Holism

From Wikipedia, the free encyclopedia

Holism (from Greek ὅλος holos "all, whole, entire") is the idea that systems (physical, biological, chemical, social, economic, mental, linguistic) and their properties should be viewed as wholes, not just as a collection of parts.^[1][2]

The term holism was coined by J. C. Smuts in Holism and Evolution.^[3][4] It was Smuts' opinion that holism is a concept that represents all of the wholes in the universe, and these wholes are the real factors in the universe. Further, that Holism also denoted a theory of the universe in the same vein as Materialism and Spiritualism.^{[3]:120–121}

Synopsis of Holism and Evolution

After identifying the need for reform in the fundamental concepts of matter, life and mind (chapter 1) Smuts examines the reformed concepts (as of 1926) of space and time (chapter 2), matter (chapter 3) and biology (chapter 4) and concludes that the close approach to each other of the concepts of matter, life and mind, and the partial overflow of each other's domain, implies that there is a fundamental principle (Holism) of which they are the progressive outcome.^[3]:86 Chapters 5 and 6 provide the general concept, functions and categories of Holism; chapters 7 and 8 address Holism with respect to Mechanism and Darwinism, chapters 9-11 make a start towards demonstrating the concepts and functions of Holism for the metaphysical categories (mind, personality, ideals) and the book concludes with a chapter that argues for the universal ubiquity of Holism and its place as a monistic ontology.

The following is an overview of Smuts' opinions regarding the general concept, functions, and categories of Holism; like the definition of Holism, other than the idea that the whole is greater than the sum of its parts, the editor is unaware of any authoritative secondary sources corroborating Smuts' opinions.

Structure

Wholes are composites which have an internal structure, function or character which clearly differentiates them from mechanical additions, aggregates, and constructions, such as science assumes on the mechanical hypothesis.^[3]:106 The concept of structure is not confined to the physical domain (e.g. chemical, biological and artifacts); it also applies to the metaphysical domain (e.g. mental structures, properties, attributes, values, ideals, etc.)^[3]:161

Field

The field of a whole is not something different and additional to it, it is the continuation of the whole beyond its sensible contours of experience.^[3]:113 The field characterizes a whole as a unified and synthesised event in the system of Relativity, that includes not only its present but also its past—and also its future potentialities.^[3]:89 As such, the concept of field entails both activity and structure.^[3]:115

Variation

Darwin's theory of organic descent placed primary emphasis on the role of natural selection but there would be nothing to select if not for variation. Variations that are the result of mutations in the biological sense and variations that are the result of individually acquired modifications in the personal sense are attributed by Smuts to Holism; further it was his opinion that because variations appear in complexes and not singly, evolution is more than the outcome of individual selections, it is holistic.^{[3]:190–192}

Regulation

The whole exhibits a discernible regulatory function as it relates to cooperation and coordination of the structure and activity of parts, and to the selection and deselection of variations. The result is a balanced correlation of organs and functions. The activities of the parts are directed to central ends; co-operation and unified action instead of the separate mechanical activities of the parts.^[3]:125

Creativity

It is the intermingling of fields which is creative or causal in nature. This is seen in matter, where if not for its dynamic structural creative character matter could not have been the mother of the universe. This function, or factor of creativity is even more marked in biology where the protoplasm of the cell is vitally active in an ongoing process of creative change where parts are continually being destroyed and replaced by new protoplasm. With minds the regulatory function of Holism acquires consciousness and freedom, demonstrating a creative power of the most far-reaching character. Holism is not only creative but self-creative, and its final structures are far more holistic than its initial structures.^{[3]:18, 37, 67–68, 88–89}

Causality

As it relates to causality Smuts makes reference to A. N. Whitehead, and indirectly Baruch Spinoza; the Whitehead premise is that organic mechanism is a fundamental process which realizes and actualizes individual syntheses or unities. Holism (the factor) exemplifies this same idea while emphasizing the holistic character of the process. The whole completely transforms the concept of Causality; results are not directly a function of causes. The whole absorbs and integrates the cause into its own activity; results appear as the consequence of the activity of the whole.^{[3]:121–124,126} Note that this material relating to Whitehead's influence as it relates to causality was added in the second edition and, of course, will not be found in reprints of the first edition; nor is it included in the most recent Holst edition. It is the second edition of Holism and Evolution (1927) that provides the most recent and definitive treatment by Smuts.

The whole is greater than the sum of its parts

The fundamental holistic characters as a unity of parts which is so close and intense as to be more than the sum of its parts; which not only gives a particular conformation or structure to the parts, but so relates and determines them in their synthesis that their functions are altered; the synthesis affects and determines the parts, so that they function towards the whole; and the whole and the parts, therefore reciprocally influence and determine each other, and appear more or less to merge their individual characters: the whole is in the parts and the parts are in the whole, and this synthesis of whole and parts is reflected in the holistic character of the functions of the parts as well as of the whole.^[3]:88

Progressive grading of wholes

A "rough and provisional" summary of the progressive grading of wholes that comprise holism is as follows:^[3]:109

1. Material structure e.g. a chemical compound
2. Functional structure in living bodies
3. Animals, which exhibit a degree of central control that is-primarily implicit and unconscious
4. Personality, characterized as conscious central control
5. States and similar group organizations characterized by central control that involves many people.
6. Holistic Ideals, or absolute Values, distinct from human personality that are creative factors in the creation of a spiritual world, for example Truth, Beauty and Goodness.

