SECOND THOUGHTS
On the heels of the 25th World Congress of Social in Marrakesh, Morocco, January 15-17, 2026, which I highlighted in my last column, I was invited to the 77th Annual Conference of the Indian Psychiatry Society in Delhi, India, with the intriguing theme, “Unshackling Psychiatry for Society’s Mental Health.” Inspired and provoked by their conference theme, my invited lecture, given on January 29, 2026, was called, “Sacred Cows and Shibboleths: Why Western Psychiatry Is Shackled and How Global Social Psychiatry May Save It.”
Overview
Western psychiatry is widely perceived to be in crisis, yet this crisis is neither new nor confined to the Global North. This presentation argues that contemporary psychiatry remains shackled by deeply ingrained “sacred cows,” convictions considered beyond critique, and “shibboleths,” group‑defining beliefs that function more as professional identity markers than as settled scientific truths. Among these are uncritical reliance on the biopsychosocial model, the narrowing effects of evidence‑based medicine, biological reductionism, and individualistic assumptions that privilege introspection and insight over relational and social dimensions of human suffering.
The crisis of psychiatry is framed as a failure to achieve consensus in 3 foundational domains: a general psychology of the human person, a coherent theory of psychiatry as a discipline, and a theory of therapeutic change. Historically, Western psychiatry has oscillated between dominant models, resulting in repeated theoretical “revolutions” that discard rather than integrate prior paradigms, producing what has been described as a “serial collapse into single‑message mythologies.”
Drawing on social psychiatry, the presentation proposes an integrative alternative grounded in 3 interconnected domains: social determinants of mental health, community psychiatry, and relational therapies. In the presentation, I drew on social psychiatry to propose non‑Western and Global South perspectives—including Indian, East Asian, African, and Latin American contributions—which foreground sociality, culture, and context in both theory and practice. Eastern psychotherapy models, such as the Gurū–Chelā relationship, Morita therapy, and Buddhist‑informed approaches such as mindfulness, are discussed as exemplars of relational and culturally embedded forms of care.
Finally, the presentation calls for the development of a clinically actionable social psychiatry that translates population‑level epidemiology, socio-cultural understanding, and relational principles into everyday clinical practice, service planning, policy, and advocacy. Confronting psychiatry’s sacred cows and shibboleths is presented as a necessary step toward a more pluralistic, globally relevant, and humane psychiatry for the 21st century.
Now, let me unpack my argument by addressing the crisis of psychiatry; its sacred cows and shibboleths; the individualism of Western psychiatry; social psychiatry as a more comprehensive, integrative, and global alternative with examples of global models of care from the Eastern and the Global South; and finally, my call for a clinically relevant social psychiatry.
Psychiatry in Crisis
Psychiatry has always been controversial—there was never an extended “Golden Age” of peace and tranquility when everyone was in agreement.
—Tom Burns1
Psychiatry has never enjoyed a stable “golden age”; controversy is intrinsic to the discipline. As we outlined in my critical review Psychiatry in Crisis, coauthored with Drozdstoj Stoyanov, MD, PhD, the current crisis reflects 3 major gaps2:
No consensual general psychology explaining what it means to be a human being.No coherent theory of psychiatry beyond descriptive “phenomenology” as the word has come to be used to describe psychopathology. No shared theory of change explaining how therapeutic transformation occurs.
To be sure, there are many competing models and theories to explain and justify clinical interventions but at present, we have no workable consensus. When a consensus does occur for a time, it is soon dropped for the next revolution and the past certainties are relegated to the dust bin of history, the subject of medical historians.
