The Crisis in Psychiatry and The Slow Way Back: Interview with Vincenzo Di Nicola

Vincenzo Di Nicola is an Italian-Canadian child and adolescent psychiatrist and a Professor of Psychiatry at the University of Montreal where he co-directs the postgraduate course in psychiatry and the humanities. He has written extensively about the importance of relationality and dialogue in therapy and is one of the leading figures of social psychiatry.

Most recently, he received the 2022 Distinguished Service Award from the American Psychiatric Association. Di Nicola’s most recent book Psychiatry in Crisis (co-authored with Drozdstoj Stoyanov) offers a critical analysis of the discipline and points to the glaring gaps that must be addressed.

Ayurdhi Dhar: You have written the manifesto on social psychiatry. What is social psychiatry?

Vincenzo Di Nicola: It’s a very important part of my personal and professional identity—a way of looking at the world.

As a child psychiatrist, I spent my entire career looking at the kids and their families through three lenses: child development, families, and culture. I see social psychiatry as the bridge between different domains of expertise, not necessarily privileging one or the other.

One of my major critiques of the history of psychiatry is that we always privilege one thing. We need more synthesis and to build more bridges among ourselves, among our own theories and schools of thought.

Social psychiatry can be a bridge between fields of expertise but also in terms of how we imagine people as personal and social beings—how does someone develop an identity, how do we develop a sense of community, how do we imagine belonging? It’s a bridge.

 

Dhar: You write about context. How have we traditionally studied humans out of context? Can you think of some examples where we study people out of context and what are the consequences of doing that for the person and for the discipline?

Di Nicola: So, only looking at behavior, you will take a disturbed child and say “How can we decrease something common like issues in terrible twos or issues like autism, phobias”. Many studies show that behavior therapy does help, that you can decrease negative behaviors, self-harm, avoidant behavior, etc.

The problem is that these things are not very satisfying on a subjective level, neither for the therapist nor for the patients. So, behavior therapy was useful in the context of what learning happened to bring the child to be fearful. But on the other hand, the salience of a parental figure giving a reward or being the source of trauma was not taken into account. We didn’t ask questions like that and I became very dissatisfied with that.

I had my own personal experience with a terrible snake phobia. I was in training in behavior therapy and thought, “this has to mean something.” In five sessions of systematic desensitization, I was slowly exposed to a snake, which happened to be called Monty and it was a Python. It was five sessions of very slow exposure. In my mind, there was a curiosity but the theory and the therapy couldn’t explain it; it didn’t address my thoughts, my feelings, they weren’t interested in that, and they didn’t have answers to what a snake symbolically represents. It was unsatisfying because I wanted to know “Why do I have this darn thing? How come I’m afraid?”

That curiosity took me to the Tavistock clinic, which is based on psychoanalysis, and my therapist listened to the questions with great curiosity and respect. I felt really understood even before finding any possible answers because the questions were validated. It opened the door to meaning.

If we want to only look at behaviors, we don’t see the whole context. We went from only looking at behavior to only looking at the brain, adding cognition and emotions. Psychoanalysis persisted; looking at the unconscious, drives, what these things represent, and how to make sense of them.

As a field, we went on this terrible journey in the last 20 years, where we said that these questions were no longer relevant. It was exciting in some ways academically and intellectually, but terrible in human terms. Along the way, we came up with other blind alleys like neuroscience—it is fascinating but it’s not psychiatry. It is very important but it doesn’t answer these other questions. Everything is useful but we have to know what we’re using them for.

 

Dhar: This experience you had of feeling heard, a more dialogical and relational experience, is this what you mean when you write about slow psychiatry? Could you tell us about slow psychiatry and what does it look like in practice, in life, in the clinic?

Di Nicola: In 1986, McDonald’s wanted to open a restaurant in one of the most beautiful historic sites of Rome and there was a spontaneous revolt against it. A guy called Carlo Petrini, a kind of leftist journalist in Italy, created this incredible movement called the slow food movement and eventually it became part of the whole slow movement. I started asking myself:

“Why do we need to speed things up? Why do we even need to think about intervening? What difference would it make?”

If you did slow psychiatry, what would we do differently? Everything and nothing is my answer. You could do the same things you always do, which I do. I didn’t throw out anything, including sometimes short-term therapy, but I’m very reflective about it. I don’t automatically value speeding things up as better.