Indications of holism in philosophy

In philosophy, any doctrine that emphasizes the priority of a whole over its parts is holism. Some suggest that such a definition owes its origins to a non-holistic view of language and places it in the reductivist camp. Alternately, a 'holistic' definition of holism denies the necessity of a division between the function of separate parts and the workings of the 'whole'. Effectively this means that the concept of a part has no absolute foundation in observation, but is rather a result of a materialist structuring of reality based on the necessity of logical and distinct units as a means to deriving information through comparative analysis. It suggests that the key recognizable characteristic of a concept of 'true' holism is a sense of the fundamental truth of any particular experience. This exists in contradistinction to what is perceived as the reductivist reliance on inductive method as the key to verification of its concept of how the parts function within the whole. Equally the potential for recognising the clarity of holistic experience within the logical terms of maths is limited by the abstract nature of numbers. In terms of real life measurements numbers have no scale or dimensional properties so have to rely on experimentally verified units (e.g. inches, volts, calories etc.), to describe reality. It is this reliance on the holistic integrity of experience which leads to the recognition that intuitive perception rather than mathematical calculation is the source of the truth of effective theories. (See references Holism, 2016.)

Philosophy of language

In the philosophy of language this becomes the claim, called semantic holism, that the meaning of an individual word or sentence can only be understood in terms of its relations to a larger body of language, even a whole theory or a whole language. In the philosophy of mind, a mental state may be identified only in terms of its relations with others. This is often referred to as "content holism" or "holism of the mental". This notion involves the philosophies of such figures as Frege, Wittgenstein, and Quine.^[5]

Epistemological and confirmation holism

Epistemological and confirmation holism are mainstream ideas in contemporary philosophy.

Ontological holism

Ontological holism was espoused by David Bohm in his theory^[6] on the implicate and explicate order.

Spinoza

The concept of holism played a pivotal role in Baruch Spinoza's philosophy.^[7][8]

Hegel

Hegel rejected "the fundamentally atomistic conception of the object," (Stern, 38) arguing that "individual objects exist as manifestations of indivisible substance-universals, which cannot be reduced to a set of properties or attributes; he therefore holds that the object should be treated as an ontologically primary whole." (Stern, 40) In direct opposition to Kant, therefore, "Hegel insists that the unity we find in our experience of the world is not constructed by us out of a plurality of intuitions." (Stern, 40) In "his ontological scheme a concrete individual is not reducible to a plurality of sensible properties, but rather exemplifies a substance universal." (Stern, 41) His point is that it is "a mistake to treat an organic substance like blood as nothing more than a compound of unchanging chemical elements, that can be separated and united without being fundamentally altered." (Stern, 103) In Hegel's view, a substance like blood is thus "more of an organic unity and cannot be understood as just an external composition of the sort of distinct substances that were discussed at the level of chemistry." (Stern, 103) Thus in Hegel's view, blood is blood and cannot be successfully reduced to what we consider are its component parts; we must view it as a whole substance entire unto itself. This is most certainly a fundamentally holistic view.^[9]

Indications of holism in physical science

Agriculture

There are several newer methods in agricultural science such as permaculture and holistic planned grazing (holistic management) that integrate ecology and social sciences with food production. Organic farming is sometimes considered a holistic approach.

Chaos and complexity

In the latter half of the 20th century, holism led to systems thinking and its derivatives. Systems in biology, psychology, or sociology are frequently so complex that their behavior is, or appears, "new" or "emergent": it cannot be deduced from the properties of the elements alone.^[10]

Holism has thus been used as a catchword. This contributed to the resistance encountered by the scientific interpretation of holism, which insists that there are ontological reasons that prevent reductive models in principle from providing efficient algorithms for prediction of system behavior in certain classes of systems.^{[citation needed]}

Scientific holism holds that the behavior of a system cannot be perfectly predicted, no matter how much data is available. Natural systems can produce surprisingly unexpected behavior, and it is suspected that behavior of such systems might be computationally irreducible, which means it would not be possible to even approximate the system state without a full simulation of all the events occurring in the system. Key properties of the higher level behavior of certain classes of systems may be mediated by rare "surprises" in the behavior of their elements due to the principle of interconnectivity, thus evading predictions except by brute force simulation.

Complexity theory (also called "science of complexity") is a contemporary heir of systems thinking. It comprises both computational and holistic, relational approaches towards understanding complex adaptive systems and, especially in the latter, its methods can be seen as the polar opposite to reductive methods. General theories of complexity have been proposed, and numerous complexity institutes and departments have sprung up around the world. The Santa Fe Institute is arguably the most famous of them.

Ecology

The Earth seen from Apollo 17.

Holistic thinking is often applied to ecology, combining biological, chemical, physical, economic, ethical, and political insights. The complexity grows with the area, so that it is necessary to reduce the characteristic of the view in other ways, for example to a specific time of duration.

John Muir, Scots born early American conservationist,^[11] wrote "When we try to pick out anything by itself we find it hitched to everything else in the Universe".

More information is to be found in the field of systems ecology, a cross-disciplinary field influenced by general systems theory.

Medicine

In primary care the term "holistic," has been used to describe approaches that take into account social considerations and other intuitive judgements.^[12] The term holism, and so-called approaches, appear in psychosomatic medicine in the 1970s, when they were considered one possible way to conceptualize psychosomatic phenomena. Instead of charting one-way causal links from psyche to soma, or vice versa, it aimed at a systemic model, where multiple biological, psychological and social factors were seen as interlinked.^[13]

Other, alternative approaches in the 1970s were psychosomatic and somatopsychic approaches, which concentrated on causal links only from psyche to soma, or from soma to psyche, respectively.^[13] At present it is commonplace in psychosomatic medicine to state that psyche and soma cannot really be separated for practical or theoretical purposes.^{[citation needed]} A disturbance on any level—somatic, psychic, or social—will radiate to all the other levels, too. In this sense, psychosomatic thinking is similar to the biopsychosocial model of medicine.^{[citation needed]}

Many alternative medicine practitioners claim a holistic approach to healing.

Neurology

A lively debate has run since the end of the 19th century regarding the functional organization of the brain. The holistic tradition (e.g., Pierre Marie) maintained that the brain was a homogeneous organ with no specific subparts whereas the localizationists (e.g., Paul Broca) argued that the brain was organized in functionally distinct cortical areas which were each specialized to process a given type of information or implement specific mental operations. The controversy was epitomized with the existence of a language area in the brain, nowadays known as the Broca's area.^[14]

Indications of holism in social science

Architecture

Architecture is often argued by design academics and those practicing in design to be a holistic enterprise.^[15] Used in this context, holism tends to imply an all-inclusive design perspective. This trait is considered exclusive to architecture, distinct from other professions involved in design projects.

