Do we need a dialectical approach to psychiatry?
PSYCHIATRIC VIEWS ON THE DAILY NEWS
“Insanity is doing the same thing over and over and expecting different results.” - attributed to Albert Einstein
We have just finished about 2 weeks of columns calling for Mayday help for various psychiatric challenges and, truth be told, there are more. Recall these that were featured, in order: loneliness, ageism, maternal mental health, anti-Semitism, gun violence, psychological pain, and migrant mental health.
All of these fall under the rubric of societal psychological problems and, thereby, need social psychiatric solutions. Although psychiatry has been paying more attention to the social determinants of health and mental health, that is only a partial solution. Fortunately, our country’s Surgeon General has begun to answer those Mayday mental health calls by recently calling out our loneliness epidemic.1 Hopefully, he will expand into some of these other social problems, which I have called social psychopathologies.
It is the social psychopathologies where psychiatry can come in, too, perhaps in partnership with the Surgeon General. The DSM-5 mostly focuses on individual psychopathology, as important as that is in our everyday clinical work. At best, a dialectical psychiatric focus would mean developing a complementary classification of social psychiatric disorders.
My own process of selecting Mayday calls ended up by focusing on the dialectical opposites that, just like in borderline personality disorder (BPD), needed the Zen and Christian psychiatric synthesis discovered by Marsha Linehan, PhD.2 In Eastern terminology, this is called Yin and Yang. Addressing only 1 side or aspect of the dialectical is easier, but generally will only be part of the solution for a clinical problem.
In relationships, opposites often attract. If the differences become complementary instead of conflictual, they end up with the best of marriages, friendships, collegial relationships, and personal growth. Relationships of the similar can be comfortable, but stagnant.
To go even further, beyond Linehan and BPD, do we need a new model of psychiatry beyond the traditional combination of the bio-psycho-social, a model that has downplayed the social and ignores the spiritual and ecological? In terms of the history of the Freudian psychodynamic model of psychiatry, the essence was a quest to resolve personal conflicts, parts of which were unconscious. For psychopharmacology, it has been crucial to document the benefits over adverse effects and harm. Here are just some of the other issues in psychiatry that can reflect the usefulness of a dialectical synthesis in a very rough working model in process:
These differences require synthesis and might suggest the need for a new model of psychiatry. This could be called a dialectical psychiatry. At the very least, we need a way to resolve apparent conflicts and differences in the field that can lead to psychological growth and better understanding.
Dr Moffic is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He is an advocate for mental health issues related to climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of Psychiatric Times.
1. New Surgeon General Advisory raises alarm about the devastating impact of the epidemic of loneliness and isolation in the United States. US Department of Health and Human Services. May 3, 2023. Accessed May 16, 2023. https://www.hhs.gov/about/news/2023/05/03/new-surgeon-general-advisory-raises-alarm-about-devastating-impact-epidemic-loneliness-isolation-united-states.html
2. Linehan M. Building a Life Worth Living: A Memoir. Random House Publishing Group; 2021.