Letter to the Editor regarding ‘Defending and demonstrating the psychodynamic orientation in psychiatry’

To the Editor

Behavioral scientists routinely publish broad claims about human psychology and behavior in the world’s top journals based on samples drawn entirely from Western, Educated, Industrialized, Rich, and Democratic (WEIRD) societies . . . Many of these findings involve domains that are associated with fundamental aspects of psychology, motivation, and behavior – hence, there are no obvious a priori grounds for claiming that a particular behavioral phenomenon is universal based on sampling from a single subpopulation. Overall, these empirical patterns suggests that we need to be less cavalier in addressing questions of human nature on the basis of data drawn from this particularly thin, and rather unusual, slice of humanity. (Henrich et al., 2010, p. 61)

Cammell (2022) recently summarised debates about the efficacy of psychodynamic psychotherapy for mood disorders and reminded us of ‘the centrality and utility of the psychodynamic orientation to psychiatry’. However, this Editorial does not fully engage with the culturally specific nature of the psychodynamic orientation, nor the model’s relevance to culturally diverse societies.

The WEIRD individualism of the psychodynamic perspective

Cammell (2022) outlined the salience of personal mentalisation and narrative for patients. We agree that these are essential considerations and observe that the interpretation of mentalisation and narrative are necessarily based on the medico-scientific models used to understand the patient, their community and circumstances. Medico-scientific models of conceptualisation, diagnosis and treatment are, as Henrich et al. (2010) outlines above, based on a predominance of research theory, data and analysis from Western, Educated, Industrialised, Rich and Democratic (WEIRD) societies. Therefore, predominant models of psychiatric diagnosis and treatment formulation may be WEIRD-specific, and not necessarily generalisable to non-WEIRD communities in countries with considerable cultural diversity, like Australia and New Zealand.

In Australia, New Zealand, Canada, the United States, United Kingdom and Europe, the predominant sociocultural environment remains WEIRD, according to Henrich et al. (2010). The term WEIRD is employed to draw attention to the small proportion of the world population living in these countries who differ fundamentally from the majority. The key elements of the WEIRD cultural environment, in which the psychodynamic orientation developed, are individualism, impersonal tone, reputationally based as opposed to kin relationships and humanist rather than religious adherence. The consequent mentalisation conditions both psychological and psychiatric research that underpins most modern WEIRD medico-scientific therapeutics (Henrich et al., 2010). While medico-scientific theories and practices developed within WEIRD societies such as psychodynamic psychotherapy are often considered nomothetic and universal, they are actually idiographic and unique to those societies, and therefore do not translate readily for culturally and linguistically diverse communities, such as those in Australia and New Zealand.

Classical psychoanalytic theory arose from the treatment of mainly wealthy women in fin de siècle upper-middle-class Viennese culture, promulgated by a neuropathologically expert neurologist, Dr Sigmund Freud. Though there are now many daughter-therapies of psychoanalysis, some of these may also be considered potentially culturally specific therapeutic approaches, as they are situated within particular scientific-theoretic-societal contexts, usually WEIRD, e.g. Lacanian psychotherapy incorporating European structuralist and post-structuralist philosophy, or cognitive-behavioural psychotherapy with origins from ancient Greek Stoic philosophy.

Bio-psycho-sociocultural approaches

Cammell (2022) situated the psychodynamic orientation in a biopsychosocial model, which should be extended to the broader ‘bio-psycho-sociocultural’ continuum for contemporary Australia and New Zealand. For example, self-psychology may be better suited for a patient and therapist who concur in a WEIRD individualistic worldview than for a patient who draws strongly upon traditional Confucian concepts of kinship-based embedded identity, respect for elders and culture, within a non-Westernised illness explanatory model (Kleinman et al., 1978). The biological, psychological and social model that (Cammell, 2022) espoused as related to the psychodynamic orientation can be situated in a broader integrative model that encompasses biomedical sciences, psychology as well as anthropology, culture and comparative religion.

Within this cross-cultural perspective, psychiatrists recognise the distinctive explanatory models that patients, their families and communities employ to understand mental illness (Kleinman et al., 1978), as opposed imposing a biomedical disease or psychodynamic framework. Patient explanatory models (Kleinman et al., 1978), based on patients’ personal characteristics, education, occupation, socioeconomic status and sociocultural network, must be incorporated into provision of care. Based on exploration of explanatory models, conceptualisation of psychiatric illness and framing of treatment necessarily involve iterative collaboration between psychiatrists and patients, as well as complementary understanding of sociocultural idioms of distress – the specific words, phrases and actions that people in different cultures use to express distress (Nichter, 2010).

Rather than embracing a unified bio-psycho-sociocultural continuum, Western psychiatry is prone to overemphasise either Mind or Body, following this dichotomy in Continental Philosophy. Frances (2016) characterises this as biological reductionism (‘mindless’ psychiatry) vs psychological exclusivism (‘brainless’ psychiatry). The US National Institute of Mental Health (NIMH) is the vanguard proponent of the ‘mindless’ position, since the NIMH focuses almost exclusively on brain research that is unlikely to deliver improved clinical care in the foreseeable future (Frances, 2016). On the other hand, the British Psychological Society is presented as an example of psychosocial reductionism that is inimical to diagnosis, medication when necessary and societally approved involuntary treatment (Frances, 2016). Instead, Frances (2016) suggests integrating the three-dimensional biological, psychological and social approaches, but neglects a wider exploration of the culturally embedded nature of both the British Psychological Society and NIMH within a WEIRD worldview.

We recommend that psychiatry takes the broader integrative approach in countries with diverse communities, encompassing biological and psychological studies within sociocultural science that eschews reductionism. Tailoring psychiatric care, including psychodynamic therapy, requires ongoing dialogue regarding the views and needs of the patient, idioms of distress, their explanatory illness model, through this broader biological, psychological and sociocultural approach. The process of care-planning needs to be cognisant of WEIRD cultural basis for medico-scientific and psychodynamic conceptualisations, research, diagnosis and treatment, in order to allow for meaningful translation to the patient and the patient’s world. Psychiatrists should aim to provide less WEIRD, and more broadly three-dimensional bio-psycho-sociocultural patient care.