, emerged to bring perspectives of disciplines such as philosophy, art, literature, film, and anthropology to bear on understanding health, illness,
and medicine (9). Importantly, the goal of this movement was not to restore a pretechnological harmony between doctor and patient, but rather to add a humanistic view to a scientifically competent medicine, thereby giving the objective facts of health and illness meaning for individual patients (10).
Many benefits have been adduced by proponents of the medical humanities (11). For example, exposure to the medical humanities may facilitate engagement with patients, giving physicians the skills to empathize with patients facing the tragedy of illness and patients the courage to be open with their doctors (12, 13, 14). Medical humanities have been increasingly important in physician education as a way of enhancing attunement to individual patients’ concerns, the meanings of illness and health, ethical care, and cultural issues (15, 16). Studying art and literature may also rebuild medical idealism and offer a window into suffering and injustice (17). Medical humanities are now a significant part of the curriculum in many medical schools (18, 19) and even form the basis for graduate programs (20).
The aim of this study was to investigate the prevalence of medical humanities articles over time in selected psychiatric and internal medicine journals. The primary hypothesis was that the percentage of overall journal text devoted to the medical humanities would increase in medicine and decrease in psychiatry for the time period studied. In addition, the breadth and diversity of the medical humanities was expected to be greater in the medical journals compared to the psychiatric journals.

On a measure of their humanities content, three leading psychiatry journals declined from a high of nearly 17% in 1960 and 1970 to a low of 2% in 2000. An apparent increase in humanities publications within psychiatry journals from 1950 to 1960 may be an artifact introduced by the Archives of Psychiatry and Neurology, which in 1959 divided into two journals, the Archives of General  Psychiatry and the Archives of Neurology. Humanities publications in Archives of Psychiatry and Neurology were negligible in 1950, decreasing the summed percentage for that time point. Removing Archives of Psychiatry and Neurology for 1950 results in a new figure of 14.8%, which is similar to the results found in 1960 and 1970.

Decline of the Humanities in Psychiatry
It is notable that the humanities in psychiatry have declined so rapidly given their historical importance in the field. Ethics, literature, history, and other humanities disciplines have been intimately entwined with psychiatry from its inception (22). The first psychiatric phenomenology involved close studies of individuals and their courses of illness, described in vivid literary narratives (23). Psychodynamic psychiatry, and, above all, psychoanalysis, have engaged in productive dialogue with literature, anthropology, and sociology to investigate unconscious processes, social systems, sexuality, gender definitions, and innumerable other issues (24). In addition, psychiatrists have traditionally come from humanities-related undergraduate backgrounds, are more interpersonally oriented, and more verbally skilled compared to residents choosing to train in specialties such as surgery or internal medicine (25, 26). The observed decline in medical humanities occurred after 1970, a period during which biological psychiatry supplanted psychoanalysis as the dominant force in American psychiatry. The humanities disciplines share aspects of psychoanalytic approaches, in that both rely heavily upon narrative and anecdote, usually lack control or comparison groups, and are generally not amenable to statistical or quantitative analyses. While many would justifiably object that psychoanalysis is not necessarily humanistic, the two fields may have been conflated, and both were discarded as the field of psychiatry emphasized replicable, quantifiable observations. The predominantly psychoanalytic focus of humanities texts that remain in psychiatric journals (such as “Introspections” in The American Journal of Psychiatry) lends support to this hypothesis (27).

