Moral engagement, combat trauma, and the lure of psychiatric dualism: why psychiatry is more than a technical discipline.

Psychiatry is not only a technical discipline concerned with matching appropriate means to pre-specified ends; it is also a discipline of moral engagement and discernment in which clinicians and patients explore the ends that patients will pursue. Moral engagement is intrinsic to psychiatric practice, particularly when psychiatrists engage issues such as combat trauma in which patients' moral self-evaluations are relevant to the perpetuation of psychological distress. Relative to technical models of practice, however, the space of moral engagement and discernment conveys risk for psychiatrists as it is less "scientific," more prone to exploitation and abuse, and the occasion for social-political critiques of psychiatry. Three prevalent forms of psychiatric dualism, each manifest in the care of combat veterans, seem to allow psychiatrists to avoid this contested moral space: dualism of the self and the self's body, dualism of the self and the self's quantifiable experience and behavior, and dualism of the self and the self's "values." Each of these dualisms is alluring but ultimately unable to protect psychiatrists from the space of moral engagement. Psychiatrists must rather cultivate practices for inhabiting that space in a morally transparent, self-questioning, and responsible way.