What's Your Orientation to Practicing Psychotherapy?

 What’s Your Orientation – to Practicing Psychotherapy?

Steven J. Ceresnie, Ph.D.

New patients sometimes ask me about my approach or orientation to psychotherapy.

After 45 years of practicing psychotherapy, I say something like, “Some people worry that

‘orientation’ means a rigid method. I draw on different approaches depending on what fits you

best. I hope to create a place where you feel comfortable to talk about whatever is on your mind

without fear of judgment. We will find out together what is helpful to you.”

Although I know there are many approaches to psychotherapy, for me, I think most

approaches fall into these five broad categories:

 Psychoanalysis and psychodynamic therapies

 Behavior Therapy

 Cognitive Behavioral Therapy

 Humanistic therapy

 Family Therapy

Psychoanalysis or psychodynamic therapy draws from the work of Sigmund Freud and

his many followers who made significant advances to his theories and practice. This therapy

explores the role of the unconscious and past experiences to understand present behaviors,

thoughts and feelings – and learn how these past experiences influence the present. Analysis of

the doctor/patient interactions – the transference - is an important part of learning how past

relationships influence the patient’s present relationships.

Freud’s best idea is the notion of the unconscious mind at war with itself. Freud was a

brilliant writer and was nominated multiple times for the Nobel Prize. He did win the prestigious

Goethe Prize for Literature. Freud’s books, such as, “Civilization and Its Discontents,” takes you

by the hand to travel the logic of Freud’s thinking. He anticipates arguments about his ideas and

offers counterarguments that make the case for his creative descriptions of how the mind works.

The are many ideas in Freud’s theories such as penis envy, the death wish, the stages of

development – oral, anal, phallic and genital – that are difficult to believe and even more difficult

to scientifically test. There is something liberating about Freud’s openness to sexuality –

particularly for those who are sexually marginalized.

In the 1990’s, I was a member of a psychoanalytic study group. The five members of the

group would meet weekly with an experienced psychoanalyst at his home and discuss cases and

read important papers from the psychoanalytic literature. I was convinced about the importance

of unconscious processes, defense mechanisms, and transference. All of the group members,

except me, became psychoanalysts. When I asked my mentor who was a psychoanalyst if I

should become a psychoanalyst, he said, “Do you have that kind of time?”

I decided I didn’t.

Behavior Therapy shuns the workings of the internal mind and focuses on observable

behaviors. The psychotherapist studies the patient’s learning history and modifies the patient’s

behavior applying a sophisticated understanding of classical conditioning, operant conditioning,

and schedules of reinforcement.

John Watson was the American psychologist who first popularized the scientific theory of

behaviorism. Watson and his second wife, Rosalie Rayner, carried out a classic study in 1920 of

“Little Albert.” Watson and Raynor conditioned Little Albert, a 9-month-old boy, to fear a white

rat. They did this by clanging an iron rod when a white rat was presented to Little Albert. First

pairing the clanging of the rod with the sight of the white rat, then showing the rat to the boy

without the clanging, demonstrating the power of classical conditioning.

Watson’s most famous quote is:

“Give me a dozen healthy infants, well-formed, and my own specified world to bring

them up in and I’ll guarantee to take any one at random and train him to become any type of

specialist I might select – doctor, lawyer, artist, merchant-chief and yes, even beggar-man and

thief, regardless of his talents, penchants, tendencies, abilities, vocations, and race of his

ancestors. I am going beyond my facts and I admit it, but so have advocates of the contrary and

they have been doing it for many thousands of years.”

Watson began a second career working in the advertising field for the U.S. advertising

agency J. Walter Thompson. Watson rose up the ranks in his advertising career, earning more

than his academic salary. Watson is credited with popularizing the “coffee break,” during an

advertising campaign he created for Maxwell House coffee.

B.F. Skinner made major contributions to the behavioral approach. Skinner was an

English major at Harvard who wanted to be a novelist. When Skinner was 23 years old, he read

an essay by H.G. Wells about Pavlov. Skinner then attended a lecture by Pavlov. While Pavlov

focused his work on classical conditioning, Skinner concentrated on operant conditioning – the

learning by experiencing the consequences of your actions. Skinner’s major research explored

how operant conditioning could shape behavior in animals and people. Like Watson, Skinner

focused on observable behavior. Skinner increased our understandings of learning mechanisms,

emphasized the power of partial reinforcement (rewards), and how a schedule of reinforcement

that offer rare and random rewards can make a behavior difficult to extinguish – like gambling.

When I started my career, I was excited about the behavior therapy approach and the

many experiments that illustrated the power of classical and operant conditioning. Although,

when I first heard the word “reinforcement” I had the image of round sticky circles stuck to the

pages of my papers in my loose leaf so the holes in the pages wouldn’t tear. I tried applying the

principles of behavior therapy to my psychotherapy work and quickly learned, as my father

would tell me to my dismay, people are complicated. But, not so complicated that people often

unwittingly reinforce unwanted behaviors. Using reinforcement to reward successive

approximations to a goal is a powerful way to shape behavior. Think of your ski instructor ---

giving you positive comments for each step you take making your way down the hill.

Cognitive Behavioral Therapy combines cognitive and behavioral techniques to treat

mental maladies. Early on, I was impressed by Albert Ellis’ book, “A Guide to Rational Living.”

The book presented a sensible guide to help rid ourselves of irrational beliefs and create a path to

mental health. I was reminded of the comedian Rodney Dangerfield who was an expert at

irrational, humorous observations who quipped, “If everybody doesn’t like you, chances are you

haven’t met everybody yet.”

I revised my view of Albert Ellis when I heard him lecture – he was a crass, creative

fellow who rarely missed a chance to make off color comments, such as: “People often say I

must do this, I must do that. These people are musterbaters.”

I felt that Ellis badgered his patients to fit his view about the poison of irrational thinking

causing mental distress. Yet, Ellis’ book, “Guide to Rational Living,” makes a strong case for

CBT and makes a significant contribution the ideas and practices of CBT.

Aaron Beck, a sensitive, gifted therapist with a background in psychoanalysis, is another

pioneer of CBT. He wrote many influential books applying CBT to depression, anxiety, OCD,

substance abuse and schizophrenia.

CBT has accumulated significant empirical support. Not all CBT therapists are like

Albert Ellis. In the hands of sophisticated, sensitive therapists, such as Aaron Beck, the

principles of CBT promote positive change. The patient learns the source of their unconscious

irrational beliefs that contributes to much of their mental maladies.

Humanistic Therapy focuses on self-awareness, personal growth, and self-healing. Carl

Rodgers popularized Client Centered Therapy. Here, the psychotherapist learns to carefully listen

to the underlying feelings of the patient, uses reflective listening as a communication skill where

the therapist focuses on what the patient is saying – including the underlying feelings – and

reflects this understanding back to the patient in the therapist’s words. The goal is to show

empathy, validate feelings, and encourage deeper understanding. This therapeutic, non-directive

approach emphasizes the client’s inherent capacity for growth and healing.