Let me give you a lovely anecdote from Jean Piaget who is considered a really great child psychologist. He talked about stages he observed in his own children. Piaget was known for his very methodical and elaborate observations of children. People would train with him, go to him and say, “Professor Piaget, can we speed up the process? Can we make children go faster? I want my kid to write at three, to draw better or improve their motor skill, start learning the violin like the Suzuki method at three, and so on.” After a while, he called this the American question—how to speed things up. Why do you want to speed up a child’s development, why not let the child enjoy being a child? That’s an embodiment of what I’m talking about. Why do we want to speed things up now?

Practically, people say the person’s suffering and you want to relieve suffering and I value that. If you have pain, you want to relieve the pain. But if you can’t change the pain, and if you can’t get rid of the phobia, and if you can’t get rid of the voices in your head, can you help people not feel like they’re crazy? Can you help people feel like there’s nothing wrong with them, like they’re not bad, deficient human beings? Can you help them learn to live with it, even if that’s all you can offer? I would argue that’s a lot.

If you say why is this happening to me? We don’t have answers to that, but we can listen to someone complain about the pain and the sufferings of their life? We can help them find meaning. We can accompany them on their journey to find meaning. Slow psychiatry would mean you can do everything the same, just at a different pace, and in a different way.

Or you could also discover new ways of being with other people. Do it more slowly, calmly, maybe with fewer words, more spaces, with fewer what Foucault called dispositifs or tools. Maybe we could listen to people more; today in Montreal, a family doctor sees a person, if you’re lucky, for 12 minutes.

When you try to speed things up, people feel unheard, disqualified. Many of the things we deal with in medicine, in life, we don’t have quick answers for, but the culture, the society, the world we live in privileges quick fixes. They ask, “are there tips and tricks you can teach?” I can suggest them but will it work for your kid? Will it work for you? We’re going to have to work through it. That’s what slow is about.

Someone who’s suffering has a story to tell and they need to tell it, but they need an audience. In narrative therapy, recruiting an audience means you have the time, patience, and capacity to learn and listen to someone’s pain.

People, even experienced therapists, move very quickly from trauma to transcendence. They listen to the story and they immediately reach for how can this person get over their trauma? First let’s have the capacity to sit with the person suffering, to experience it for 20 minutes or maybe an hour or five hours. I think it’s enough to listen and help them find meaning for their pain and then, if possible, to find ways out. But to immediately reach for transcendence is to disqualify—to not honor their story.

That’s slow thought: giving people a chance to tell their story. By listening to people’s pain, by giving them time, that itself is a gift that we owe to each other as human beings, never mind as therapists.

 

Dhar: Trauma is one of my areas of research and I understand the importance of being there with suffering, but there is often an implication that the only way to be there is to talk about it and I come from a culture where that’s not always true. Both my grandparents and parents were part of separate refugee conflicts and the problem is that when professionals intervene, they insist that the only people who can hold your space are psy-discipline professionals. It can’t be people in your community. When we meet during weddings and funerals, we talk about our loss in the language of grief and not as a frozen traumatic memory. The problem is when the discipline necessitates that witnessing has to be done only one way—pain must be verbalized and only to a professional.

Di Nicola: The people who do this work are very aware of that. There are people that are guilty of acting as if (and I don’t think they believe it) only professionals can be there. I think they just feel duty-bound to offer something.

Two people from France, both doctors and anthropologists Didier Fassin and Richard Rechtman, wrote a wonderful book called The Empire of Trauma. They took one example of a huge chemical factory that exploded. A lot of people were hurt and there was an assumption that people would be traumatized. People come in with entire SWAT teams of psychologists, exactly what you’re saying: “people are necessarily traumatized. They need to be debriefed.” They criticized that very strongly.

I spent a lot of time thinking about this—we don’t think that professionals are the only ones who can help. The vast majority of human pain and suffering is addressed, or not, by the resources of the individual: the family, the community, the religion, the elders, and so on. Sometimes there is shame, disqualification, invalidation. We try to be aware of that through medical anthropology, cultural psychiatry and to construct a way where we don’t let people fall through the cracks.

But Fassin and Rechtmanalso say we should not impose on people. People got fed up—a person would be interviewed three and four times by different people. Some people would say, “But I’m not traumatized. I’m fine. Let me be!” A problem with any institution is it develops a life and logic of its own. So, because we have psychiatry, we must send out psychiatrists.

