The Nature of Proof in Psychiatry

This vivid clinical report illustrates recognizably, and provocatively, a number of routine, but often unexamined, clinical questions. In its few paragraphs, it depicts challenges that each practitioner confronts, and, in the flux of clinical work, addresses, however implicitly and imperfectly, every day: From what data, and by what processes, does a clinical formulation, or way of understanding, come into being? How do we appraise its accuracy and adequacy? Of what value is even a well-substantiated understanding, in the mind of the therapist, to the patient? What is the power of empathy as a treatment tool? How do we assess someone's status as a “good candidate for therapy?” When, typically, only the outlines of a problem are visible, and its origins and implications are largely hidden, by what right do we recommend psychotherapy, and with what conception, at what level of detail, of what its outcome will be? These are among the questions that Dr. Bailey's story challenges us to address.

They are clinical questions, of course, because they deal with empirical matters of fact—psychological processes, outcomes studies, and evidence. But they are also philosophical because, as Freud insisted and Dr. Bailey shows, information obtained in the clinical situation often has power and authority that lead us to believe we understand what is going on, understand the other person, even in the absence of scientifically tested hypotheses, or the clear application of research-based evidence. Interactions between people—including clinical interactions—have a life and ability to engage us. Their meanings can seem so transparent and convincing that no doubt or questioning may seem cogent. At their most powerful, such experiences can reawaken us to important realms of experience and feeling which we might, otherwise, forget, ignore, suppress, deny, or in other ways keep out of awareness; they have the potential to arouse us and reconnect us with truths that, once revived, can seem both valid and important—perhaps the kind of experience that we may derive from works of art or literature (in fact, Dr. Bailey's account could be seen as a clinical parable—meant to be neither true nor false, but instructive). But even less dramatic examples are commonplace: we do routinely claim to know and be able to interpret and understand the actions of other people from our everyday interactions with and observations of them.

What is less clear is how to account for these convictions and how to appraise their value, because they do not derive from established scientific procedures. Clinical intuition has a role throughout medicine, but we usually expect it to be subjected later to more rigorous tests to establish the correct diagnosis. Yet, as Dr. Bailey's case illustrates, clinical intuition in the psychiatric encounter seems somehow different. When Colin leads Dr. Bailey to the conclusion that a “painful lack of wounds” has made him depressed, we find this credible. It seems similarly credible that Dr. Bailey might be anxious about his own capacity to defend his young family, because he says he is, that he perceives Colin as testing his manhood or sincerity, because that seems to fit Colin's temperament, that being accurately understood is helpful, because most of us have had that experience and valued it, and that, most generally, an absence of challenge or of activity could be depressing. But suppose a patient believed that a painful lack of wounds produced diabetes instead of depression, or suppose he had developed epilepsy and attributed that to an absence of combat experience. We might see these as ‘pre-scientific’ or ‘hypothesis-generating’ (or worse). By contrast, it seems timid to consider psychiatric formulations to be always and only provisional or hypothetical.

In what ways and to what extent should we expect psychiatry to be different, and why? Several considerations suggest that psychiatry's reasons are not, always and everywhere, the same as those of general medicine, nor are its objectives.

In general medicine, we distinguish between signs and symptoms, on the one hand, and “underlying” disease processes, on the other. But in psychiatry, this distinction can be...