My work in psychotherapy and psychopathology is guided by several basic commitments concerning science, philosophy, and diagnosis. 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 and diagnosis tell us what condition or syndrome is present; psychodynamic formulation may help us understand how and why a person's characteristic patterns developed and are sustained. Psychiatry is impoverished when either approach is neglected. Psychodynamic understanding 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 traits, but they risk obscuring personality syndromes with substantial empirical validity, specifically borderline personality disorder and antisocial personality disorder. Like Gunderson, I believe that 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 desperately seek attachment yet act in ways that undermine it, evoking the 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 reality 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 and diagnosis tell us what condition or syndrome is present; psychodynamic formulation may help us understand how and why a person's characteristic patterns developed and are sustained. Psychiatry is impoverished when either approach is neglected. Psychodynamic understanding 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 traits, but they risk obscuring personality syndromes with substantial empirical validity, specifically borderline personality disorder and antisocial personality disorder. Like Gunderson, I believe that 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 desperately seek attachment yet act in ways that undermine it, evoking the 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 reality 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