Psychiatrists have a tendency to become quite excited when they are confronted with a ‘classical’ or ‘textbook’ presentation of a mental disorder. Generally speaking, clinical situations that conform closely to those described in scientific papers or great monographs seem to be the most uncommon of all presentations of mental health problems. The vast majority of people have problems that are coloured and complicated by real life, with all its multiple facets and blurred edges. In the face of this reality, one of the central challenges of mental health practice is to find rational and effective ways of intervening in situations where there is no unambiguous ‘right’ way of doing things.

The triangle of forces

Psychiatrists should aspire to be applied scientists, because their claim to a special credibility and expertise in helping people with mental disorders rests entirely on their scientific training. Of course, psychiatrists need to be much more than this. They especially need those essential skills that call upon their ability to empathise with other people and to understand lifestyles and mental states that are utterly different to their own. However, without access to a rational basis for intervention, we are no more useful than any other well-intentioned and empathetic member of the general public.

The trouble with this is that clinicians are constantly confronted with real situations that fall outside of the ambit of the scientific evidence, and with situations that are so complex that there is no well-established treatment pathway.