My uncle George went to the University of Chicago when Carl Rodgers was a counselor

there. In his freshman year, George met once with Rodgers for help to choose a major. George

was floundering and had no idea about a career path. I asked George about his meeting with

Rodgers and Uncle George said, “I couldn’t get advice from him, he kept repeating what I had to

say.”

Motivational Interviewing (MI) builds on the work of Rodgers and has four core principles:

1. Resist the righting reflex. Avoid telling people what to do.

2. Understand the patient’s own motivations. Help the person identify his or her values

and goals.

3. Listen with empathy, with an emphasis on reflecting listening.

4. Empower. Connect with the patient’s inner motivations, strengths, abilities and how

they want to accomplish change.

William Miller and Stephen Miller developed MI and describe the theoretical and

practical guidelines of MI in their excellent book, “Motivational Interviewing,” now in its fourth

edition.

I have taught part-time at a dental school for many years. First teaching five students

enrolled in the post-graduate orthodontic program and then teaching undergraduate dental

students. I found MI an effective method to teach dental students communication skills learning

reflective listening. MI offers a structured list of principles and rules to guide students, and

gently confronts the patient’s ambivalence for change. Who is not ambivalent about going to the

dentist?

Family Therapy was a new, exciting therapeutic approach when I worked at a residential

psychiatric hospital for children and adolescents in the 1980’s. This was a time when, for

example, Salvatore Minuchin, a leader in family therapy, was featured in a long, influential

article in The New Yorker titled “The One-Way Mirror,” written by Janet Malcolm. Malcolm

went on to write: “Psychoanalysis: The Impossible Profession.” Jay Haley was another

prominent family therapist. His books include “Strategic Therapy,” “Ordeal Therapy,” and

“Leaving Home.”

I learned the world works in mysterious ways. I was relying on Haley’s book “Leaving

Home” when working with a mother and her 23-year-old daughter, who said she wanted to leave

home. Her mother was a waitress at a hotel near the airport. The mother came to one session

telling me there was a conference on family therapy in her hotel. She said, “I waited on a fellow

named Jay Haley.” Was this a message from God, a coincidence, or something else?

With my hospital colleagues, we formed a group to study and practice the tenets of

family therapy. We brought in an expert consultant in family therapy to discuss our therapy

cases. We would observe each other behind a one-way mirror meeting with an inpatient child or

adolescent with his parents. I thought I was on the cutting edge of a new therapeutic approach

that would make individual therapy obsolete. Unless you see the child with the family, the story

goes, there was no way you get to understand the family dynamics keeping the child the

“identified patient.”

So, early in my private practice, I met with families. What I didn’t know was that to be a

family therapist was to work bartender hours if you wanted to meet with working parents.

My excitement for practicing family therapy dwindled when I met with a child and his

parents for one year in my office. I was silently congratulating myself for my work with this

family – the child improved his school grades, showed improved relationships with his parents,

and made better friends. On the last session, as the family was leaving my office, I overheard the

child’s father say to his mother, “Now that this therapy is over, you think we can start having sex

again?” Oops.

All these psychotherapies mentioned work for some people, some of the time. My

experience teaches me there as many minds as there are bodies.

I like to use humor in my psychotherapeutic work. I have a rule I follow about using

humor: I never use humor with people I don’t like.

Over the years, I keep coming back to a book I read when I started my career. The book

is “Persuasion and Healing: A Comparative Study of Psychotherapy” by Jerome D. Frank, MD,

PhD. (Baltimore: The Johns Hopkins University Press, 1991; The third edition of this book is

available). In this book, Frank makes the case that the effectiveness of psychotherapy is more

about universal elements present in all therapeutic systems, and less about the specific techniques

tied to specific theories of psychotherapy.

Frank claims that successful psychotherapy must achieve four key conditions:

1. An emotionally charged confiding relationship between therapist and patient.

2. A healing setting instilled with cultural authority and legitimacy.

3. A rational or conceptual scheme that explains the patient’s distress.

4. A ritual or procedure consistent with that rationale, followed by patient and therapist.

That there are common factors underlying all theories does not mean a beginning

psychotherapist should not immerse themselves in a theory that fits her temperament and

understanding of human nature. With experience, we all learn to hold our theories lightly and

adjust to the needs of our patients.

Frank offers a trenchant quote about the least common denominators of all therapies:

“…the least common denominator of all therapies, and the one to which their claims to

success must depend on, is the ability to combat a destructive state of mind which characterizes

persons who seek psychotherapy, whatever their specific symptoms. The state may be termed

demoralization…feelings of helplessness, hopelessness, impotence, isolation…Since the

meaning of life derives from the ties of individuals with persons whose values they share,

alienation may contribute to a sense of meaninglessness.”

(To comment on this article contact Dr. Ceresnie at sceresnie@gmail.com)

Evolutionary Psychologist David Buss on his book, "Men Behaving Badly."

 4/27/25

Can evolutionary psychology untangle the roots of sexual conflict?

IN MARCH, FACING MULTIPLE COMPLAINTS of sexual harassment, New York’s three-term Democratic governor, Andrew Cuomo, issued an apology. “I never knew at the time that I was making anyone feel uncomfortable,” he said. “I never, ever meant to offend anyone or hurt anyone or cause anyone pain.”

To many, the apology seemed only to underline Cuomo’s cluelessness—or disingenuousness. How could he not have known that sexually charged conversations with subordinates, some of them young enough to be his grandchildren, were bound to offend?

Evolutionary psychologist and Berkeley Ph.D. grad David M. Buss has some answers.

“One of the pioneers of evolutionary psychology, David Buss lays out a theory of sexual conflict between men and women involving a co-evolutionary arms race.”

“On average, men find women more attractive than women find men,” says Buss, 68, professor of psychology at the University of Texas at Austin. Studies also have found that men tend to prefer women younger than themselves—and, as they grow older, their preferred age gap increases. Men in this situation tend to commit “mind-reading errors,” Buss says, finding it “unfathomable that the woman is not also attracted to them.” A male “sexual over-perception bias” could have led Cuomo to mistake a friendly or ambiguous signal, such as a smile, for sexual receptiveness.

“Not all men are equally susceptible to the sexual over-perception bias,” Buss adds. “What we found in our lab study is that men who are most inclined to do this are high in narcissism.” Other research shows that men with status or wealth “feel a sense of entitlement,” and “have this psychological proclivity to feel that the rules are made for other people, not for them,” he says. In other words: When you’re a star, they let you do it.