Branding

A holistic brand (also holistic branding) is considering the entire brand or image of the company. For example, a universal brand image across all countries, including everything from advertising styles to the stationery the company has made, to the company colours.

Economics

With roots in Schumpeter, the evolutionary approach might be considered the holist theory in economics. They share certain language from the biological evolutionary approach. They take into account how the innovation system evolves over time. Knowledge and know-how, know-who, know-what and know-why are part of the whole business economics. Knowledge can also be tacit, as described by Michael Polanyi. These models are open, and consider that it is hard to predict exactly the impact of a policy measure. They are also less mathematical.

Education reform

The Taxonomy of Educational Objectives identifies many levels of cognitive functioning, which can be used to create a more holistic education. In authentic assessment, rather than using computers to score multiple choice tests, a standards based assessment uses trained scorers to score open-response items using holistic scoring methods.^[16] In projects such as the North Carolina Writing Project, scorers are instructed not to count errors, or count numbers of points or supporting statements. The scorer is instead instructed to judge holistically whether "as a whole" is it more a "2" or a "3". Critics question whether such a process can be as objective as computer scoring, and the degree to which such scoring methods can result in different scores from different scorers.

Psychology

Psychology of perception

A major holist movement in the early twentieth century was gestalt psychology. The claim was that perception is not an aggregation of atomic sense data but a field, in which there is a figure and a ground. Background has holistic effects on the perceived figure. Gestalt psychologists included Wolfgang Koehler, Max Wertheimer, Kurt Koffka. Koehler claimed the perceptual fields corresponded to electrical fields in the brain. Karl Lashley did experiments with gold foil pieces inserted in monkey brains purporting to show that such fields did not exist. However, many of the perceptual illusions and visual phenomena exhibited by the gestaltists were taken over (often without credit) by later perceptual psychologists. Gestalt psychology had influence on Fritz Perls' gestalt therapy, although some old-line gestaltists opposed the association with counter-cultural and New Age trends later associated with gestalt therapy. Gestalt theory was also influential on phenomenology. Aron Gurwitsch wrote on the role of the field of consciousness in gestalt theory in relation to phenomenology. Maurice Merleau-Ponty made much use of holistic psychologists such as work of Kurt Goldstein in his "Phenomenology of Perception."

Teleological psychology

Alfred Adler believed that the individual (an integrated whole expressed through a self-consistent unity of thinking, feeling, and action, moving toward an unconscious, fictional final goal), must be understood within the larger wholes of society, from the groups to which he belongs (starting with his face-to-face relationships), to the larger whole of mankind. The recognition of our social embeddedness and the need for developing an interest in the welfare of others, as well as a respect for nature, is at the heart of Adler's philosophy of living and principles of psychotherapy.

Edgar Morin, the French philosopher and sociologist, can be considered a holist based on the transdisciplinary nature of his work.

Mel Levine, M.D., author of A Mind at a Time,^[17] and co-founder (with Charles R. Schwab) of the not-for-profit organization All Kinds of Minds, can be considered a holist based on his view of the 'whole child' as a product of many systems and his work supporting the educational needs of children through the management of a child's educational profile as a whole rather than isolated weaknesses in that profile.

Anthropology

There is an ongoing dispute as to whether anthropology is intrinsically holistic. Supporters of this concept consider anthropology holistic in two senses. First, it is concerned with all human beings across times and places, and with all dimensions of humanity (evolutionary, biophysical, sociopolitical, economic, cultural, psychological, etc.) Further, many academic programs following this approach take a "four-field" approach to anthropology that encompasses physical anthropology, archeology, linguistics, and cultural anthropology or social anthropology.^[18]

Some leading anthropologists disagree, and consider anthropological holism to be an artifact from 19th century social evolutionary thought that inappropriately imposes scientific positivism upon cultural anthropology.^[19]

The term "holism" is additionally used within social and cultural anthropology to refer to an analysis of a society as a whole which refuses to break society into component parts. One definition says: "as a methodological ideal, holism implies ... that one does not permit oneself to believe that our own established institutional boundaries (e.g. between politics, sexuality, religion, economics) necessarily may be found also in foreign societies."^[20]

Émile Durkheim

Émile Durkheim developed a concept of holism which he set as opposite to the notion that a society was nothing more than a simple collection of individuals. In more recent times, Louis Dumont^[21] has contrasted "holism" to "individualism" as two different forms of societies. According to him, modern humans live in an individualist society, whereas ancient Greek society, for example, could be qualified as "holistic", because the individual found identity in the whole society. Thus, the individual was ready to sacrifice himself or herself for his or her community, as his or her life without the polis had no sense whatsoever.

Cosmomorphism

The French Protestant missionary Maurice Leenhardt coined the term "cosmomorphism" to indicate the state of perfect symbiosis with the surrounding environment which characterized the culture of the Melanesians of New Caledonia. For these people, an isolated individual is totally indeterminate, indistinct, and featureless until he can find his position within the natural and social world in which he is inserted. The confines between the self and the world are annulled to the point that the material body itself is no guarantee of the sort of recognition of identity which is typical of our own culture.^[22][23]

Theology

Holistic concepts are strongly represented within the thoughts expressed within Logos (per Heraclitus), Panentheism and Pantheism.^{[citation needed]}

In theological anthropology, which belongs to theology and not to anthropology, holism is the belief that body, soul and spirit are not separate components of a person, but rather facets of a united whole.^[24]

Psychiatry

From Wikipedia, the free encyclopedia

Psychiatry

Occupation
Names	Physician
Activity sectors	Medicine
Description
Education required	Doctor of Medicine (MD) Doctor of Osteopathic Medicine (DO) Bachelor of Medicine, Bachelor of Surgery (MBBS/MBChB)
Related jobs	Medical specialties Medicine Glossary of psychiatry Glossary of medicine

Psychiatry is the medical specialty devoted to the diagnosis, prevention and treatment of mental disorders.^[1][2] These include various maladaptations related to mood, behaviour, cognition, and perceptions. See glossary of psychiatry.