My son who’s a lawyer, says, “Dad, get to work. There are two or three people on the planet that don’t have a label yet.” I think it’s very funny but also sadly true. In my lifetime, between DSM 2 and 5, we went from a little pamphlet-like spiral-bound 50 or so pages to DSM 5 which is a thousand pages of tiny type, trying to document every possible vicissitude. It’s not psychiatry alone that’s responsible for that. For people to be paid, to have certificates for school or work, they ask a psychiatrist to give them an assessment.

I don’t think we should impose categories on people to validate them as human beings or as having special status based on what one person says about them, like a therapist, psychologist, or psychiatrist. I agree with those criticisms, but that does not mean that some of us aren’t motivated to alleviate suffering. I work in a public system and we have easier access to care in Canada, compared to the United States. I don’t have to compete for patients to build up a business. Here we don’t need a thousand pages of DSM 5 to justify what we do. I can just see people and write nothing in their charts. Eventually, someone will complain that I should write a diagnosis, but I don’t have to justify it like they do in the United States. So, the social and administrative logic changes a lot. Back to trauma, no one owns trauma!

 

Dhar: Your new book is about Psychiatry in Crisis. What do you mean by psychiatry in crisis, and what does this crisis imply on the ground for both practitioners and patients. How has this crisis impacted their lives?

Di Nicola: I am a professor of psychiatry and I did my graduate work in trauma at Harvard but I was unsatisfied. I learned a lot, but there was a lot I didn’t understand. That’s what propelled me into philosophy.

In looking across from another place and discipline at the practice, it became very obvious to me that not only are patients suffering and the public dissatisfied, but the psychiatrists themselves are very dissatisfied and it shows up in funny ways.

When I was young, people would go to general meetings and inform each other and different perspectives were presented. Now, people go to very specialized meetings, like a neuroscience or neuropsychiatry research meeting. In general meetings, there are no confrontations and people have actually given up on having a consensus. I miss the debates when psychologists and psychiatrists would go at each other. At case conferences, there would be psychologists, social workers, medical anthropologists, and psychiatrists with different perspectives. People were listening to each other. They don’t even listen to each other anymore. So, part of the crisis is people are almost afraid to express their dissatisfaction with the lack of a shared general theory.

The standard model of psychiatry in my generation became the DSM, which was ridiculously successful. You can’t go to any country where the medical students do not carry around the translated version in their pockets. When they talk psychology or psychiatry, they mean the DSM. It is very successful with terrible consequences.

The other part of the standard model was the biopsychosocial model. But, as Allen Frances says, it became the bio-bio-bio model. Many well-intentioned, goodhearted practitioners would say, “that’s not true about me,” but it is true in how money was given, what was valued for academic promotion, how people got power in their departments for their line of research, or in even clinical practice. When I was a kid, psychiatry meant clinical psychiatry. What was valued was being a fine clinician that could listen to people, and that’s not valued anymore. Now if you don’t do certain kinds of research in a certain kind of way, you don’t get a promotion.

In psychiatry and psychology, those of us who pretend to help people, we need to have our feet firmly in the clinic. So, the crisis of psychiatry is that we don’t have a shared consensual model, and there’s a sense of disquiet. People are listening to their patients and they are talking about side effects and I’m worried about it too but you cannot throw the baby out with the bathwater.

Let me talk about the in-house problems of psychiatry. We have three critical gaps. We don’t have a psychology, by which I mean a theory of people. How do people function? What is the psychology of psychiatry? It’s not that we don’t have one, it’s that we have many. There’s a psychology associated with behavior therapy, with cognitive therapy, even in psychopharmacology and neuroscience. It’s become about genes and brains, what Raymond Tallis decries as neuromania and Darwinitis.

We don’t have a general psychology. What’s the practical implication of that? Instead of saying what was younger Vincenzo’s snake fear about, we have a psychiatric diagnosis. He has a snake phobia. Now that’s not too bad. But what if I said I had a schizophrenic or psychotic experience, where I thought people were against Italians in London because of World War II. Inside the experience might have been terror, paranoia “Oh my God, they’re going to find out that I’m Italian, my grandfather was a fascist, and they are going to arrest me.” If you listen to people who are having experiences like that, it would take a long time to discover the logic.

 

Dhar: Are you saying the diagnosis can foreclose certain possibilities of dialogue and relationality?

Di Nicola: Absolutely. It happens all the time. That may not be the intention of the person but either because of the vagaries of the situation, or going too fast, or because words hurt and people feel disqualified, discredited, and devalued—it’s very delicate. So, we’ve learned to be careful with some experiences, but not all. It’s not very disqualifying to say you have a phobia but it’s still rather difficult to tell people in public that I hear voices.