Should Psychiatry be “Rehumanized”?
No: Against Rehumanization. Given the foregoing, the question arises of whether the medical humanities may still have a role in psychiatry—whether psychiatry should be “rehumanized.” Many reasonable psychiatrists would say no. Generations of psychoanalysts have explored the humanities, and perhaps no further benefit can be obtained. Besides, psychiatrists practice differently from busy internists or surgeons, who may need reminding to listen to their patients. Psychiatry is already humanistic by its very nature, with its focus on the patient’s subjective experience and on patient-clinician interactions. The humanities only offer vague illustrations of clinical concepts about which modern psychiatrists have become very sophisticated, such as projection or transference.
Others might go further. While agreeing that psychiatry does not need to be rehumanized, they might also argue that psychiatry is much better off without the humanities. Given their dubious history, the humanities may be actively harmful to psychiatry by purporting to offer competing, nonscientific explanations of pathology or treatment recommendations. A focus on humanities might also divert attention and resources from proper psychiatric education, treatment, and research.
These positions are understandable given the history of psychiatry, and the purpose of this discussion is not to refute them. Currently, they cannot be refuted, because of an absence of data quantifying the value of medical humanities to psychiatry. What is striking, however, is that the field of psychiatry has proceeded as if one of the above hypotheses were correct, while alternative hypotheses are equally valid at present.

Yes: For Rehumanization. Others have argued that it is “self-evident that whatever benefits the medical humanities may have for the rest of medicine, they are equally relevant for psychiatry” (28). While the standardization of psychiatric nosological nomenclature has been tremendously valuable from a research perspective, commentators both within and outside psychiatry have criticized psychiatrists for reducing patients’ stories to DSM categories or checklists. Humanities readings and writing could enhance clinicians’ ability to describe phenomenology in a more complex and diverse way, just as they have assisted internal medicine physicians in appreciating the human stories underlying diagnoses and chief complaints. Psychiatric humanities could potentially enhance psychiatric care, as there is growing evidence that some psychiatric patients do not feel listened to by their doctors. A recent survey of outpatient clients revealed significant dissatisfaction with the 5 minute psychopharmacologic check-in visit (29).
Many internal medicine physicians have found engagement with the humanities increases physicians’ capacity for self-awareness and self-reflection. Given the strong emotional responses patients with some psychiatric disorders generate in the clinician, the humanities may prove similarly valuable to psychiatrists in metabolizing intense countertransference feelings and using them to better understand the patient. Additionally, by leading to more gratifying patient-doctor interactions, studying the humanities may improve psychiatrists’ work satisfaction, just as it has been reported to do in internal medicine.
There also may be unique potential benefits for psychiatry in reengaging with the medical humanities. Today’s psychiatrists have the opportunity to synergistically integrate diverse disciplines. For instance, discoveries such as mirror neurons provide a brain basis of empathy and intersubjective experiences. Individuality of personality and behavioral patterns are no longer seen solely as “mental” phenomena but may be related to epigenetic DNA changes or alterations in brain connectivity or anatomy resulting from individual experiences. The humanities may provide an integrative, cross-disciplinary perspective as well as a common language for understanding and exploring phenomena that range from intrapsychic to organ-level to cellular to molecular.
Additionally, the stigma of mental illness remains significant, and nonclinicians often find mental illness frightening and difficult to understand. Writing about the experience of having or treating mental illness may increase public understanding of entities like depression and ECT (30, 31).

It should be noted that proponents of integrating the humanities and biological psychiatry do not advocate a return to the 1960s psychiatry, when the humanities were sometimes held out as a competing explanation or scientific paradigm. Rather than being confronted by the ageold debate between scientific biological psychiatry and nonscientific (or antiscientific) humanistic traditions, today’s neuroscience informed psychiatrists are offered opportunities for integrating different perspectives (33). In this setting the humanities may produce a different type of evidence, one that can illuminate (and be illuminated by) scientific approaches.

Conclusion and Future Directions
This is the first study to our knowledge that quantifies the decrease over time of humanities material in psychiatry journals. While many psychiatrists would likely find these results consistent with their anecdotal impressions, this subject has not been studied to date. It bears emphasizing that this article does not provide data on whether or not the decline of medical humanities in psychiatric journals is good or bad for the field as a whole. In fact, we are critical of strong positions held for or against the humanities’ utility to psychiatry formed in the absence of such data. Our point is to highlight the divergent trends in the fields of psychiatry and internal medicine and call for further discussion and empirical study. Among the most helpful future studies would be determination of whether exposure to the medical humanities in fact improves psychiatric education, patient outcomes, and the physicians’ experience.