Initial psychiatric assessment of a person typically begins with a case history and mental status examination. Physical examinations and psychological tests may be conducted. On occasion, neuroimaging or other neurophysiological techniques are used.^[3] Mental disorders are often diagnosed in accordance with clinical concepts listed in diagnostic manuals such as the International Classification of Diseases (ICD), edited and used by the World Health Organization (WHO) and the widely used Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association (APA). The fifth edition of the DSM (DSM-5) was published in 2013 which re-organized the larger categories of various diseases and expanded upon the previous edition to include information/insights that are consistent with current research.^[4]

The combined treatment of psychiatric medication and psychotherapy has become the most common mode of psychiatric treatment in current practice,^[5] but contemporary practice also includes a wide variety of other modalities, e.g., assertive community treatment, community reinforcement, and supported employment. Treatment may be delivered on an inpatient or outpatient basis, depending on the severity of functional impairment or on other aspects of the disorder in question. An inpatient may be treated in a psychiatric hospital. Research and treatment within psychiatry as a whole are conducted on an interdisciplinary basis, e.g., with epidemiologists, mental health counselors, nurses, psychologists, public health specialists, radiologists, and/or social workers.

Etymology

The word psyche comes from the ancient Greek for soul or butterfly.^[6] The fluttering insect appears in the coat of arms of Britain's Royal College of Psychiatrists^[7]

The term "psychiatry" was first coined by the German physician Johann Christian Reil in 1808 and literally means the 'medical treatment of the soul' (psych- "soul" from Ancient Greek psykhē "soul"; -iatry "medical treatment" from Gk. iātrikos "medical" from iāsthai "to heal"). A medical doctor specializing in psychiatry is a psychiatrist. (For a historical overview, see Timeline of psychiatry.)

Theory and focus

Psychiatry refers to a field of medicine focused specifically on the mind, aiming to study, prevent, and treat mental disorders in humans.^[8][9][10] It has been described as an intermediary between the world from a social context and the world from the perspective of those who are mentally ill.^[11]

People who specialize in psychiatry often differ from most other mental health professionals and physicians in that they must be familiar with both the social and biological sciences.^[9] The discipline studies the operations of different organs and body systems as classified by the patient's subjective experiences and the objective physiology of the patient. ^[12] Psychiatry treats mental disorders, which are conventionally divided into three very general categories: mental illnesses, severe learning disabilities, and personality disorders.^[13] While the focus of psychiatry has changed little over time, the diagnostic and treatment processes have evolved dramatically and continue to do so. Since the late 20th century the field of psychiatry has continued to become more biological and less conceptually isolated from other medical fields.^[14]

Scope of practice

Disability-adjusted life year for neuropsychiatric conditions per 100,000 inhabitants in 2002.

  no data

  less than 10

  10-20

  20-30

  30-40

  40-50

  50-60

  60-80

  80-100

  100-120

  120-140

  140-150

  more than 150

Though the medical specialty of psychiatry uses research in the field of neuroscience, psychology, medicine, biology, biochemistry, and pharmacology,^[15] it has generally been considered a middle ground between neurology and psychology.^[16] Because psychiatry and neurology are deeply intertwined medical specialties, all certification for both specialties and for their subspecialties is offered by a single board, the American Board of Psychiatry and Neurology, one of the member boards of the American Board of Medical Specialties.^[17] Unlike other physicians and neurologists, psychiatrists specialize in the doctor–patient relationship and are trained to varying extents in the use of psychotherapy and other therapeutic communication techniques.^[16] Psychiatrists also differ from psychologists in that they are physicians and have post-graduate training called residency (usually 4 to 5 years) in psychiatry; the quality and thoroughness of their graduate medical training is identical to that of all other physicians.^[18] Psychiatrists can therefore counsel patients, prescribe medication, order laboratory tests, order neuroimaging, and conduct physical examinations.^[3]

Ethics

Like other purveyors of professional ethics, the World Psychiatric Association issues an ethical code to govern the conduct of psychiatrists. The psychiatric code of ethics, first set forth through the Declaration of Hawaii in 1977, has been expanded through a 1983 Vienna update and, in 1996, the broader Madrid Declaration. The code was further revised during the organization's general assemblies in 1999, 2002, 2005, and 2011.^[19] The World Psychiatric Association code covers such matters as patient assessment, up-to-date knowledge, the human dignity of incapacitated patients, confidentiality, research ethics, sex selection, euthanasia,^[20] organ transplantation, torture,^[21][22] the death penalty, media relations, genetics, and ethnic or cultural discrimination.^[19]

In establishing such ethical codes, the profession has responded to a number of controversies about the practice of psychiatry, for example, surrounding the use of lobotomy and electroconvulsive therapy. Discredited psychiatrists who operated outside the norms of medical ethics include Harry Bailey, Donald Ewen Cameron, Samuel A. Cartwright, Henry Cotton, and Andrei Snezhnevsky.^{[23][page needed]}

Approaches

Psychiatric illnesses can be conceptualised in a number of different ways. The biomedical approach examines signs and symptoms and compares them with diagnostic criteria. Mental illness can be assessed, conversely, through a narrative which tries to incorporate symptoms into a meaningful life history and to frame them as responses to external conditions. Both approaches are important in the field of psychiatry,^[24] but have not sufficiently reconciled to settle controversy over either the selection of a psychiatric paradigm or the specification of psychopathology. The notion of a "biopsychosocial model" is often used to underline the multifactorial nature of clinical impairment.^[25][26][27]