One of the pioneers of evolutionary psychology, Buss details these ideas in a new, ripped-from-the-headlines book, When Men Behave Badly: The Hidden Roots of Sexual Deception, Harassment, and Assault (Little, Brown Spark). Juxtaposing more than three decades of laboratory research with case studies from the animal kingdom, hunter-gatherer societies, and the Wild West of internet dating, he lays out a theory of sexual conflict between men and women involving a co-evolutionary arms race.

Evolutionary psychologists maintain that natural selection and sexual selection have favored specific traits and tendencies. One of the discipline’s core tenets is that reproductive biology has given rise to psychological differences between men and women—such as the male desire for sexual variety and the female preference for long-term commitment—that enhance mating success. Conflicts naturally arise because what is good for women is not always good for men, and vice versa.

Our modern cultural environment may have exacerbated these conflicts, Buss argues, leading to widespread sexual harassment, stalking, assault, and rape—patterns of conduct that the #MeToo movement and societies around the world have only just begun to confront. But Buss notes that he has been studying these issues for years. “The cultural zeitgeist happens to be coinciding with my work,” he says.

With its emphasis on human universals, evolutionary psychology has long been criticized for downplaying the role of culture, or for failing to disentangle culture and biology. Feminists have taken the discipline to task for what they see as an endorsement of gender-based distinctions and a sexist status quo. And there remain strong academic currents of what Buss calls “sex difference denialism,” exemplified by books such Gina Rippon’s Gender and Our Brains: How New Neuroscience Explodes the Myths of the Male and Female Minds (2019), which emphasizes brain plasticity, and Cordelia Fine’s Testosterone Rex: Myths of Sex, Science, and Society (2017). Fine suggests that the social impact of overstating evolutionary differences is the denigration of women’s professional ambitions.

In this new book, his first in a decade, Buss confronts such criticisms directly, positing a complex relationship between patriarchal cultural institutions and evolved psychology. He also seeks to identify the personality types of men most likely to transgress against women. Far from endorsing the status quo, Buss writes that he hopes to raise consciousness and spur change, to “reduce the occurrence of sexual conflict and heal the harms it creates.”

IN THE EARLY 1970s and early 1980s, evolutionary psychology did not yet exist. “No one studied human mating strategies, and sex differences were believed to be trivial or nonexistent,” Buss wrote in a 2003 paper, “Sexual Strategies: A Journey into Controversy,” in the journal Psychological Inquiry. “If there was a nature to humans, according to mainstream assumptions, it was that humans had no fundamental nature. People were plastic, formless, passive receptacles whose adult form was achieved solely by input that occurred during development.”

Buss himself has been integral to changing these attitudes. “David is the world’s foremost researcher on the psychology of sexuality,” says Steven Pinker, the renowned Harvard professor and experimental cognitive psychologist. “He has a grasp of deep ideas from evolutionary biology, insight into human motives and emotions, ingenuity about research methods, and the right combination of moral seriousness and good-natured humor.”

Buss describes his own nature as rebellious. Born in Indianapolis, he moved repeatedly as a child—from Pittsburgh to northern New Jersey to Austin—each time his father, a psychology professor, switched jobs. His mother, a homemaker, worked with the NAACP to combat housing discrimination. Buss’s adolescence was bumpy. “My grades absolutely plummeted, in part because of the peer group that I got involved with,” he says. He dropped out of high school after two marijuana possession arrests (both times the charges were dropped) but earned a diploma at night school.

Matriculating at the University of Texas, he finally found his academic footing. He encountered evolutionary theory—“the first intellectual idea that mesmerized me,” he says—in a freshman geology class. His 1975 psychology term paper, “Dominance and Access to Women,” made the then-novel argument that men competed for status to gain sexual access to women.

At Berkeley, Buss focused on personality psychology. One of his mentors, Jeanne H. Block, was a leading exponent of the idea that sex differences were the result of socialization, not biology. But as an assistant professor at Harvard, Buss met others who shared his evolutionary outlook—including the husband-and-wife team of John Tooby and Leda Cosmides and the entomologist E.O. Wilson, author of the controversial 1975 book Sociobiology, which emphasized the biological roots of social behavior. Buss also incorporated into his lectures the ground-breaking 1970s work of the anthropologist Donald Symons, on the evolution of human sexuality, and the biologist Robert Trivers, on sexual selection and parental investment.

Buss came to believe, “that mating was the center of the psychological universe”—and that men and women had different sexual psychologies.

Buss’s breakthrough was a collaborative multiyear study of mating preferences, the International Mate Selection Project, encompassing 10,047 subjects from 37 cultures. (“My Nigerian colleague wished to know whether I sought mate preferences for a man’s first wife, second wife, or third wife,” Buss noted wryly in Psychological Inquiry.) Published in 1989, after Buss had moved to the University of Michigan, the study demonstrated that men universally valued youth and physical attractiveness in women—presumptive markers of fertility. Women, by contrast, sought long-term mates with high status and economic resources to provide for them and their offspring.

Buss came to believe, he wrote in Psychological Inquiry, “that mating was the center of the psychological universe”—and that men and women had different sexual psychologies. Over the years, he refined and expanded his theories, looking, for example, at the varied mating strategies—both long- and short-term—employed by men and women. Buss (who has taught at the University of Texas at Austin since 1996) has written several books for popular audiences: The Evolution of Desire, The Dangerous Passion (on jealousy), The Murderer Next Door (on homicide), and, with Cindy M. Meston, Why Women Have Sex. He also authored a textbook, Evolutionary Psychology: The New Science of the Mind, the first, and still the dominant text, in the field.

Buss’s research has given him insight into his own behavior, too. He describes himself as “basically, exclusively, a long-term mating guy”—divorced, with two children; widowed when his second wife died of cancer after a 20-year marriage, and now in a “very happy” more than eight-year-long partnership with another professor at the University of Texas at Austin.

“For much of my life, I’ve been very shy with women,” Buss reflects. Evolutionary psychology predicts that women will prefer self-confident men, since self-confidence is a cue to status. And as he attained professional success, Buss says, “I’ve shown more self-confidence in approaching women who strongly attract me.”

WHEN MEN BEHAVE BADLY IS, in part, the product of Buss’s growing consciousness of the prevalence and impact of sexual assault and harassment. So many women he knew “had been touched by sexual violence,” he says. “The range was tremendous, from mild to horrific. But I saw the psychological scars it created.”

Buss remembers a friend of his college girlfriend “sobbing hysterically about being sexually abused.” He heard a girlfriend consoling her best friend, who “screamed in rage and anguish for hours,” after being raped by two strangers. Yet another girlfriend told him she had been raped by someone she met in a bar. A former partner revealed a history of repeated rape that led to chronic “black hole” depression.

He recalls examples of sexual harassment as well: Four female graduate students complaining to their department chair about a male professor’s unwelcome advances. A graduate student told by an interviewer that he could not hire her “because he wanted to ask her out, and he couldn’t do so if she were in his employ.”

