Toward a New Psychiatric Pluralism: The Resurgence of Psychotherapy

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SPECIAL REPORT: PSYCHOTHERAPY

For those who have been around long enough, or for those who take an interest in the history of psychiatry, it is clear that the field has long been prone to major paradigm shifts and, in particular, a vacillation between predominantly biological and predominantly psychological modes of understanding. It is becoming apparent that the strong emphasis on neuroscience in the 1990s and early 2000s is now giving way to a new psychiatric pluralism, one that increasingly views psychotherapy as a bona fide medical treatment and sees psychosocial factors as fundamental to understanding the causes and basic nature of psychopathology.

As a nonpsychiatrist who teaches in 2 psychiatry residency programs, I believe the field is only enriched by pluralism: a diversity of views, theoretical models, and clinical approaches. Indeed, we must remain wary of totalizing narratives of psychopathology, which for so long have plagued our fields. Given the various types of problems we classify as mental disorders—from diseases of the nervous system to disturbances related chiefly to interpersonal functioning mediated more by the environment—no single approach could account for all forms of psychopathology.

This need for theoretical and clinical pluralism has been described elegantly by such great minds as Leston L. Havens, MD, in his book Approaches to the Mind: Movement of the Psychiatric Schools From Sects to Science;Paul R. McHugh, MD, and Phillip R. Slavney, MD, in their book The Perspectives of Psychiatry;and my friend and Tufts colleague S. Nassir Ghaemi, MD, MPH, in his book The Concepts of Psychiatry: A Pluralistic Approach to the Mind and Mental Illness. (All 3 are must-read texts for those interested in the philosophy and history of psychiatry.)

Today, we see psychiatry with a resurgent interest in psychotherapy as a primary treatment for psychopathology, not merely an adjunctive treatment to the “real work” of pharmacotherapy. Psychiatry residents are increasingly interested in psychotherapy and in psychosocial modes of understanding. Almost every medical student I have interviewed in the past few years has expressed an interest in learning and practicing psychotherapy. Training opportunities in psychotherapy for psychiatry trainees continue to expand. Psychotherapy is no longer relegated to a second-class position in the field; to the contrary, many are seeing it for what it is: a scientifically grounded, evidence-based form of medical treatment, with real effects on the brain and nervous system.

In recent years, we have seen major advances in the development and refinement of various psychotherapies for specific mental disorders. For instance, psychodynamic theorists of the object relations school, many of them psychiatrists, have developed an empirically supported form of treatment called transference-focused psychotherapy for severe personality disorders. A psychotherapeutic approach called general psychiatric management, developed by John Gunderson, MD, has allowed for the broader, evidence-based care of individuals with borderline personality disorder. And the cognitive and behavioral therapists, too, have adapted and refined their methods to effectively treat a broader range of patients, including those with more severe forms of illness, such as schizophrenia.

This is all to say that it is an exciting time to be a psychotherapist or psychiatrist interested in psychotherapy. As Chair of this Special Report, I am proud to present this collection of articles broaching various topics relating to psychotherapy and psychosocial modes of treatment and understanding. In embracing the complexity of human suffering and psychopathology, psychiatry must continue to draw from its rich array of perspectives and methods. Only through such pluralism can we hope to offer the most comprehensive, humane, and effective care to those we treat.

Dr Ruffalo is an assistant professor of psychiatry at the University of Central Florida College of Medicine in Orlando and adjunct assistant professor of psychiatry at Tufts University School of Medicine in Boston, Massachusetts.