My work in psychiatry and psychotherapy is guided by several basic commitments concerning science, philosophy, diagnosis, and clinical practice. They are described here.
Psychiatry requires methodological pluralism rather than allegiance to a single explanatory framework. Following Jaspers, Havens, McHugh, Slavney, and Ghaemi, I favor using biological, psychodynamic, phenomenological, and other methods according to the problem at hand. This is not theoretical eclecticism: different questions require different methods, each judged by appropriate standards of evidence, coherence, and validity.
Descriptive and psychodynamic approaches are complementary, not antagonistic. Careful description or diagnosis tell us what condition or syndrome is present; psychodynamic formulation helps us understand how and why that person's characteristic patterns are sustained. Psychiatry loses something essential when either level is neglected. Psychodynamic approaches should be informed by descriptive diagnosis.
Psychiatric diagnoses should be valid, not merely reliable or pragmatic. Reliability is necessary, but agreement among clinicians does not by itself establish that a diagnosis identifies a real disease or condition. Psychiatric classification should be guided by validity: diagnostic categories should correspond, as closely as possible, to genuine psychopathological entities rather than merely useful conventions.
Personality disorders should not all be treated as equally dimensional. Dimensional approaches may be appropriate for personality syndromes of weak validity, but they risk obscuring conditions with substantial empirical support, specifically borderline personality disorder and antisocial personality disorder. These conditions should be preserved as distinct syndromes while the remaining personality disorders are more comfortably dimensionalized.
Borderline personality disorder is fundamentally a disorder of paradox. BPD is organized around recurrent contradictions in the experience of self and others, particularly the simultaneous need for and fear of interpersonal closeness (the need-fear dilemma). Patients may desperately seek attachment while sabotaging it, or provoke the very rejection they most fear. These paradoxes are central characteristics of the borderline syndrome.
Postmodernism has had a pervasive and detrimental influence on psychiatry and psychotherapy. Skepticism toward objective knowledge and the tendency to treat truth as socially or relationally constructed have weakened attention to diagnosis, psychopathology, and the enduring intrapsychic mind. Social and interpersonal context are important, but they do not displace the possibility of objective knowledge about the human psyche.
Mark L. Ruffalo
University of Central Florida College of Medicine
Tufts University School of Medicine
New Jersey Institute for Training in Psychoanalysis
Psychiatry requires methodological pluralism rather than allegiance to a single explanatory framework. Following Jaspers, Havens, McHugh, Slavney, and Ghaemi, I favor using biological, psychodynamic, phenomenological, and other methods according to the problem at hand. This is not theoretical eclecticism: different questions require different methods, each judged by appropriate standards of evidence, coherence, and validity.
Descriptive and psychodynamic approaches are complementary, not antagonistic. Careful description or diagnosis tell us what condition or syndrome is present; psychodynamic formulation helps us understand how and why that person's characteristic patterns are sustained. Psychiatry loses something essential when either level is neglected. Psychodynamic approaches should be informed by descriptive diagnosis.
Psychiatric diagnoses should be valid, not merely reliable or pragmatic. Reliability is necessary, but agreement among clinicians does not by itself establish that a diagnosis identifies a real disease or condition. Psychiatric classification should be guided by validity: diagnostic categories should correspond, as closely as possible, to genuine psychopathological entities rather than merely useful conventions.
Personality disorders should not all be treated as equally dimensional. Dimensional approaches may be appropriate for personality syndromes of weak validity, but they risk obscuring conditions with substantial empirical support, specifically borderline personality disorder and antisocial personality disorder. These conditions should be preserved as distinct syndromes while the remaining personality disorders are more comfortably dimensionalized.
Borderline personality disorder is fundamentally a disorder of paradox. BPD is organized around recurrent contradictions in the experience of self and others, particularly the simultaneous need for and fear of interpersonal closeness (the need-fear dilemma). Patients may desperately seek attachment while sabotaging it, or provoke the very rejection they most fear. These paradoxes are central characteristics of the borderline syndrome.
Postmodernism has had a pervasive and detrimental influence on psychiatry and psychotherapy. Skepticism toward objective knowledge and the tendency to treat truth as socially or relationally constructed have weakened attention to diagnosis, psychopathology, and the enduring intrapsychic mind. Social and interpersonal context are important, but they do not displace the possibility of objective knowledge about the human psyche.
Mark L. Ruffalo
University of Central Florida College of Medicine
Tufts University School of Medicine
New Jersey Institute for Training in Psychoanalysis