During Buss’s undergrad years, professors threw keg parties where teaching assistants would have “their arms draped around the undergraduates,” he says. And it was not unusual for professors themselves to sleep with undergraduates.

“I started talking to more and more women, some close female friends, some just women I knew. And many confided in me,” Buss says. “I started to realize how pervasive various forms of sexual violence were.” He published a 2011 paper, “The Costs of Rape,” examining its traumatic aftermath. “Even though I think of myself as empathic for a man,” he says, “I realized that, at some level, I had been clueless. And, undoubtedly, I still am clueless, since I don’t think it’s possible for a man to fully grasp how psychologically devastating these things are to women.”

WHEN HE FIRST CONCEIVED OF WRITING a book on sexual conflict, Buss figured he would try to be even-handed—to note, for example, that both men and women engage in tactics designed to enhance their mating prospects. Women’s efforts to avoid what Buss calls “subpar males” or their requirement of “extensive courtship displays before consenting to sex” have inspired male adaptations designed “to circumvent these barriers,” including lying about their income and their interest in commitment, he writes in When Men Behave Badly. Women, too, engage in deception—for instance, by under-reporting their weight or posting photoshopped or old pictures on dating sites, he says.

But the even-handedness Buss contemplated had its limits, he discovered. “When you get to sexual violence,” Buss says, “it is the case that men are primarily the perpetrators, and women are primarily the victims.” Predator-prey analogies, gleaned from the animal kingdom, are “disturbingly on point,” he writes, and help explain behavior such as sexual harassment, stalking, rape, and intimate partner violence.

Stalking and violence may arise from male jealousy, provoked by fears of sexual infidelity, mate defection, and paternity uncertainty. Studies have shown that female jealousy, by contrast, focuses more strongly on emotional infidelity, linked to the possibility of losing male investment in current or future offspring.

Another trigger of violent, controlling, or abusive behavior is what Buss calls “mate-value discrepancy,” which can be aggravated by changing circumstances. A man who loses his job, for example, might worry that his diminished resources would impel a partner to “mate switch”—that is, trade him in for a newer, more prosperous model.

One ongoing (if somewhat arcane) discussion within evolutionary psychology concerns whether men have evolved specific rape adaptations because sexual aggression results in more offspring. The alternative view is that rape is instead a byproduct of such factors as the male desire for sexual variety and low-investment sex. Parsing the evidence, Buss prefers the byproduct theory, and argues that rape could be reduced by “[a] diminution of patriarchal ideology, stronger enforceable laws, greater police sensitivity to victims of sex crimes, and a more educated populace.”

Throughout the book, Buss insists that evolutionary psychology should not be tarred by the so-called naturalistic fallacy, which confounds what is with what should be. “Adaptive … does not mean morally good,” he writes. “Identifying evolutionary origins of nefarious behavior in no way justifies or excuses it.”

Buss also aims to present a nuanced view of the relationship between culture and sexual psychology. The failure of patriarchal legal systems to recognize spousal rape, for example, is an artifact of “men with an evolved sexual psychology that prioritizes their rights,” he says. “Once those laws exist, though, they do exert a social pressure.” By the same token, changing legal and social norms can discourage patriarchal or sexist behavior.

In fact, human beings are intensely responsive to such factors as social reputation and group consensus, if only because reputation bears on mating success. (Accusations of sexual misconduct, one might recall, led to divorces for men such as the film producer Harvey Weinstein and former New York governor Eliot Spitzer.) “Sexual psychology gets played out in a social and cultural context,” Buss says, and contemporary developments such as the #MeToo movement are sending tremors through government, academe, Hollywood, publishing, and the rest of the culture.

Not all men, of course, are guilty of offensive conduct against women. To pinpoint those who are, Buss returns to personality theory and the research of Delroy L. Paulhus, professor of psychology at the University of British Columbia at Vancouver (who did a sabbatical at Berkeley). Paulhus has identified three subclinical personality types whom he calls the “Dark Triad”: men high in narcissism (marked by a sense of personal entitlement), Machiavellianism (the tendency to manipulate and exploit), and psychopathy (lack of empathy). In a 2002 paper with Kevin M. Williams, Paulhus called these “overlapping but distinct constructs.” (He and two collaborators have since added “everyday sadism,” making for a “Dark Tetrad.”)

In Buss’s view, it is Dark Triad men who are most apt to sexually harass, stalk, assault, and rape women. Geographic mobility and the potential for anonymity in urban settings have made Dark Triad personalities harder to detect and ostracize, Buss hypothesizes. And women living alone, lacking the “kin protection” of their hunter-gatherer ancestors, are more vulnerable to their predations. Modern life may be spawning an increase in “a psychopathic strategy,” Buss says. “It’s just easier for men to get away with deception,” and worse.

Buss says he used to consider himself a pure scientist, uninterested in applications of his work. But that has changed. “Over time,” he says, “I’ve actually realized that this work has profound implications for solving some real social problems, and I think sexual violence against women is … the most pervasive human rights problem in the world.” Not that scientific knowledge is “a magic bullet that’s going to cure everything. … [But] the assumption that male and female sexual psychologies are identical is a harmful position to take, given that we know that they are not.”

There are lessons in evolutionary psychology for both men and women, Buss suggests. Learning about such phenomena as “the male tendency to infer interest where there is none” can be helpful, he says. “It doesn’t necessarily mean you’re going to be able to prevent experiencing the bias, but you might be able to correct it.” (Andrew Cuomo, take note.)

“In an ideal world,” Buss adds, women would be free not to worry that certain behaviors, such as imbibing intoxicants or rejecting undesirable suitors, might subject them to male sexual aggression or coercion. But, in our world, he says, “not informing women about the circumstances in which they’re at risk is morally problematic, to put it mildly.”

Julia M. Klein, a cultural reporter and critic in Philadelphia, has written for the New York Times, Wall Street Journal, Los Angeles Times, Mother Jones, Slate, and other publications. Follow her on Twitter @JuliaMKlein.

Book Review: "In a Different Key. The Story of Autism"

 4/27/25

This is an extraordinary book. John Donvan is a television correspondent for ABC, and Caren Zucker is a journalist and producer. Together, they have dug deep into the history of autism – from an unknown psychiatric disorder to a diagnosis climbing from 4 to 5 cases per 10,000 people in 1966 to approximately 1 per 100 today. Donvan and Zucker tell the story of autism in 46 fast-paced chapters, presenting detailed accounts of the biographies of the characters: parents, children, psychologists, physicians, advocates and more --- each viewed as if seen through a hand held camera.

When a child in a family is not right, the whole family suffers.

Such was the case when Donald who was born in 1933 to affluent parents in Forest, Mississippi.