That is a consequence of not having a psychology—everything automatically becomes a pathology. Not only do we not open space to listen to a person’s experience and help them develop a narrative, but we have a very diminished view.

When I was in training, never mind the patients, the residents would pester each other with labels: “You’re manic today. You’re paranoid.” These are adults and they didn’t know better than to call each other crazy. If they don’t respect each other, what can we expect them to think about other people?

The second problem is we don’t have a theory of psychiatry. What we have are competing models of what should dominate: the community mental health revolution, the psychopharmacology revolution, now the neuroscience revolution. Each of them represented a way of thinking. Each of them open doors but when you open some doors, you close others.

In the field of psychiatry, when we open one door, we suddenly forgot about all the others. The psychopharmacologists decried family therapy. People doing research on schizophrenia—like Robin Murray—later acknowledged that, in his own department, there were powerful models of family interactions, and he kind of ignored it or dismissed it, just like perhaps the social psychiatry group dismissed the genetics and the biology.

The problem in psychiatry is not that we don’t have promising models; it’s that people come along and they want to dominate the field. We have too many theories and we don’t have a model. From a scientific progress point of view, it’s great to have a rich debate but people are not talking to each other. What’s the impact of that? People are in their little corners.

The third problem is we don’t have a theory of change. We have descriptions of change. We have competing models. We have many rich and promising therapies that are sensible but there’s no integration. We have these critical gaps. So why is that a problem for the people? In Montreal, depending on which child psychiatrist you see, you might get someone who prescribes medications in a responsible way or someone who wants to do psychotherapy or cognitive or dialectical behavior therapy. Is it justifiable? It’s rich from the point of view of offering diverse options to people but for the person knocking on the door and not knowing who’s going to answer, it’s a bit of a puzzle.

I saw a young girl recently with a clear and strong version of obsessive-compulsive disorder. I asked for cognitive behavioral therapy because that’s what the data and the clinical experience show. The person who does that is going to be on sick leave soon. So, they said what about psychotherapy? I think the world of psychotherapy but the data and clinical experience suggest that if you want alleviation of the symptoms in a very reasonable time, it’s much more effective to use cognitive behavioral therapy. Even within a service, you have these dilemmas. The problem is we don’t have enough evidence to resolve all our clinical problems.

It would take a very well-informed consumer doing research, going online, and asking people’s opinions to make an informed choice. Is that desirable? Would it be better to have a uniform model? They did that in the National Health Service in England, where you go for a kind of mental health problem, you will get cognitive behavior therapy because that’s what the government says. I’m also not very comfortable with that because it takes away freedom and a sense of choice. There are no easy answers to this, but those are gaps. This is why I think psychiatry is in crisis and I get resistance.

My colleague from Bulgaria and I had different starting points but we ended up with very similar disquiet about where psychiatry is and where it’s heading. We went to conferences and started talking.

I got three kinds of answers from psychiatrists. One, a very influential senior psychiatrist said that psychiatry has always been in crisis, for 200 years. It was founded under crisis, which is true. Another person who’s a very famous family therapist said, what crisis? He has basically opted out of psychiatry, so for him, the crisis isn’t there because he doesn’t confront these conundrums anymore. Most people were in between, saying we have problems but we need to adapt. And because of the polarization, especially in North America, people are turning to these single messages—cognitive behavior therapy or social psychiatry has all the answers! I do not have the answers; all I am saying is let’s round out our practice by creating context and understanding what is social.

 

Dhar: Before we end, are there any last statements or something important that you would like to touch upon?

Di Nicola: In psychiatry, some of us are ambitious or arrogant enough to believe we can get to the bottom of human experience through ontology, which means being, the way we are in the world.  But the problem is convincing people that the questions of psychiatry will be answered by looking at being, understanding human beings as they are.

I’m a little optimistic that people are finally coming around. DSM is an asset, it has value, but it’s the same as translating questionnaires to other cultures. It’s got limits.

Getting to the heart of what people experience on their terms is a very different beast than taking Western ideas and exporting them around the world. I’m not interested in exporting what we do around the world. I’m genuinely curious about how Indians, Chinese, Taiwanese, and people in a small village experience the world.

Does that mean that we’ll never have the very thing I’m looking for? A consensual psychology-psychiatry-psychotherapy. Maybe. So be it. But I would prefer for things to be valid, speaking to the real human experience, something authentic. This is what slow psychiatry and psychotherapy is about.

 

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MIA Reports are supported, in part, by a grant from the Open Society Foundations