To make this clearer, any helping profession, from clinical psychology to clinical psychiatry, must explain:
How people function. Cognitive psychologist Steven Pinker, PhD, at Harvard offered his theory in How the Mind Works.3 Philosopher Jerry Fodor, who spent his career addressing the problems of psychological explanation,4 countered with his critique, The Mind Doesn’t Work That Way.5 In my own view as a relational psychologist and therapist, sociocultural psychiatrist, and social philosopher, any such theory cannot limit itself to mind and must address at least 4 levels of human being: mind, brain, behavior, and social relations. It is important to assert against many popular and professional movements that none of these domains can be reduced or conflated with the others.How problems arise. Each theory privileges one kind of information but founders when faced with explaining and integrating other domains. While psychoanalysis has an internally coherent and compelling view of mental processes, many philosophers of science and clinicians have pointed out its limitations; behavior theory cannot explain the mind since it simplistically translates all mental states into behavior; cognitive theory does not integrate emotions and neuroscience; neuroscience inexplicably reduces mind to brain; and evolutionary psychology offers even more simplistic teleological explanations. They are all interesting, yet all limited.How change and novelty become possible. This is perhaps the ultimate test of any theory of human being. Just as Noam Chomsky challenged behavioral accounts of language with the question of how new sentences can be produced by a young speaker, any theory of change must explain how change through innovation occurs in light of genetic and evolutionary wiring, behavioral habits, psychodynamic defenses, cognitive schemas, and social determinants and cultural patterns.Sacred Cows of Western Psychiatry
It may surprise the reader that I am critical of 2 of psychiatry’s most cherished sacred cows.
The first is the vaunted biopsychosocial (BPS) model. As I said in my column on manifestos in our field, the last consensual model of psychiatry, the BPS model by George Engel, MD, argued for the integration of biological, psychological, and social factors into a broader psychiatric formulation.6 Engel’s BPS model was a true manifesto and possibly the most successful paradigm for an integrated and more comprehensive view of psychiatry than the so-called biomedical model—not, however, without its critics.7
As Shakespeare said in Hamlet, “it is a custom more honour’d in the breach than the observance.” I was rigorously trained in the BPS model in the 1980s at McGill University where it was presented as a comprehensive view of psychiatry by most and as a substitute for the psychodynamic formulation by psychodynamic psychiatrists. Yet, even there, depending on the hospital center, it was used as a way to flaunt being comprehensive while actually privileging the given house model. At the Jewish General Hospital, psychotherapy was privileged either as individual psychodynamic psychotherapy or systemic family therapy, and to a lesser extent among a few researchers, social and cultural aspects. At the Allan Memorial Institute, where I was chief resident, there were distinct groups of clinicians and researchers who asserted the priority of their claims, often with little acknowledgement or outright criticisms of other approaches. In the end, as many people have observed, BPS became distorted, privileging biology over psychology and social context, and BPS became “bio‑bio‑bio.”
The roots of the BPS model were in fact in a critique of psychoanalysis as the dominant model and an attempt to be comprehensive. All models that are tilted against another are bound to fail in the end as parochial and limited. Finally, what serves the progress of scientific research, narrowly conceived, as my mentors in both academic psychology and psychiatry insisted, is not necessarily a good model for clinical practice. I understand that researchers and promoters of their clinical models—including myself with my model of cultural family therapy8,9—must present the best arguments for our theories and models, but this is not necessarily a comprehensive model for clinical practice which is still at its best when it is eclectic with a comprehensive tool kit of approaches and interventions, from biological to psychosocial and community interventions.
The second sacred cow, evidence‑based medicine (EBM), is even more ardently held by psychiatrists today. Now, I trained at McMaster Medical School where the basic science was not physiology or pharmacology, as important as they are, but clinical biostatistics and epidemiology. The architects of this approach were Gord Guyatt, MD, and David Sackett, MD. Many of our professors, regardless of the stage of their careers undertook master’s degrees in this approach and promoted it throughout our clinical training.
My concerns are that EBM risks suppressing innovation by elevating narrow methodological canons of scientific rigor over clinical meaning and context. As I told Sackett when we invited him to other faculties where I practiced, if I only practiced child psychiatry according to EBM, I would do very little, including talking to children, since few studies demonstrate the clinical utility of actually talking to children who have attention-deficity/hyperactivity disorder, for example. That diagnosis is largely based on external behavioral criteria, best reported by parents and teachers. That excludes the neurodevelopmental challenges that youngsters actually experience as their lived experience.
Bringing these 2 concerns together, we may formulate a rule that historically, psychiatric medicine privileges biological theories over psychological ones and psychological theories over social ones, expressed in this shorthand:
Bio > psycho > social.