Donald was an odd child:

When he was seven, an examiner asked him a question for the Binet-Simon IQ test. If I were to buy four cents’ worth of candy and give the storekeeper ten cents, how much would I get back? I’ll draw a hexagon, Donald replied….He showed scant interest in the inhabitants of the outside world, and that included his parents. Of all his peculiarities, this was the most difficult for them to accept – that he never ran to his father when he came home from work, and that he almost never cried for his mother. Relatives were unable to engage him…Oblivious to those around him, he would turn violent the instant his activities were interrupted…it became clear he was protecting sameness.

Mary Triplett, Donald’s mother concluded that he was hopelessly insane, before the diagnosis of autism was invented. Her husband, Oliver, a lawyer, was known as Beamon to everyone, and was the former mayor’s son. Their doctor advised them that they had overstimulated Donald and he should be placed in an institution.

During the first half of the twentieth century, children like Donald were called a string of derogatory labels:

Cretin, ignoramus, simpleton, maniac, lunatic, dullard, dunce, demented, derange, schizoid, spastic, feebleminded, and psychotic.

Even in Dr. Benjamin Spock’s (1903 – 1998), “The Common Sense Book of Baby and Child Care,” first published in 1946, he recommended that parents immediately place a Mongolian baby in an institution.

For families like Donald’s, sending their child to an institution far from their home created shame, guilt, sorrow, confusion and loss:

They sent away their children in secret, and in time, the children themselves became secrets, never to be spoken of again.

Mr. and Mrs. Triplett brought Donald back home from the institution and took him to be evaluated by the eminent child psychiatrist Leo Kanner (pronounced “Kahner”; 1894 - 1981) at Johns Hopkins hospital in Maryland.

Donald was case number 1 in Kanner’s major work published in 1943, “Autistic Disturbances of Affective Contact.” Dr. Kanner studied eleven cases, 3 girls and 8 boys, he later called autism. ”It was Kanner who identified the two defining traits common to all of them: the extreme preference for aloneness and the extreme need for sameness.” Donald is now 82 years old.

The first time I evaluated an autistic child in the 1970s, I met two warm, loving, guilt-ridden parents telling me through their tears about their unresponsive, odd five year old child who didn’t talk and was obsessed with playing with door knobs and hinges. When this child entered my office, he walked past me as if I wasn’t there and went straight to the curtain and began sucking the on the cloth.

I was aware that blaming mothers for causing autism --- and other psychiatric disorders --- was the theory many clinicians studied to diagnose and treat autistic children.

Bruno Bettelheim (1903 – 1990), a prominent child psychologist, who had a Ph.D. in art history, was a famous clinician who promoted that theory. He wrote and lectured that “refrigerator mothers” raised their children in a climate of emotional frigidity causing autism. Bettelheim recommended a “parentectomy”, taking these autistic children away from their parents and putting them in a therapeutic milieu. Bettelheim founded the Orthogenic School at the University of Chicago as a residential treatment program.

I couldn’t square my subsequent many encounters with autistic kids and their parents with the refrigerator mother theory expressed in Bettelheim’s famous book, “The Empty Fortress.” My doubts about this blame the mother theory of autism were reinforced in a yearlong seminar taught by Fritz Redl, a contemporary of Bettelheim, and a brilliant teacher and writer. In this seminar of 8 students, 3 of the students had worked for Bettelheim, whose nickname they said was Bruno Brutalheim --- because of how he treated staff, children and parents.

In 1990 Bettelheim committed suicide, his method placing a plastic bag over his head. My thought was he recognized the monstrous damage he inflicted on children and their families with his cockamamie theory and treatment approach to autism. But who can know for sure.

Donvan and Zucker uncover the stories of courageous characters who fought against the blame theory of autism. Scientists, sometimes with an autistic child of their own, and parents of autistic kids worked tirelessly to get kids out of institutions, band together to make the education establishment teach autistic kids in public schools, find behavioral treatments that worked, and more.

The media did much to broadcast and humanize the life of autistic people For example, the brilliant movie “Rain Main” told the sensitive story about an autistic man starring Dustin Hoffman (1937 - ); Temple Grandin (1947 - ), the first celebrity autistic adult with a Ph.D. in biological sciences and a professor of animal sciences at Colorado State University wrote best-selling books about growing up with autism and lectures around the world. A movie about the life of Temple Grandin garnered rave reviews, starring Claire Danes (1979 - ). Oliver Sacks (1933 – 2015), the brilliant neurologist, wrote a book of essays called, “Anthropologist on Mars,” with the title referring to his chapter on Temple Grandin.

Along the way there were many missteps among autistic advocacy groups and scientific findings:

It was an early harbinger of the tragic tendency of autism advocacy groups, or individuals in them, all supposedly dedicated to the same cause, to turn against one another. It had been there at the beginning, and it would flare up, again and again, to the detriment of the greater cause, in every decade to follow.

In 1998, a British physician published a shocking paper in the well-respected Lancet journal claiming that the MMR (measles-mumps-rubella) vaccine may cause autism. The study was eventually discredited, the physician lost his license, but not without significant panic in the community about the safety of giving children vaccines. Many educated people stopped giving their children the MMR vaccines and “measles was becoming active again the United States, with reported infections reaching a twenty –year high in 2014.”

Whether we are witnessing a true increase in the autistic population, or whether the definition of autism on a spectrum makes the difference in numbers remains controversial.

Because we know so little about the complex etiology of autism, crank, expensive treatments masquerading as science promising quick cures lurk at the doors of progress, waiting to lure parents down the road of dangerous psychiatric misadventures.

Advocacy for autistic children and adults is essential and must be driven by scientists.

My Letter about Autism Published in the Wall Street Journal

 4/27/25

Progress in Treating Autism but No Magic Bullet So Far

Crank, expensive autism treatments masquerading as science promising quick cures, lurk at the doors of progress, waiting

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Jan. 29, 2016 11:05 am ET

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Regarding Dr. Richard McNally’s fine review of John Donvan and Caren Zucker’s extraordinary book “In a Different Key” (Books, Jan. 23): The first time I evaluated an autistic child, in the 1970s, I met two warm, loving, guilt-ridden parents telling me through their tears about their unresponsive, odd five-year-old child who didn’t talk and was obsessed with playing with door knobs and hinges. When this child entered my office, he walked past me as if I wasn’t there, and went straight to curtains and began sucking on the cloth.

Scientists discovered the importance of genetics in autism and devised behavioral methods to help some autistic children reach closer to their potential and live lives of meaning. Because we know so little about the complex etiology of autism, crank, expensive treatments masquerading as science promising quick cures lurk at the doors of progress, waiting to lure parents down the road of dangerous psychiatric misadventures.

Steven J. Ceresnie, Ph.D.

Plymouth, Mich.

Interview with psychiatrist Paul McHugh, M.D.

