A False Dichotomy

One of the things that bothers me most about my field is the false dichotomy between biology and psychology. On the one hand, there are psychiatrists who over-diagnose and overmedicate without taking the time to get to know patients and truly understand their symptoms. They spend very little time with patients and try to solve everything with a pill, rather than providing psychotherapy or referring patients to a psychotherapist. These psychiatrists do not take into account the role of environmental stressors, lifestyle (nutrition, sleep, substance use), and learned patterns of thinking that can be successfully treated without medication.

On the other hand, there are therapists who over-pathologize and overanalyze. These therapists are married to unscientific, unsupported psychodynamic theories about the etiology of psychological problems which tend to attribute symptoms to supposed family dysfunction and internal conflicts. These therapists fail to take into account the powerful role of genetics and neurobiology in contributing to the patient’s symptoms. They ignore or discount the recent scientific advances in our field, and they do not employ empirically-supported treatments which have been demonstrated to be effective. They rely instead on their opinions and “clinical judgment.”

Neither side of this dichotomy serves its patients well, as both sides fail to appreciate the true complexity of the human experience. One side places all eggs in one very small proverbial basket (a pill), effectively abnegating the patient of any responsibility for behavioral, psychological, or environmental change. The other side places an unfair amount of blame on the patient and / or her family, searching for root causes that may not exist, traumas that may never have occurred, or dysfunction in normal thoughts and behaviors. Consequently, it is implied, if not blatantly asserted, that biologically-driven thoughts and behaviors are freely chosen and can be un-chosen just as freely with enough insight into said root causes, traumas, and dysfunction.

I am often disappointed by those mental health professionals who have so little scientific understanding of the interaction between genes and environment, between biology and psychology, between experience and neurodevelopment. They seem to forget that the mind is an abstraction of the brain, and the brain is part of the body. Their thinking is so dichotomous – disorder X was caused by either genes OR environment; treatment must be medication OR psychotherapy; it’s a neurobiological illness OR it is caused by environmental factors. They don’t seem to understand that, with mental illness, it’s rarely a question of “nature or nurture.” Rather, it is nature AND nurture, both of which come in many forms. Biology, psychology, and environment are constantly interacting, with each of these components profoundly impacting the other two.

I would like to see all mental health professionals develop a full understanding of and appreciation for biopsychosocial models of mental illness and evidence-based treatments. It is my hope that psychologists, psychiatrists, and mental health professionals from all disciplines will begin taking a more well-rounded approach to treating psychiatric disorders and helping people achieve mental health.

4 Replies to “A False Dichotomy”

  1. This is a very interesting post, and I agree, although I’m coming at it from the researcher/scientist view. The way I see it, the same is true in the most basic eukaryotic organism: Yeast.

    If you take away something in it’s environment, the yeast will alter it’s gene expression in order to adapt to survive and grow. Or maybe you can add something else to help the yeast survive.

    If the yeast has a certain genetic background (for example, what makes me different than you), the yeast will respond differently to the environment and environmental changes.

    With people, there are obviously so many more genes and environmental contributors (and interactions between both at all points of development) involved in making us humans as amazingly complex and unique as we are…

    I’m thinking, though, that if the data’s strong enough to support or refute a particular viewpoint, why shouldn’t it be applied in practice? It’s hard to argue with good data.

  2. Shells,

    You make an excellent point about the gene/environment interaction, and I love your yeast analogy. I agree completely that clinical practice should follow empirical data. If there is enough scientific evidence to support a particular treatment, it should be offered as the first line of defense unless there is a clear and convincing reason to do otherwise!

  3. Shells,

    w00t for microbiology! I was reading the book “Microcosm” by Carl Zimmer and he talked about the profound effects that environment has on E. coli and how the nature/nurture debate goes both ways: environment affects genes AND genes affect environment. You couldn’t split the two concepts, even if you wanted to.

  4. Terrific work! This is the type of information that should be shared around the web. Shame on the search engines for not positioning this post higher!

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