In this notion the word "model" is not used in a strictly scientific way though.^[25] Alternatively, a "biocognitive model" acknowledges the physiological basis for the mind's existence, but identifies cognition as an irreducible and independent realm in which disorder may occur.^[25][26][27] The biocognitive approach includes a mentalist etiology and provides a natural dualist (i.e. non-spiritual) revision of the biopsychosocial view, reflecting the efforts of Australian psychiatrist Niall McLaren to bring the discipline into scientific maturity in accordance with the paradigmatic standards of philosopher Thomas Kuhn.^[25][26][27]

Once a medical professional diagnoses a patient there are numerous ways that they could choose to treat the patient. Often psychiatrists will develop a treatment strategy that incorporates different facets of different approaches into one. Drug prescriptions are very commonly written to be regimented to patients along with any therapy they receive. There are three major pillars of psychotherapy that treatment strategies are most regularly drawn from. Humanistic psychology attempts to put the "whole" of the patient in perspective; it also focuses on self exploration.^[28] Behaviorism is a therapeutic school of thought that elects to focus solely on real and observable events, rather than mining the unconscious or subconscious. Psychoanalysis, on the other hand, concentrates its dealings on early childhood, irrational drives, the unconscious, and conflict between conscious and unconscious streams.^[29]

Practitioners

All physicians can diagnose mental disorders and prescribe treatments utilizing principles of psychiatry. Psychiatrists are physicians who specialize in psychiatry and are certified to treat mental illness. They may treat outpatients, inpatients, or both; they may practice as solo practitioners or as members of groups; they may be self-employed, be members of partnerships, or be employees of governmental, academic, nonprofit, or for-profit entities; they may treat military personnel as civilians or as members of the military; and in any of these settings they may function as clinicians, researchers, teachers, or some combination of these. Although psychiatrists may also go through significant training to conduct psychotherapy, psychoanalysis or cognitive behavioral therapy, it is their training as physicians that differentiates them from other mental health professionals.

As a career choice

Psychiatry is not a popular career choice amongst medical students, even though medical school placements are rated favorably.^[30] This has resulted in a significant shortage of psychiatrists in the United States and elsewhere.^[31] Strategies to address this shortfall have included the use of short 'taster' placements early in the medical school curriculum ^[30] and attempts to extend psychiatry services further using telemedicine technologies and other methods.^[32]

Subspecialties

The field of psychiatry has many subspecialties that require additional training and certification by the American Board of Psychiatry and Neurology (ABPN). Such subspecialties include:^[33]

• Addiction psychiatry
• Brain Injury Medicine^[34][35]
• Child and Adolescent Psychiatry
• Clinical neurophysiology
• Epilepsy^[36][37]
• Forensic psychiatry
• Geriatric psychiatry
• Hospice and palliative medicine
• Pain medicine^[38]
• Psychosomatic medicine^[39] (also known as consultation-liaison psychiatry)
• Sleep medicine^[40]

Additional psychiatry subspecialties, for which ABPN does not offer certification, include:^[41]

• Cross-cultural psychiatry
• Emergency psychiatry
• Learning disability
• Neurodevelopmental disorder
• Cognition diseases as in various forms of dementia
• Biological psychiatry
• Community psychiatry
• Global Mental Health
• Military psychiatry
• Social psychiatry
• Neuropsychiatry

Addiction psychiatry focuses on evaluation and treatment of individuals with alcohol, drug, or other substance-related disorders, and of individuals with dual diagnosis of substance-related and other psychiatric disorders. Biological psychiatry is an approach to psychiatry that aims to understand mental disorders in terms of the biological function of the nervous system. Child and adolescent psychiatry is the branch of psychiatry that specializes in work with children, teenagers, and their families. Community psychiatry is an approach that reflects an inclusive public health perspective and is practiced in community mental health services.^[42] Cross-cultural psychiatry is a branch of psychiatry concerned with the cultural and ethnic context of mental disorder and psychiatric services.

Emergency psychiatry is the clinical application of psychiatry in emergency settings. Forensic psychiatry utilizes medical science generally, and psychiatric knowledge and assessment methods in particular, to help answer legal questions. Geriatric psychiatry is a branch of psychiatry dealing with the study, prevention, and treatment of mental disorders in the elderly. Global Mental Health is an area of study, research and practice that places a priority on improving mental health and achieving equity in mental health for all people worldwide,^[43] although some scholars consider it to be a neo-colonial, culturally insensitive project.^{[44][45][46][47]} Liaison psychiatry is the branch of psychiatry that specializes in the interface between other medical specialties and psychiatry. Military psychiatry covers special aspects of psychiatry and mental disorders within the military context.

Neuropsychiatry is a branch of medicine dealing with mental disorders attributable to diseases of the nervous system. Social psychiatry is a branch of psychiatry that focuses on the interpersonal and cultural context of mental disorder and mental well-being.

In larger healthcare organizations, psychiatrists often serve in senior management roles, where they are responsible for the efficient and effective delivery of mental health services for the organization's constituents. For example, the Chief of Mental Health Services at most VA medical centers is usually a psychiatrist, although psychologists occasionally are selected for the position as well.^{[citation needed]}
In the United States, psychiatry is one of the few specialties which qualify for further education and board-certification in pain medicine, palliative medicine, and sleep medicine.