 4/27/25

Explanatory Methods in Psychiatry: The Importance of Perspectives

Author(s):

Awais Aftab, MD

Series|Conversations in Critical Psychiatry

It is a rare feat for a conceptual book on psychiatry to generate as much acclaim, influence, longevity, and readership within the profession as has The Perspectives of Psychiatry. Paul R. McHugh, MD is featured in this Conversations series.

Awais Aftab, MD

Paul R. McHugh, MD

Conversations in Critical Psychiatry is an interview series aimed to engage prominent critics within and outside the profession who have made meaningful criticisms of psychiatry and have offered constructive alternative perspectives to the current status quo.

CONVERSATIONS IN CRITICAL PSYCHIATRY

Paul R. McHugh, MD, is University Distinguished Service Professor of Psychiatry at the Johns Hopkins University School of Medicine. He was the Henry Phipps Professor and Director of the Department of Psychiatry and Behavioral Sciences at the Johns Hopkins University School of Medicine and Psychiatrist-in-Chief at Johns Hopkins Hospital for 26 years. He is also the inaugural Director of the Paul R. McHugh Program for Human Flourishing. Dr McHugh is a nationally recognized figure: he was elected a member of the National Academy of Medicine in 1992, and from 2002 to 2009, he was a member of the President’s Council on Bioethics. He is the author of many books, most popularly of The Perspectives of Psychiatry (co-written with Phillip Slavney, MD), which presents a conceptual framework for the proper evaluation and understanding of psychiatric disorders.

Building on the philosophical work of forerunners such as Adolf Meyer and Karl Jaspers, The Perspectives of Psychiatry identifies four explanatory methods underlying the practice of the profession. In Perspectives, generations of psychiatrists have found a nuanced, unifying approach to the field, which the biopsychosocial model and the DSM had promised but never delivered. Although the Perspectives approach was not formally taught during my residency, I was fortunate to work with several attendings who exposed me to the book, which led me to delve into the ideas on my own. The Perspectives approach demonstrates to me what a mature, pluralistic psychiatry can look like. It is my honor that Dr McHugh accepted my request to engage in a conversation regarding his ideas.

Awais Aftab, MD: It is a rare feat for a conceptual book on psychiatry to generate as much acclaim, influence, longevity, and readership within the profession as has The Perspectives of Psychiatry. When the first edition was published in 1983, did you expect that the book would be such a hit and that people would still be reading and recommending it nearly four decades later? Why do you think the book has endured for so long?

Paul McHugh, MD: When Phillip Slavney and I conceived and wrote The Perspectives of Psychiatry, we certainly expected it to be noticed because it strove to make explicit what was often implicit (and, to patients, mysterious) in psychiatric thought. And, we expected it in some way to endure in that it identified fundamentals of mental life that would not change. We didn’t expect it to be a hit given its challenges to several established views and, for that matter, we do not think it is a hit now given that few departments of psychiatry teach from it. Although it may not have boomed, it certainly did survive-this year it is being translated and published in Japan-and mainly for the reason I mentioned: both psychiatrists and patients recognize that it clarifies the clinical enterprise by identifying, distinguishing, and reflecting on the methods psychiatrists employ in making sense of mental distress and disorder. It also heuristically directs treatment and research gives it practical value.  

Aftab: As popular as the Perspectives approach is, the biopsychosocial model remains the closest thing to an officially accepted conceptual framework in the field. From the nuanced viewpoint of Perspectives, the biopsychosocial model appears very vacuous and eclectic. Perhaps it’s the very vacuousness and eclecticism that explain the model’s widespread acceptability?

McHugh: You’re certainly correct in noting the common acceptance of the biopsychosocial model that George Engel was describing (and deriving from Adolf Meyer) just at about the time we were composing Perspectives. We think the biopsychosocial model survives because it can act as a slogan justifying any practice. It falters because it is neither refutable nor heuristic. By solemnly noting the obvious underpinnings of human life but providing no way to derive mental distresses and disorders from them-essentially offering ingredients without recipes-it’s sophistry.

Aftab: You have outlined in detail four perspectives (ie, brain diseases, personality dimensions, motivated behaviors, and life encounters), and the list has remained unchanged over your career so far. Are you open to the idea that there are valid perspectives other than these four? For instance, I can think of at least two. First, the evolutionary perspective, particularly situations of design-environment mismatch in which a brain mechanism that has evolved via natural selection thousands of years ago is now placed in a modern 21st century environment for which it was not designed, leading to distress or impairment. (There is no internal broken part, hence no disease). Second, the sociological perspective, which sees mental health issues in a population as a response to various social forces (for instance, Allan Horwitz’s work on depression). The sociological perspective is different from the individual life story perspective because it deals with complex phenomenon at the social level that cannot be described in terms of individual psychology.

McHugh: Although we believe that together the four perspectives we’ve outlined broadly and inclusively address the clinical explanatory problems of psychiatrists, we are open to the idea of other perspectives.  We certainly have had many such proposed to us, including a developmental perspective, a neurobiological perspective, a sociological perspective, and many others, but we have usually concluded that the proposers have not grasped what we mean when we speak about psychiatric perspectives and what we were doing in choosing these four.

Specifically, we were not writing a book that could carry the title “Causes of Psychiatric Disorder.” We were writing a treatise on the different methods psychiatrists need and use to make sense of mental disorders, and we were proposing that they derive those methods from what they can “see” of conscious mental life. We think psychiatrists are (or should be) aware of four basic, interactive, functional features of the mind that represent the compositional attributes structuring conscious mental life. Each of them can be viewed as a potential site of mental unrest. Those four are:

1. The intrinsic features-consciousness itself, memory, language, cognition, affect and the like;

2. The self-defining features-the individual’s intelligence, temperament, maturity, etc.;

3. The teleological features-hunger, thirst, sex, etc., and the wants and ‘needs’ tied thereto; and

4. The extrinsic/experiential features-responsivity to life events, social networks, education, etc.

Together, our four perspectives offer a way of making sense of mental disorders by drawing on these features and simultaneously offer a way of making sense of (ie, formulating) mental disorders in particular patients where a mix of perspectives can be expected. The disease perspective describes how psychiatrists strive to make sense of how neurobiological injuries can come to disrupt the functioning of one of the intrinsic features, as with delirium, dementia, or bipolar depression.  The dimensional perspective describes how psychiatrists strive to make sense of the vulnerabilities of some individuals to emotional unrest tied to aspects of the self-defining features characterizing them, such as the intellectually disabled, the histrionic, or the compulsive.  The behavior perspective describes how psychiatrists strive to make sense of such problematic, habit-sustained activities that arise from the teleological features, as with anorexia nervosa, alcohol dependency, or the sexual paraphilias. The life story perspective describes how psychiatrists strive to make sense of the emotional distresses that are generated by the play of events upon the extrinsic/experiential features of mind, as with grief, post-traumatic stress disorder, or demoralization.

