Psychiatry and Its Dichotomies

THE CULTURAL CORNER

Psychiatry has been perhaps the most controversial medical specialty throughout history, and many reasons can be invoked to justify the assertion. The very nature of the pathological conditions demanding its attention, the proliferation of theories attempting to explain complex behaviors, enigmatic symptoms or conflictive interpersonal transactions, the pre-eminence of charismatic leaders at the vanguard of militant organizations, or the relative delay in providing itself with technology-based resources for the diagnosis and management of hundreds of clinical conditions listed in its nomenclature catalogues are some of them. The dialectics of the psychiatric discourse include apodictic pronouncements, severe criticisms of opposing schools of thought, and the impact of changing but pervasive sociocultural factors. Over the centuries these factors have generated fear, anger, stigma, prejudice, discrimination, curiosity, confusion, avoidance or ambivalence-to cite only some of the individual and collective reactions to the clinical spectra.

As happens in many fields of knowledge, those in position to judge and deal with psychiatry and its entities (relatives, clinicians, researchers, educators, administrators, politicians, the so-called “public opinion”) have sought the support of a great variety of arguments. In the process, several dichotomies (from the Ancient Greek dikho, division in two, apart, and tomía, cutting) have emerged to offer doses of understanding or prescriptive explanations. Unquestionably, progress has been made; yet, the dichotomies persist as trenches in a battlefield or pulpits in incompatible churches, each proclaiming particular segments of an elusive truth. Occasionally, the combatants may share truces, smiles, or compliments to show that “tolerance” has not yet left the stage.

This picture reflects the essence of pieces of knowledge and wisdom that, at times, seem to reach dogmatic dimensions. Nowadays, a dichotomy entails confrontation of mutually exclusive, opposing, or contradictory views, perspectives, rules, and results. And in psychiatry (and its cousin, mental health), the most prevalent dichotomy is that which makes biology and humanism face each other with passion and, sometimes, bitterness. Biology invokes “true, hard (not soft) science” as its preeminent ally, whereas humanism calls for compassion and genuine consideration of suffering to confer a seal of authenticity to psychiatry’s mission. Science (more properly, neuroscience) is laboratories, chemical tests, neuroimaging, unchallengeable genotypes, animal experimentation, quantitative estimates, statistical reasoning. Humanism means never forgetting the he or she who thinks and feels in an unchangeable setting of uniqueness, one who loves, suffers, hopes, and fights beyond the cold estimation of his or her body or brain-much closer to a philosophical comprehension of life.

In fact, humanism attempts to rescue the essence of medicine as a profession, as a respectful recognition of “the other” and his existential meanders. Science and biology versus medicine and humanism are the most prevalent dichotomy of today’s psychiatry. Neurology and psychology, psychopharmacology and psychotherapy or neurogenetics and psychometrics are some sub-dichotomies, precocious by-products of the process.

But there is more. The term “sociocultural” used above may give the impression of being one more or less solid epistemological piece. A deeper inquiry into its 2 components, however, reveals features of another dichotomy, society and culture. Society is a concept that attempts to encompass surroundings, the classic and narrow notions of “environment,” lifestyle, written or unwritten rules of supposed (or desirable) coexistence, the collectivity, groups of people, the idea that the individual does not, or must not, count much if and when the “social interests” are to be considered. Nowadays, society (and “the social”) engages itself with science and creates the concept of epigenetics to study phenotypical changes induced by a variety of factors, but not so in the underlying DNA sequence. And, in this frame, society also proclaims the engagement of culture as one of its components-an appendix perhaps.

Yet, there are those who proclaim culture as a purer, more genuine body of knowledge that embraces equally the individual and social realities of this and other periods in history. Culture reflects society and its components in terms such as context, identity, language, religion, traditions, beliefs, interpersonal transactions, and many other so-called “cultural variables.” Culture confers a truly human dimension to society’s being and living; it does not “depersonalize” the former nor does it dilute the presence of the individual in the group but, quite the contrary, by means of its own dynamics, the livelihood of cultural interactions avoids and prevents egotism or what clinicians call “narcissism.” As such, culture involves society, revealing more eloquently the genuine substance of human existence.

The society/culture dichotomy also entails clinical considerations. From the social perspective there are, of course, group experiences that, due to a variety of factors, generate group-spread psychopathology, from panic in the face of natural disasters to the massive violence of fanatic terrorism. But to neglect the cultural components of any given diagnosis or behavior, to ignore the role of culture-based individual attitudes, beliefs or practices in the face of adversity, would be a disservice. In this sense, the dichotomous nature of the society and culture equation may be less radically separated than that of the science and medicine one. That is why it is easier and more frequent for us to say or hear “sociocultural” than to articulate or define “medicoscientific” or even “biomedical.”

An interesting phenomenon in today’s world of knowledge is that of integration, the growing acceptance of a style of work that entails multidisciplinary, team-based approaches, better communication, adequate follow-up, and preventive measures at their best. Psychiatry is part of this healthy movement, in close allegiance with primary care physicians and other mental health professionals. It can be said that the “culture of medicine” is experiencing salutary changes, approving and accepting on one hand the solid contributions of a humanistic science, and on the other, the fraternal embrace of culture and society. By doing this, our profession and our specialty are showing maturity and a progressive vision, hopefully leaving behind rigid doctrines, extremist, and selfish practice styles. It is possible that, at some point, the camps delineated by arbitrary dichotomies, a convolution of stereotypes and slogans, will become a vibrant display of solidarity, harmonious work, and effective results.

Disclosures:

Dr Alarcón is Emeritus Professor and Consultant in the department of psychiatry and psychology at Mayo Clinic College of Medicine in Rochester, Minnesota, and an Editorial Board member of Psychiatric Times.