Psychiatric Polarities: Methodology and Practice

During the summer of 1989, as a newly minted resident in psychiatry, I was struggling with how to apply DSM-III and the biopsychosocial approach to patient care. I had chosen to do residency at Johns Hopkins because I was drawn to the Perspectives of Psychiatry approach to learning psychiatry articulated by McHugh and Slavney more than a decade earlier (1). As a second-year resident, I was forced to think carefully about the logic and ideas underlying how psychiatrists make sense of patients.

My struggle came to a head around the case of a middle-aged woman with bipolar disorder hospitalized because of severe depression after she and her husband were divorced. In trying to apply DSM taxonomy, I was torn between diagnosing her with a relapse of bipolar illness in a depressed phase versus an adjustment disorder as a disproportionate reaction to divorce. DSM-III provided a helpful way to differentiate the clinical presentation, albeit one that was not fully satisfying. While I was able to identify the biopsychosocial “levels” relevant to her condition, I was having great difficulty using that to lay out the logic of what caused my patient’s illness.

Enter my attending at the time, Phillip Slavney, one of the articulators of the Perspectives. After I presented the patient and pointed out my struggles, he referred me to a chapter on “Explanation and Understanding” in his book Psychiatric Polarities. Reading that chapter in the context of seeing this patient was a true eye-opening experience. It crystallized my intuitive sense that using a single approach to making sense of my patient’s entire condition was inadequate. The DSM-III’s atheoretical approach, which unfortunately persists to this day, was an oversimplification that failed to articulate the full richness of her illness. It provided neither an understanding of the etiology of her condition nor a clear direction about what I could do to help her.

The biopsychosocial approach, while suggesting factors I should take into account when trying to understand how my patient became ill, did not provide a logical way of integrating the several factors together. It was not clear, for example, how I should weigh molecular factors of a diseased brain with social factors that had to do with her divorce.

Polarities, in contrast, emphasized that I could concurrently apply two logics to make sense of my patient. On the one hand, I could think of her suffering from a brain disease—bipolar disorder—which I recognized because of its syndromic presentation. This led me to realize that she likely had a “broken part” in her brain, perhaps genetically inherited. I could explain her current presentation as a relapse of this brain disease in the context of stress, very much like how a patient with coronary artery disease might suffer a heart attack when hearing bad news. I could relate to this disease reasoning because it was familiar from my medical training and followed causal scientific explanations derived from empirical research.

On the other hand, reading Polarities helped me see my patient in a way that did not conflict with my scientific explanation of her brain disease. I recognized that I could relate to her suffering and demoralization resulting from the recent divorce. This approach of understanding did not require me to apply scientific causal reasoning. Rather, I only had to relate to the narrative of another human being through verisimilitude, in that her experience made sense to me.

As I continued through psychiatric training, I frequently returned to reading Polarities when I had to deal with ambiguities that arose while grappling with patients and their conditions. Our field by nature is ambiguous as it concerns itself with mental life and behavior. Ambiguities emerge in our thinking in the form of polarities, that, in addition to explanation and understanding, contrast mind with brain, the conscious with the unconscious, the intellectual (Hellenic) with the moral (Hebraic), patients with clients, and autonomy with paternalism. The latter two are unique given how vulnerable our patients can be, not infrequently limited in their ability to fully engage with decision-making.

Psychiatric Polarities has just been reissued, to my great delight. It gives me the opportunity to strongly recommend it as a must-read for all psychiatrists, especially those entering our field, to help deal with the abundant ambiguities of daily psychiatric practice. I recognize that I am biased in that my psychiatric training is grounded in the Perspectives and by the fact that I teach this myself these days (2). However, in this era where the “DSM-ology” remains the law of the land, and while the biopsychosocial model is fading because of its limited ability to help us think etiologically about patients, it is essential to revisit the fundamental thinking that underlies psychiatry.

The clearly written, carefully detailed chapters of Polarities provide an essential foundation in satisfying this need. Coupled with the four explanatory methods and logics of the Perspectives—disease, dimension, behavior, and life story—Polarities nourishes us by laying out the ideas behind two critical concepts central to the future of psychiatry. A single approach to making sense of patients is inadequate, and thinking about their conditions must, by necessity, result in formulation as opposed to simple diagnosis as DSM-5 would want us to do. In my case, Polarities set me up with a way of thinking that supports and sustains my confidence and success as a clinician to this day.