This separation of the perspectives must not presume their independence of one another given that the functional features on which they rest interact. For example, an anxious patient (dimensional perspective) may develop an alcoholic dependency (behavior perspective) that could cause a demoralizing job loss (life story perspective) thereby prompting an increase in drinking, all leading to his clinical presentation with delirium tremens (disease perspective).

Given all this, we would view your two suggestions not as new or separate perspectives but as causal factors either shaping one of the mind’s basic features or an element in one of the four we describe. Thus, the evolutionary facts you identify as presenting problems in the contemporary era usually do so by altering the teleological features of mental life. So, for example, the genetic controls on food intake and calorie storage that evolved in some peoples and were useful for survival in times of shortage and deprivation can lead, if persisting amongst them, to overeating and obesity in times of plenty in today’s world. Still, the presenting problem of the patients would be behavioral in expression and emerge as alterations needing therapeutic attention in the drive, conditioning, and decisional aspects of their food intake. The social forces (including those studied by Allan Horwitz or Nicholas Christakis) provide the setting of the subject’s life experience and would be grasped in the life story perspective, where the triad of setting, sequence, and outcome make sense of the problems. While we are open to new perspectives, we argue, from what we mean by perspective, that a new one awaits the description of another compositional feature of the mind.

Aftab: What conceptual issues in psychiatry are the most important in your view? Issues that the new generation of psychiatrists and their conceptual comrades should focus on?

McHugh: The most important issue for psychiatrists to recognize today is that their discipline is at stalemate; it’s hesitating to come of age. This is an obvious problem of leadership.  Officially, the discipline will only codify the disorders it takes for its concerns rather than strive to classify them by their presumed nature as does internal medicine. Many psychiatrists are at a loss as to what disorders their discipline should claim. Instead of boldly stating that this discipline takes responsibility for any expression of human mental disarray from Alzheimer disease to zoophilia, many psychiatrists wonder whether mental disorders with known brain derivations shouldn’t be surrendered to neurologists. They anticipate that the advance of neuroscience will deprive them of their professional position, rather than enhancing what they could know and do.

The solution? Psychiatrists must understand that all aspects of mental life (including the mental disorders) are derived in some way from the brain but not in the way urine is derived from the kidney or bile from the liver. The derivation of mind from brain takes the form of an emergent property with constituent features and functional rules that cannot be directly reduced to knowledge of the neural systems from which it, the mind, emerges. Psychiatry is thus an autonomous medical discipline dealing with the kinds of clinical problems that present within the emergent mind. It’s time for its practitioners to start thinking and acting accordingly, perhaps by officially noting the ways those clinical problems can be organized according to what’s known of their natures.       

Aftab: In your opinion, what determines whether a particular condition is or is not a mental disorder? Is there an objective, fact-based answer to this (at least in part), or is it a thoroughly value-laden determination?

McHugh: We hold, and have specifically stated in our book, that because psychiatrists must employ several distinct methods to make sense of all the various disorders and distressful states they see, the definition of psychopathology, what is meant by normal, and the treatments that are suitable will differ with the perspective or perspectives that fit.

For example, the identification of a broken part or pathologic entity confirms the categorical designation of abnormality by the Disease Perspective. A patient here is somebody who has something “normal” people don’t. Similarly, the Dimensional Perspective makes sense of a troubled person as “abnormal” only in a statistical and arbitrary sense by showing their  vulnerability or at-risk status for emotional unrest depends upon their psychological deviation from the mean along the normal Bell-shaped distribution curves of human intelligence or temperament. One is identified as a psychiatric patient because of who one is.

The Behavioral Perspective encompasses people who are patients because they persist in enslaving activities that bring physical, psychological, and social disasters in their wake. They are identified as patients because they are doing something ordinary people don’t. Those whom psychiatrists recognize as people responding to a set of circumstances-such as the grief stricken, the demoralized, the traumatized, and the like-and whose plight psychiatrists grasp within the Life Story Perspective are patients primarily in the sense that they are people seeking professional (ie, diagnostic, prognostic, or therapeutic)  help because of the persistence or severity of their “normal” suffering, and those features usually depend not on them but on the intensity and significance of their loss or injury. They are patients because of what they’ve encountered. We think all these matters are of an objective fact-based nature and relate coherently to the complex issue of “normality.”

Aftab: In The Mind Has Mountains: Reflections on Society and Psychiatry, you wrote: “It certainly was no coincidence that Engel’s biopsychosocial concept, a restatement of Meyer’s position, emerged into prominence in the same decade as DSM-III. It met and satisfied the same felt need as had its predecessor. Psychiatry in the United States is replaying a set of themes from earlier in this century. It is both neo-Kraepelinian and neo-Meyerian.”

Your approach in some ways channels a different 20th century predecessor-Karl Jaspers. It’s interesting that more than a century later the Kraepelinian, Meyerian ,and Jasperian ghosts are still alive in psychiatry.

McHugh: We have, as you know, made no secret of the influence of Karl Jaspers on our thought. He did produce the first coherent study of methods of psychiatric reasoning that emphasized their strengths, weakness, and apt employment. Inspired by his example, we have striven to advance from Jaspers by both operationalizing methodological themes that he recognized and specifically differentiating methods of reasoning tied to distinct patient populations from one another. We believe that we have succeeded in that The Perspectives of Psychiatry has proven its value in advancing teaching, treatment planning, and research in our department at Hopkins in a way that the abstractions of Jaspers alone could not.   

Aftab: The Perspectives approach applies to individual patients, but you also talk of Perspectives approach as applying to particular conditions or disorders. Unless we can demonstrate that individuals with a particular condition are highly homogenous in terms of etiology (which is rarely the case in psychiatry), I am not sure we can validly talk about Perspectives applying to a disorder as a uniform category rather than individual patients, since whatever is said of a disorder may or may not be applicable to a particular individual with that condition?

McHugh: What you are saying is of course the very reason why we chose the metaphor perspectives-to remind ourselves and our students that an approach to an individual patient requires us to take into account several different aspects of their life and state of mind in making sense of their presentation; reminds us to formulate rather than simply diagnose the problem.  A Perspectival review structures and operationalizes the several elements of a formulation. On the other hand, it would be wrong to ignore that, for many clinical presentations, one perspective is so salient it can stand for the generative nature of the case. Some presentations are those of disease, some are behaviors, etc. Such examples can be used to develop a psychiatric classificatory system that will move from a denotative one (DSM-III et al.) in which disorders are named, described, and listed as would a field guide to birds or flowers  to a connotative one in which psychiatric conditions are distinguished and separately classified according to what’s understood of their primary cause, provocation, or generative mechanism as is standard with medical classifications.    