Research

Psychiatric research is, by its very nature, interdisciplinary; combining social, biological and psychological perspectives in attempt to understand the nature and treatment of mental disorders.^[48] Clinical and research psychiatrists study basic and clinical psychiatric topics at research institutions and publish articles in journals.^{[15][49][50][51]} Under the supervision of institutional review boards, psychiatric clinical researchers look at topics such as neuroimaging, genetics, and psychopharmacology in order to enhance diagnostic validity and reliability, to discover new treatment methods, and to classify new mental disorders.^{[52][page needed]}

Clinical application

Diagnostic systems

Psychiatric diagnoses take place in a wide variety of settings and are performed by many different health professionals. Therefore, the diagnostic procedure may vary greatly based upon these factors. Typically, though, a psychiatric diagnosis utilizes a differential diagnosis procedure where a mental status examination and physical examination is conducted, with pathological, psychopathological or psychosocial histories obtained, and sometimes neuroimages or other neurophysiological measurements are taken, or personality tests or cognitive tests administered.^{[53][54][55][56][57]} In some cases, a brain scan might be used to rule out other medical illnesses, but at this time relying on brain scans alone cannot accurately diagnose a mental illness or tell the risk of getting a mental illness in the future.^[58] A few psychiatrists are beginning to utilize genetics during the diagnostic process but on the whole this remains a research topic.^[59][60][61]

Diagnostic manuals

Three main diagnostic manuals used to classify mental health conditions are in use today. The ICD-10 is produced and published by the World Health Organization, includes a section on psychiatric conditions, and is used worldwide.^[62] The Diagnostic and Statistical Manual of Mental Disorders, produced and published by the American Psychiatric Association, is primarily focused on mental health conditions and is the main classification tool in the United States.^[63] It is currently in its fifth revised edition and is also used worldwide.^[63] The Chinese Society of Psychiatry has also produced a diagnostic manual, the Chinese Classification of Mental Disorders.^[64]

The stated intention of diagnostic manuals is typically to develop replicable and clinically useful categories and criteria, to facilitate consensus and agreed upon standards, whilst being atheoretical as regards etiology.^[63][65] However, the categories are nevertheless based on particular psychiatric theories and data; they are broad and often specified by numerous possible combinations of symptoms, and many of the categories overlap in symptomology or typically occur together.^[66] While originally intended only as a guide for experienced clinicians trained in its use, the nomenclature is now widely used by clinicians, administrators and insurance companies in many countries.^[67]

The DSM has attracted praise for standardizing psychiatric diagnostic categories and criteria. It has also attracted controversy and criticism. Some critics argue that the DSM represents an unscientific system that enshrines the opinions of a few powerful psychiatrists. There are ongoing issues concerning the validity and reliability of the diagnostic categories; the reliance on superficial symptoms; the use of artificial dividing lines between categories and from 'normality'; possible cultural bias; medicalization of human distress and financial conflicts of interest, including with the practice of psychiatrists and with the pharmaceutical industry; political controversies about the inclusion or exclusion of diagnoses from the manual, in general or in regard to specific issues; and the experience of those who are most directly affected by the manual by being diagnosed, including the consumer/survivor movement.^{[68][69][70][71]} The publication of the DSM, with tightly guarded copyrights, now makes APA over $5 million a year, historically adding up to over $100 million.^[72]

Treatment

General considerations

NIMH federal agency patient room for Psychiatric research, Maryland, USA.

Individuals with mental health conditions are commonly referred to as patients but may also be called clients, consumers, or service recipients. They may come under the care of a psychiatric physician or other psychiatric practitioners by various paths, the two most common being self-referral or referral by a primary-care physician. Alternatively, a person may be referred by hospital medical staff, by court order, involuntary commitment, or, in the UK and Australia, by sectioning under a mental health law.

Persons who undergo a psychiatric assessment are evaluated by a psychiatrist for their mental and physical condition. This usually involves interviewing the person and often obtaining information from other sources such as other health and social care professionals, relatives, associates, law enforcement personnel, emergency medical personnel, and psychiatric rating scales. A mental status examination is carried out, and a physical examination is usually performed to establish or exclude other illnesses that may be contributing to the alleged psychiatric problems. A physical examination may also serve to identify any signs of self-harm; this examination is often performed by someone other than the psychiatrist, especially if blood tests and medical imaging are performed.

Like most medications, psychiatric medications can cause adverse effects in patients, and some require ongoing therapeutic drug monitoring, for instance full blood counts serum drug levels, renal function, liver function, and/or thyroid function. Electroconvulsive therapy (ECT) is sometimes administered for serious and disabling conditions, such as those unresponsive to medication. The efficacy^[73][74] and adverse effects of psychiatric drugs may vary from patient to patient.

For many years, controversy has surrounded the use of involuntary treatment and use of the term "lack of insight" in describing patients. Mental health laws vary significantly among jurisdictions, but in many cases, involuntary psychiatric treatment is permitted when there is deemed to be a risk to the patient or others due to the patient's illness. Involuntary treatment refers to treatment that occurs based on the treating physician's recommendations without requiring consent from the patient.^[75]

Mental health issues such as mood disorders and schizophrenia and other psychotic disorders were the most common principle diagnoses for Medicaid super-utilizers in the United States in 2012.^[76]

Inpatient treatment

Psychiatric treatments have changed over the past several decades. In the past, psychiatric patients were often hospitalized for six months or more, with some cases involving hospitalization for many years. Today in most countries, people receiving psychiatric treatment are more likely to be seen as outpatients. If hospitalization is required, the average hospital stay is around one to two weeks, with only a small number receiving long-term hospitalization.^{[citation needed]}. However, in Japan psychiatric hospitals continue to keep patients for long periods, sometimes even keeping them in physical restraints, strapped to their beds for periods of weeks or months ^[77][78].

