Abstract
To the editor,
I am writing in reference to the article published by Harari and Grant (2022), which reviews the potential contributions of psychodynamic concepts to clinical psychiatry. A further concept with clinical ramifications is, no less, the very nature of what we diagnose and treat.
Our prevailing clinical paradigm is governed by categorical diagnoses, such as those found in Diagnostic and Statistical Manual of Mental Disorders (DSM). Mental-illness is defined by lists of symptoms, which treatments aim to ameliorate.
Whilst discussing the transference phenomenon as a clinical tool, Freud noted that it is used: Not for suppressing the symptoms – this distinguishes the analytic method from other psychotherapeutic procedures (Freud and Strachey, 1969).
Freud was pointing out that analytic methods utilise the presence of symptoms, in the ‘here-and-now’, to usher in a deeper level of self-awareness. The essence of this idea was expressed by Freud as ‘Where It was, there should become I’.
Freud was espousing the value of facing the parts of ourselves which are unbearable and intolerable, and suggesting that the goal of psychoanalysis was integration. Psychodynamic treatments aim to integrate the psyche rather than remove symptoms. These are very different, and potentially contradictory goals, and require different clinical techniques. An informed psychiatrist should be equipped with the knowledge and know-how to apply both forms of treatment as indicated by the patient and their pathology.
Psychodynamic thinking is indeed a neglected gift. Without it, psychiatry becomes a conceptual wasteland which retreats into reductive, biological models of mental ill-health. Without dynamic models of the mind, we can lose focus and treat DSM diagnoses rather than people. This, I fear, will lead not only to poorer clinical outcomes. A reductive symptom-driven approach may alienate certain members of the public who have a more subjective sense of their own suffering, rendering psychiatry and its treatments irrelevant.