Aftab: In the heyday of psychoanalysis, it was a particular version of the life story perspective that reigned tyrannically, and these days the disease perspective threatens to engulf all the other perspectives. This problem is evident in the rhetorical statement “‘all mental disorders are diseases’” that has become the de facto mantra of not just psychiatrists but also patient and mental health advocacy groups. It seems to me the term disease is now being used in such a flexible manner that it is beginning to lose any specificity with which it may originally had.

McHugh: We, of course, are in full agreement with your view and attribute it to the commitment of psychiatry to the top-down checklist method of diagnosis tied to DSM. Steve Sharfstein said something of the same when he noted in his APA presidential address that the biopsychosocial approach had become the bio-bio-bio approach. However, there are many defenders of this development, some believing that it’s the way to advance a sense of the neuroscientific foundations of psychiatry; others believing that it reduces stigma and helps psychiatric patients by fundamentally making them all “victims” of some impersonal entity or afflicting disease. As far as the addictions are concerned, it has become an ideology-and one that will ultimately frustrate progress and patient care.    

Aftab: What are your thoughts on how to address psychiatry’s uneasy medical identity? For me, there are two ways to think about it. One, we can expand the boundaries of medical model to include all mental health conditions within it. This is the approach that we seem to have adopted at present. Since there is no hard and fast distinction between disorder and problems of living, it brings with it the downside of medicalization and pathologization (which is a constant complaint we hear these days). The other option, in my mind, is to acknowledge that psychiatry is a branch of medicine but that it is not just a branch of medicine; there are aspects and traditions within it that extend beyond the domain of medical model as traditionally understood (psychoanalysis, for instance-Freud never wanted to restrict it within the domain of medicine) and medicine does not have sole authority over psychological distress.

McHugh: This is an awkward question for me to answer given that I’ve never felt uneasy in my medical identity, that is, of being a doctor working to understand and treat patients with problems in mental life. I’ve also never felt the salvationist urge that provoked Freud to venture forth with his presumptions about human civilization and take on the mantle of Moses. In fact, I’m happy to accept the traditional, patient-centered limits to psychiatric service by devoting my thoughts and actions to the care of people who in one way or another are expressing distress or dismay in how they’re thinking, feeling, or behaving.

I’m happy to leave to other professions-those of law, education, government, and the like-the problems and solutions that they develop and derive from their experience and traditions. I’m happy to help-and sometimes to correct-if any enterprise in these arenas touches upon psychiatric matters or seems to be moved by erroneous views of disordered mental life. Those are rare. There is, though, one sense that all doctors including psychiatrists should extend their services beyond the strictly medical enterprises of diagnosis and treatment and that is in the public health arena of prevention and flourishing. I hold that psychiatrists have their own understandings about human development and welfare that, like physical hygiene, offers not only protection against illness but also advice on life directions and social protections that facilitate a person’s full, natural, healthy flourishing. I just don’t see that this kind of effort stretches the medical identity of psychiatry.

Aftab: You’ve been vocal about various cultural fads of diagnoses in which psychiatrists have been complicit. Do you have any hope that psychiatrists of the new generation are in a better position to protect themselves against such trends, or does your experience lead you to a state of despair in this regard?

McHugh: I have spoken out on a variety of psychiatric misdirections in my time, considering it my duty as one holding a distinguished academic position in the country. Along with that experience, I have occasionally wondered whether it is the fate of this discipline to take up some new craze every 15 or 20 years. Like physical health, mental health is open to social enthusiasms and presumptions that can sway the thought and actions of practitioners. Physical medicine, in contrast to psychological medicine, is protected from persisting in a craze by following fairly objective criteria-often laboratory based-in assessing success and failure. In the realm of the mind, fads run more freely and critics of them don’t often face convincing, reassuring data from the fad’s champions but insulting charges of bad faith and personal hang-ups. Sigmund Freud’s savagery against any critic of his views is the classical example. Also, to win a place in the medical taxonomy requires more than the simple votes of practitioners that brings admittance to DSM. New and protective demands thwarting fads might be found if the psychiatric classificatory method moves beyond the descriptive DSM. Demanding a place in one of the Perspectives might be a good start.  

Aftab: A lack of reliability has plagued psychiatry since the very beginning. DSM’s agnostic approach to psychiatry was partly meant to remedy that. Does reliability tend to be a problem for the Perspective approach? Since many individuals present with a mix of affective problems, anxiety, personality traits, traumatic life stories, and behavioral addictions, I’m sure psychiatrists can and do disagree on which perspective to consider most salient in a particular individual case.

McHugh: Like everyone in the early 1980s, I supported the reliability enterprise that Bob Spitzer advanced in the midst of the diagnostic confusions in psychiatry that came with the collapse of psychoanalysis and the rise of psychopharmacology. Much good came from this amazing feat of statesmanship on Bob’s part, as in pacifying clinical argument and in providing consistency for cross-laboratory case identification and for a population-wide census of mental disorders understood in DSM terms. It gradually dawned on me that DSM functions in identifying mental disorders just as does a naturalist’s field guide for naming birds, wildflowers, or trees with all the seductive ease and narrow purposes of that artificial classificatory method. It ran on the hope that future research-which with its “agnostic”, a-heuristic approach, it could not even suggest-would rescue it.  I had my doubts, then and now, closing on forty years later. I see that we’ve not advanced but are practicing psychiatry with checklist diagnoses and rule of thumb therapies, and we are still hypnotized by reliability as a gold standard. With the Perspectives of Psychiatry, we’ve striven to replace the DSM mantra of “reliability first, validity second” with the more challenging, future advancing one of our own: “intelligibility first, explanation second.”

And so to finally answer the question you’ve asked: Does our approach produce diagnostic and therapeutic disagreements? Indeed it does, but disagreements of the healthiest kind in which the arguments are about what makes the most sense for the patient at hand given the mixture of generative sources of distress and disorder the Perspectives bring to light. These disagreements (mostly over what to emphasize in a formulation and what to do given what we agree on) matter because they identify what doctors and patients want to know. That is,  have you really thought through the issues this patient presents and formulated them and the linkages between them coherently? Will your experience with this patient add to your capacity to care for others like him or her? And, finally, what research tied to your conclusions should we encourage to confirm or refute them so as to advance us all? When this is the daily enterprise of psychiatrists everywhere, the field will, at last and like medicine and surgery, have come of age.

Aftab: Any words of advice for psychiatry trainees?

McHugh: Know where you are and where this discipline must eventually go. In the process, see many patients, study each of them with a bottom-up method of assessment similar to that originally described by Adolf Meyer, then formulate and discuss the patients according to the interactive themes that The Perspectives of Psychiatry suggest. When possible, alone or with others, launch some research into questions your patients present. If you do all that, you’ll play a role in advancing your times. And I’m assuming that’s what you wanted to do when you joined the profession.  

Aftab: Thank you!