Psychiatric inpatients are people admitted to a hospital or clinic to receive psychiatric care. Some are admitted involuntarily, perhaps committed to a secure hospital, or in some jurisdictions to a facility within the prison system. In many countries including the USA and Canada, the criteria for involuntary admission vary with local jurisdiction. They may be as broad as having a mental health condition, or as narrow as being an immediate danger to themselves and/or others. Bed availability is often the real determinant of admission decisions to hard pressed public facilities. European Human Rights legislation restricts detention to medically certified cases of mental disorder, and adds a right to timely judicial review of detention.^{[citation needed]}

People may be admitted voluntarily if the treating doctor considers that safety isn't compromised by this less restrictive option. Inpatient psychiatric wards may be secure (for those thought to have a particular risk of violence or self-harm) or unlocked/open. Some wards are mixed-sex whilst same-sex wards are increasingly favored to protect women inpatients. Once in the care of a hospital, people are assessed, monitored, and often given medication and care from a multidisciplinary team, which may include physicians, pharmacists, psychiatric nurse practitioners, psychiatric nurses, clinical psychologists, psychotherapists, psychiatric social workers, occupational therapists and social workers. If a person receiving treatment in a psychiatric hospital is assessed as at particular risk of harming themselves or others, they may be put on constant or intermittent one-to-one supervision, and may be put in physical restraints or medicated. People on inpatient wards may be allowed leave for periods of time, either accompanied or on their own.^[79]

In many developed countries there has been a massive reduction in psychiatric beds since the mid 20th century, with the growth of community care. Standards of inpatient care remain a challenge in some public and private facilities, due to levels of funding, and facilities in developing countries are typically grossly inadequate for the same reason. Even in developed countries, programs in public hospitals vary widely. Some may offer structured activities and therapies offered from many perspectives while others may only have the funding for medicating and monitoring patients. This may be problematic in that the maximum amount of therapeutic work might not actually take place in the hospital setting. This is why hospitals are increasingly used in limited situations and moments of crisis where patients are a direct threat to themselves or others. Alternatives to psychiatric hospitals that may actively offer more therapeutic approaches include rehabilitation centers or "rehab" as popularly termed.^{[citation needed]}

Outpatient treatment

Outpatient treatment involves periodic visits to a psychiatrist for consultation in his or her office, or at a community-based outpatient clinic. Initial appointments, at which the psychiatrist conducts a psychiatric assessment or evaluation of the patient, are typically 45 to 75 minutes in length. Follow-up appointments are generally shorter in duration, i.e., 15 to 30 minutes, with a focus on making medication adjustments, reviewing potential medication interactions, considering the impact of other medical disorders on the patient's mental and emotional functioning, and counseling patients regarding changes they might make to facilitate healing and remission of symptoms (e.g., exercise, cognitive therapy techniques, sleep hygiene—to name just a few). The frequency with which a psychiatrist sees people in treatment varies widely, from once a week to twice a year, depending on the type, severity and stability of each person's condition, and depending on what the clinician and patient decide would be best.

Increasingly, psychiatrists are limiting their practices to psychopharmacology (prescribing medications), as opposed to previous practice in which a psychiatrist would provide traditional 50-minute psychotherapy sessions, of which psychopharmacology would be a part, but most of the consultation sessions consisted of "talk therapy." This shift began in the early 1980s and accelerated in the 1990s and 2000s.^[80] A major reason for this change was the advent of managed care insurance plans, which began to limit reimbursement for psychotherapy sessions provided by psychiatrists. The underlying assumption was that psychopharmacology was at least as effective as psychotherapy, and it could be delivered more efficiently because less time is required for the appointment.^{[81][82][83][84][85][86]} For example, most psychiatrists schedule three or four follow-up appointments per hour, as opposed to seeing one patient per hour in the traditional psychotherapy model.^[a] Because of this shift in practice patterns, psychiatrists often refer patients whom they think would benefit from psychotherapy to other mental health professionals, e.g., clinical social workers and psychologists.^[87]

History

The earliest known texts on mental disorders are from ancient India and include the Ayurvedic text, Charaka Samhita.^[88][89] The first hospitals for curing mental illness were established in India during the 3rd century BCE.^[90]

The Greeks also created early manuscripts about mental disorders.^[91] In the 4th century BCE, Hippocrates theorized that physiological abnormalities may be the root of mental disorders.^[92] In 4th to 5th Century B.C. Greece, Hippocrates wrote that he visited Democritus and found him in his garden cutting open animals. Democritus explained that he was attempting to discover the cause of madness and melancholy. Hippocrates praised his work. Democritus had with him a book on madness and melancholy.^[93] During the 5th century BCE, mental disorders, especially those with psychotic traits, were considered supernatural in origin,^[92] a view which existed throughout ancient Greece and Rome,^[92] as well as Egyptian regions.^{[94][page needed]} Religious leaders often turned to versions of exorcism to treat mental disorders often utilizing methods that many consider to be cruel and/or barbaric methods. Trepanning was one of these methods used throughout history. ^[92]

The Islamic Golden Age fostered early studies in Islamic psychology and psychiatry, with many scholars writing about mental disorders. The Persian physician Muhammad ibn Zakariya al-Razi, also known as "Rhazes", wrote texts about psychiatric conditions in the 9th century.^[95] As chief physician of a hospital in Baghdad, he was also the director of one of the first psychiatric wards in the world. Two of his works in particular, El-Mansuri and Al-Hawi, provide descriptions and treatments for mental illnesses.^[95]

Abu Zayd al-Balkhi, known to the west as "Avicenna", was a Persian polymath during the 9th and 10th centuries and one of the first to classify neurotic disorders. He pioneered cognitive therapy in order to treat each of these classified neurotic disorders. He classified neurosis into four emotional disorders: fear and anxiety, anger and aggression, sadness and depression, and obsession. Al-Balkhi further classified three types of depression: normal depression or sadness (huzn), endogenous depression originating from within the body, and reactive clinical depression originating from outside the body.^[96]

Specialist hospitals were built in Baghdad in 705 AD,^[97] followed by Fes in the early 8th century, and Cairo in 800 AD.^{[citation needed]} Specialist hospitals such as Bethlem Royal Hospital in London were built in medieval Europe from the 13th century to treat mental disorders, but were used only as custodial institutions and did not provide any type of treatment.^[98]

The beginning of psychiatry as a medical specialty is dated to the middle of the nineteenth century,^[91] although its germination can be traced to the late eighteenth century. In the late 17th century, privately run asylums for the insane began to proliferate and expand in size. In 1713 the Bethel Hospital Norwich was opened, the first purpose-built asylum in England.^[99] In 1656, Louis XIV of France created a public system of hospitals for those suffering from mental disorders, but as in England, no real treatment was applied.^[100]

During the Enlightenment attitudes towards the mentally ill began to change. It came to be viewed as a disorder that required compassionate treatment. In 1758 English physician William Battie wrote his Treatise on Madness on the management of mental disorder. It was a critique aimed particularly at the Bethlem Hospital, where a conservative regime continued to use barbaric custodial treatment. Battie argued for a tailored management of patients entailing cleanliness, good food, fresh air, and distraction from friends and family. He argued that mental disorder originated from dysfunction of the material brain and body rather than the internal workings of the mind.^[101][102]

Dr. Philippe Pinel at the Salpêtrière, 1795 by Tony Robert-Fleury. Pinel ordering the removal of chains from patients at the Paris Asylum for insane women.