This hierarchy contributes to the repeated theoretical collapses of our models. A perfect example is in the study of eating disorders. In spite of being clearly and convincingly described and named in the late 19th century in England and France as a psychological and psychiatric problem, research and treatment of anorexia nervosa was retarded by pseudo explanations with the discovery of cachexia associated with Simmonds Disease (hypopituitarism, named in 1914) and Sheehan Syndrome (postpartum pituitary necrosis, named in 1939). It was not until after WWII in Europe that serious study of anorexia nervosa as a psychiatric and sociocultural illness afforded better understanding and treatments for his serious psychiatric disorder.10-12
Shibboleths (Identity‑Defining Beliefs)
We may define shibboleths as longstanding beliefs that distinguish one group of psychiatrists from others. The origin of this Hebrew term is from the Book of Judges in the Bible where the ability to pronounce certain sounds was a marker of being native speakers of the language, used as a test to spot spies or unwanted people. Taggid shibboleth, “Say shibboleth,” the guardians of the border of Gilead would demand of the conquered Ephraimites who wanted to sneak back into their home territory. And the Ephraimites, unable to hear the difference, would answer saying sibboleth and give themselves away. It has come to mean a password, a sign of loyalty and affinity, and an identification. Members of any professional guild share common beliefs that become shibboleths, a shared jargon that is spoken even when it is used ironically. For example, behavior therapists still called themselves psychologists although they did not adhere to anything that the root word psyche (mind, spirit, or soul) implies.
Here are some key assumptions distinguishing “acceptable” thinking in the psy disciplines:
Psychodynamics and the primacy of the unconscious. Coming into psychiatry after training in behavior therapy, references to the unconscious, its processes and defenses were a shibboleth that separated me from my some of my teachers and other residents. After psychotherapy training, I did come to understand the notion—but as a construct, a framework rather than as established science. Rather than Henri Ellenberger, MD’s history of the “discovery of the unconscious,”13 I see psychodynamic psychiatry rather as the construction of the unconscious as a way to understand nonconscious experience.Psychiatry defined strictly as a branch of medicine.14Samuel Guze, MD’s little volume is a strong argument for seeing psychiatry squarely in the medical tradition and I agree—but with medicine defined in larger terms that include the social determinants of health along with its social, relational, and cultural contexts.The reduction of mind to brain. Thomas Insel’s15 gamble on neuroscience research for the future of psychiatry with the decade of the brain has borne very little fruit except for a Nobel Prize for Eric Kandel, MD, and pretty-colored brain scans. As Allen Frances, MD, has said, billions of dollars in research funds did not help a single patient. Crucially, the notion of identifying mind with brain is the biggest challenge to concept of mental states since behaviorism. Jerome Kagan, PhD, a brilliant developmental psychologist asserted that a complete account of the brain will not be a full account of the mind.16Framing development as nature vs nurture. The rise of more sophisticated methodologies and theories in developmental psychology and psychiatry, notably epigenetics, has made this conundrum irrelevant. Older works by 2 leading developmental psychologists highlight how outmoded this debate has become.17,18Reliance on general systems theory without sufficient integration. There was a time when Ludwig von Bertalanffy’s general systems theory was a promising integrative thread throughout the sciences and it was memorably taken up by family therapists, many of whom identify as systems theorists and therapists.19 Yet, the blind spots of systemic family therapy include theoretical opaqueness and a lack of interest in reconciling individual psychology with systemic theory which I prefer to frame as relational psychology, not to mention its adversarial relationship to the cornerstones of psychiatric thought, including classification, diagnosis, and individual and biological treatments. Instead, systemic properties and recondite references to first-, second-, and third-order thinking (do not ask!) are invoked without clarifying the issues. As family therapist Maurizio Andolfi, MD, recently summed it up in his Assisi Manifesto, “No labels, no pills.”20
These beliefs often function more as professional identity markers than as empirically or even philosophically settled truths.
Individualism in the Psy Disciplines
Western psychiatry, psychology, and psychotherapy—the “psy disciplines”—rest on 3 I‑centered assumptions:
The individual as the primary unit of analysis and intervention.Introspection as the central therapeutic method.Insight as the primary therapeutic goal.
