The title of this blog is the title of a book by John A. Nagle. I was reminded of the book, which I read many years ago, by the current news especially the unconventional conflict in Syria and with ISIS. The title clearly points to doing something that is unconventional. The book compares the British Army's response in Malaya to the American Army's response in Vietnam. The British adapted to the insurgency while the Americans continued a conventional war approach. The British won, the Americans lost.
I began to wonder whether the lessons of war could inform the skillful practice of psychiatry especially in a multicultural world. One of the first lessons of war is to understand the enemy, i.e., the enemy's values, beliefs, history, religious beliefs, economic organization, social structure, response to interventions, and their way of seeing the conflict. The understanding of these attributes of a human being is fundamental to good psychiatric practice. This understanding is usually referred to as empathy and involves listening to the patient and "climbing into their skin". This will inform the psychiatrist about their attitude toward treatment, medication, and interactions with other people and institutions as well as how these attitudes have developed and their consequent strength and constancy. This information is invaluable in developing an approach to a specific issue or problem that is effective and efficient. Simple reasoning to arrive at an approach is insufficient, empathic understanding is required to be successful . Contemporaneously, the military commander must be aware of current and past events that might be influencing his decision making in battle. Likewise, the psychiatrist must be aware of the impact of current and past events in his or her life that could be influencing the response to the patient. This is an active and dynamic process which often results in a response or feedback to a patient which should be framed in as many words as are necessary to convey the idea but not more.
In war there should be a proportionality between magnitude of the enemy's action and the response. So too, when assessing the severity of the patient's problem, including social, financial, vocational, and other environmental component contributions, the formulation of the response should be proportional to the severity of the gestalt which should maximize efficiency. With regard to individuals with psychotic problems, it is crucial to make the best selection of agents at an appropriately scaled dose which is an example of proportionality. In these cases it is important to hit the bullseye because the consequences of missing it can be substantial and might include unpredictable and disturbed acts in the community with possible self-harm or harm to others. it also supports or fosters the idea in the patient that psychiatric intervention is ineffective.
In war it is important to get the data and to constantly reexamine your thinking especially if failing to achieve goals. In psychiatric practice I have learned to value what I am seeing in front of me more than any belief based on education or experience. When facing poor clinical response, I am always prepared to reexamine the reasoning that got me to that point and I am always prepared to change my mind. In war one should be suspicious of the common or standard response to a problem. The most uncommon responses are often the most successful. So too in psychiatric practice the most uncommon interventions are often the most successful. Above all when choosing an intervention or strategy, never say never. Keep your mind as open as possible because we are dealing with the human mind which is the most complex object in the universe.
I wondered whether the lessons of war could inform the practice of psychiatry. The answer is yes. However, the reverse is also true, i.e., the lessons drawn from psychiatric practice can also inform the decision making in war.