The introduction of moral treatment was initiated independently by the French doctor Philippe Pinel and the English Quaker William Tuke.^[92] In 1792 Pinel became the chief physician at the Bicêtre Hospital. Patients were allowed to move freely about the hospital grounds, and eventually dark dungeons were replaced with sunny, well-ventilated rooms. Pinel's student and successor, Jean Esquirol (1772–1840), went on to help establish 10 new mental hospitals that operated on the same principles.^[103]

Although Tuke, Pinel and others had tried to do away with physical restraint, it remained widespread into the 19th century. At the Lincoln Asylum in England, Robert Gardiner Hill, with the support of Edward Parker Charlesworth, pioneered a mode of treatment that suited "all types" of patients, so that mechanical restraints and coercion could be dispensed with — a situation he finally achieved in 1838. In 1839 Sergeant John Adams and Dr. John Conolly were impressed by the work of Hill, and introduced the method into their Hanwell Asylum, by then the largest in the country.^{[104][105][page needed]}

The modern era of institutionalized provision for the care of the mentally ill, began in the early 19th century with a large state-led effort. In England, the Lunacy Act 1845 was an important landmark in the treatment of the mentally ill, as it explicitly changed the status of mentally ill people to patients who required treatment. All asylums were required to have written regulations and to have a resident qualified physician.^{[106][full citation needed]} In 1838, France enacted a law to regulate both the admissions into asylums and asylum services across the country. In the United States, the erection of state asylums began with the first law for the creation of one in New York, passed in 1842. The Utica State Hospital was opened approximately in 1850. Many state hospitals in the United States were built in the 1850s and 1860s on the Kirkbride Plan, an architectural style meant to have curative effect.^{[107][page needed]}

At the turn of the century, England and France combined had only a few hundred individuals in asylums.^[108] By the late 1890s and early 1900s, this number had risen to the hundreds of thousands. However, the idea that mental illness could be ameliorated through institutionalization ran into difficulties.^[109] Psychiatrists were pressured by an ever-increasing patient population,^[109] and asylums again became almost indistinguishable from custodial institutions,^[110]

In the early 1800s, psychiatry made advances in the diagnosis of mental illness by broadening the category of mental disease to include mood disorders, in addition to disease level delusion or irrationality.^[111] The 20th century introduced a new psychiatry into the world, with different perspectives of looking at mental disorders. For Emil Kraepelin, the initial ideas behind biological psychiatry, stating that the different mental disorders are all biological in nature, evolved into a new concept of "nerves", and psychiatry became a rough approximation of neurology and neuropsychiatry.^[112] Following Sigmund Freud's pioneering work, ideas stemming from psychoanalytic theory also began to take root in psychiatry.^[113] The psychoanalytic theory became popular among psychiatrists because it allowed the patients to be treated in private practices instead of warehoused in asylums.^[113]

Otto Loewi's work led to the identification of the first neurotransmitter, acetylcholine.

By the 1970s, however, the psychoanalytic school of thought became marginalized within the field.^[113] Biological psychiatry reemerged during this time. Psychopharmacology became an integral part of psychiatry starting with Otto Loewi's discovery of the neuromodulatory properties of acetylcholine; thus identifying it as the first-known neurotransmitter.^[114] Neuroimaging was first utilized as a tool for psychiatry in the 1980s.^[115] The discovery of chlorpromazine's effectiveness in treating schizophrenia in 1952 revolutionized treatment of the disorder,^[116] as did lithium carbonate's ability to stabilize mood highs and lows in bipolar disorder in 1948.^[117] Psychotherapy was still utilized, but as a treatment for psychosocial issues.^[118]

In 1963, US president John F. Kennedy introduced legislation delegating the National Institute of Mental Health to administer Community Mental Health Centers for those being discharged from state psychiatric hospitals.^[119] Later, though, the Community Mental Health Centers focus shifted to providing psychotherapy for those suffering from acute but less serious mental disorders.^[119] Ultimately there were no arrangements made for actively following and treating severely mentally ill patients who were being discharged from hospitals, resulting in a large population of chronically homeless people suffering from mental illness.^[119]

Controversy and criticism

Controversy has often surrounded psychiatry, and the term anti-psychiatry was coined by psychiatrist David Cooper in 1967 and was later made popular by Thomas Szasz. The basic premise of anti-psychiatry is that: psychiatrists attempt to maliciously classify "normal" people as "deviant;" psychiatric treatments are ultimately more damaging than helpful to patients; and psychiatry's history involves (what may now be seen as) dangerous treatments, such as the frontal lobectomy (commonly called, a lobotomy).^[120] Several former patient groups have been formed often referring to themselves as "survivors."^[121]

Additionally, the Church of Scientology (through one of its self-described "Humanitarian Efforts"^[120]) created a "museum" in Los Angeles, CA (USA) which purports to show the evolution of the "evils" of psychiatry and psychology over time.^[122] The specific Scientology-related organization, the Citizens Commission on Human Rights (CCHR), is entirely devoted to the Anti-Psychiatry movement. That said, there has been a great deal of criticism about the veracity of specific information provided to the public and the conclusions drawn within the "exhibits."