These assumptions marginalize relational, cultural, and structural dimensions of suffering and healing. I owe this formulation to my mentor at McGill University, Raymond Prince, MD, MSc.21
Consequences and Corollaries of These AssumptionsPsychiatry repeatedly collapses into single‑message mythologies, replacing one dominant model with another rather than integrating them. This insight is from the work of Paul Hoff, MD, a Swiss psychiatrist and medical historian.22Philosophical questions of meaning, from epistemology (the branch of philosophy concerned with knowledge) to ontology (the branch of philosophy that deals with being), are reduced to technical debates about reliability and validity (eg, DSM‑III prioritizing reliability over validity. The was the greatest weakness of DSM-III. Agreeing on what to call something (interrater reliability) without understanding what that something is (validity) offers only an illusion of knowledge.“Revolutions” in psychiatry often represent U‑turns, discarding rather than synthesizing previous models.22Social Psychiatry as an Integrative Alternative
In my social psychiatry manifesto, I discerned 3 branches of social psychiatry23:
Social determinants of health and mental health (SDoH/MH) or social epidemiology.24Community psychiatry and mental health systems.Relational therapies.
Social psychiatry operates at the interface of these domains, emphasizing relationships, context, and community realities.
Global and Eastern Contributions
To these branches and strengths of social psychiatry in the West, we may add contributions from Eastern societies and the Global South.25
Non‑Western and Eastern models challenge Western I-centered assumptions, including:
The Gurū–Chelā (teacher–disciple) relationship.26Morita therapy.Buddhism and mindfulness traditions.
Countries such as India, Brazil, Japan, Pakistan, The Philippines, New Zealand, and parts of Africa offer locally adapted models that foreground sociality, meaning, and community.
Clinical Social Psychiatry
A proposed clinical social psychiatry would:
Base service planning on population‑level epidemiology, not anecdotal salience.Address risks of overdiagnosis and overprescription.Integrate care across primary, specialty, and community settings (collaborative care).27-29Translate social research into:Clinical practiceEducation and trainingPolicy and service planningAdvocacy (eg, stigma and suicide prevention)30Develop tools modeled on the DSM‑5 Cultural Formulation Interview (CFI) to integrate social context and the structural determinants of health into clinical work.31Conclusions and a Call to ActionWestern psychiatry must confront its sacred cows and shibboleths.It must rebuild a coherent theory of psychology, psychiatry, and therapeutic change.Social psychiatry—especially as practiced in the Global South—offers valuable, context-sensitive alternatives.Taking SDoH/MH seriously requires constructing a clinically actionable social psychiatry, not merely invoking the term rhetorically or in generic terms in the background of our patients’ lives. We need to bring the SDoH/MH and all the insights of social psychiatry into the foreground which means making them clinically relevant or be relegated to just another “single-message mythology” in the history of Western psychiatry’s ongoing crisis.Resources
Here are some key resources to define and understand social psychiatry, the crisis of psychiatry, the argument for and debates about BPS, and the future of psychiatry:
Dr Di Nicola is a child psychiatrist, family psychotherapist, and philosopher in Montreal, Quebec, Canada, where he is professor of psychiatry & addictology at the University of Montreal. He is also clinical professor of psychiatry & behavioral health at The George Washington University and past president of the World Association of Social Psychiatry (WASP). Dr Di Nicola has received numerous national and international awards, honorary professorships, and fellowships. Of note, Dr Di Nicola was elected a Fellow of the Canadian Academy of Health Sciences (FCAHS), given the Distinguished Service Award of the American Psychiatric Association (APA), and is a Fellow of the American College of Psychiatrists (FACPsych) and Fellow of the Royal Society of Canada (FRSC). His work straddles psychiatry and psychotherapy on one side and philosophy and poetry on the other. Dr Di Nicola’s publications include: A Stranger in the Family: Culture, Families and Therapy (WW Norton, 1997), Letters to a Young Therapist (Atropos Press, 2011), and Psychiatry in Crisis: At the Crossroads of Social Sciences, the Humanities, and Neuroscience (with D. Stoyanov; Springer Nature, 2021).
Acknowledgements
I wish to express my gratitude to the leaders of the Indian Psychiatric Society, Dr J.M. Wadhawan, Dr Nimesh G. Desai, and Dr Deepak Raheja, for their invitation to present at their 77th Annual Conference. Thanks, as usual, to my privileged interlocutor for this column, John Farnsworth, PhD, for his astute and helpful comments and corrections.
