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September 9, 2020

Psychiatry’s Myopia—Reclaiming the Social, Cultural, and Psychological in the Psychiatric Gaze

Author Affiliations
  • 1UCLA Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles
  • 2USC Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles
  • 3UCLA Department of Anthropology, University of California, Los Angeles, Los Angeles
  • 4Icahn School of Medicine at Mount Sinai, New York, New York
  • 5Department of History, University of California, Los Angeles, Los Angeles
JAMA Psychiatry. 2021;78(4):349-350. doi:10.1001/jamapsychiatry.2020.2722

Over the last 50 years, outcomes for individuals with serious mental illness (SMI) in the US have worsened. Individuals with schizophrenia die 20 to 25 years sooner than those without SMI,1 and—although it was unthinkable 50 years ago—many find themselves incarcerated or homeless because of their psychiatric disease. Explanations include stigma, welfare state contraction, and limited access to evidence-based treatments. Less scrutinized is the role of clinical psychiatry. We suggest that clinical psychiatry’s taken-for-granted, everyday beliefs and practices about psychiatric disease and treatment have narrowed clinical vision, leaving clinicians unable to apprehend fundamental aspects of patients’ experiences.

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6 Comments for this article
Brilliant wake up call
Patrick Bradley, MB ChB | Retired family medicine
This article is a brilliant analysis of how psychiatry can better improve the lives of the mentally ill.
Psychotropic medications are of limited use and may do more harm than good when they foster the assumption that mental illness is largely a biological phenomenon.
Superb analysis
Carolyn Quadrio, MD | University of New South Wales (Sydney)
A truly superb analysis of the problems of contemporary psychiatry.

A/Prof Carolyn Quadrio
School of Psychiatry, UNSW
Cogent and Compelling
Barry Herman, M.D., M.M.M. | Employee, Atentiv Health, Beverly, MA (Mar 2020 to present); Employee, Tris Pharma, Monmouth Junction, NJ (Oct 2017 to Jan 2020).
A powerful clarion call to re-examine how to consider all dimensions of psychological functioning, not just those of the seriously mentally ill.
experiential training of psychiatrists
Zahid Imran, MBBS | private practice
I believe that those who never experienced the stress of living in an urban crime infested slums cannot really understand the factors contributing to non-response/relapse/re-hospitalization and develop meaningful therapeutic alliance with the mentally ill. May be an extreme statement but my practice changed after I started to visit my patients in their group homes and responding to emergency calls by their family members in a real time. I started on this path during my residency training when i was asked to be the coordinator of Clozaril clinic in Bronx. They used to say that I am either insane or saint but I felt that I became more of a real human being who could see the hardships facing my patients first hand rather than pretending that I understand what their experience may be from an academic perspective. Sitting with homeless patients living under the tunnels or occupying bus stop benches trying to convince them to get treated added another layer of understanding the ravages of psychosis. I am not recommending this for everyone but suggesting that it may help add to the knowledge gained by attending seminars on mechanisms of drugs in nice steak houses paid by big pharma, which I also attended and learnt from the master academicians.
Clinical Care as a Human Science
George Geysen, PsyD Doctor of Psychology | Private practice of clinical and forensic psychology
After reading the article, I was reminded how our profession also, from time to time, has had spasms of recognizing that bioreductionistic "explanations" for psychological distress and suffering can be reduced to a single causal mechanism. I've always been intrigued by the human sciences having a self-conscious need to be taken seriously as a "real" science, e.g. biology, physics, chemistry. I'm pleased that psychiatry also appears to be trying to recognize the limitations of this view when it comes to treating the whole person.
BioPsychoSocial Model
Donald Oken, MD | retired Professor (and Dept Chair) of Psychiatry
This message is excellent and badly needed.  The fundamental issue - for all of Medicine, not just Psychiatry - is utilizing the correct conceptual model for understanding the nature of the human organism in health and disease: a BioPsychoSocial model.    That concept was elegantly and thoroughly laid out some years ago by George L. Engel in his article: Engel, George L. "The need for a new medical model: a challenge for biomedicine". Science.1977.196(3):129-136. -- a classic that merits re-reading frequently.