References
Burns T. Psychiatry: A Very Short Introduction. 2nd ed. Oxford University Press; 2018.Di Nicola V, Stoyanov DS. Psychiatry in Crisis: At the Crossroads of Social Science, the Humanities, and Neuroscience. Springer Nature; 2021.Pinker S. How the Mind Works. W.W. Norton & Co; 1997.Fodor JA. Psychological Explanation: An Introduction to the Philosophy of Psychology. Random House; 1968.Fodor JA. The Mind Doesn’t Work That Way: The Scope and Limits of Computational Psychology. MIT Press; 2000.Engel GL. The need for a new medical model: a challenge for biomedicine. Science. 1977;196(4286):129-136.Ghaemi SN. The Rise and Fall of the Biopsychosocial Model: Reconciling Art and Science in Psychiatry. The Johns Hopkins University Press; 2009.Di Nicola V. A Stranger in the Family: Culture, Families, and Therapy. W.W. Norton & Co; 1997.Di Nicola V. Letters to a Young Therapist: Relational Practices for the Coming Community. Atropos Press; 2011.Di Nicola V. Anorexia multiforme: self‑starvation in historical and cultural context. Part I: self‑starvation as a historical chameleon. Transcultural Psychiatric Research Review. 1990;27(3):165‑196.DiNicola V. Anorexia multiforme: self‑starvation in historical and cultural context. Part II: anorexia nervosa as a culture‑reactive syndrome. Transcultural Psychiatric ResearchReview. 1990;27(4):245‑286.Selvini Palazzoli M, Di Nicola VF (translator). Anorexia nervosa: a syndrome of the affluent society. Transcultural Psychiatric Research Review. 1985;22(3):199‑205.Ellenberger HF. The Discovery of the Unconscious: The History and Evolution of Dynamic Psychiatry. Basic Books; 1970.Guze SB. Why Psychiatry Is a Branch of Medicine. Oxford University Press; 1992.Insel TR, Landis SC. Twenty-five years of progress: the view from NIMH and NINDS. Neuron. 2013;80(3):561-567.Kagan J. An Argument for Mind. Yale University Press; 2000.Kagan J. The Nature of the Child. Basic Books; 1984.Bruner J. Acts of Meaning. Harvard University Press; 1990.Von Bertalanffy L. The History and Status of General Systems Theory. The Academy of Management Journal. 1972;15(4):407-426.Andolfi M, D’Elia A, Fraenkel, P, eds. International Family Systems Therapy: Global Perspectives on the Healing Power of Families. Routledge; 2025.Di Nicola V. Raymond H. Prince, MD, MSc, FRCPC (1925-2012): a pioneering Canadian social and transcultural psychiatrist. World Social Psychiatry. 2025:7(2):61-66.Fulford KWM. Foreword: beyond single message mythologies. In: Di Nicola V, Stoyanov D, eds. Psychiatry in Crisis: At the Crossroads of Social Science, The Humanities, and Neuroscience. Springer Nature; 2021:vii-xix.Di Nicola V. Review article—“A person is a person through other persons”: A Social Psychiatry manifesto for the 21st century. World Social Psychiatry. 2019;1(1):8-21.Di Nicola V. The Global South: an emergent epistemology for social psychiatry. World Social Psychiatry. 2020;2(1):20-26.Jeste DV, Pender VB. Social determinants of mental health: recommendations for research, training, practice, and policy. JAMA Psychiatry. 2022;79(4):283-284.Di Nicola V. The Gurū-Chelā relationship revisited: the contemporary relevance of the rork of Indian psychiatrist Jaswant Singh Neki. World Social Psychiatry. 2022;4(3):182-186.Ivbijaro G, ed. Companion to Primary Care Mental Health. CRC Press; 2010.Kates N, McPherson-Doe C, George L. Integrating mental health care services within primary care settings: The Hamilton Family Health Team. J Ambul Care Manage. 2011;34(2):174-182.Di Nicola V. Beyond shared care in child and adolescent psychiatry: collaborative care and community consultations. World Social Psychiatry. 2022;4(2):78-84.Arboleda-Flórez J, Sartorius N. Understanding the Stigma of Mental Illness: Theory and Interventions. John Wiley and Sons; 2008.Jarvis GE, Kirmayer LJ, Gómez-Carrillo A, et al. Update on the Cultural Formulation Interview. Focus (Am Psychiatr Publ). 2020;18(1):40-46.