The dangers of dualistic thinking in mental health care

Background: The “either/or” mentality

Binary thinking, or binary thinking, is the antithesis of quantified, dimensional thinking and is particularly dangerous in the fields of medicine and mental health. That’s the idea of ​​division. In complexity he has not even reached one dimension. For example, who can deny that there is always a tendency to identify flank bloating? presence or absence ascites, heart attack presence or absence Chest pain and, as a corollary of prudent mental health, self- or other homicide. presence or absence mental illness.

Is this a deeply ingrained trend or strategy in mental health? Indeed, its use, whether inadvertent or intentional, can effectively obscure meaningful understandings beyond mere explanation. there is. It represents a cognitive shortcut, or a defense against excruciatingly complex problems. In fact, in the field of mental health, this approach has resulted in the severely traumatized public not being able to make sense of interviews and commentaries, or to trusting those responsible for mental health care.

Foreground: Dimensional Thinking

I trained and practiced in the very chaotic and disturbing world of the psychiatric emergency room. Whatever the personal or professional challenge, the danger to ourselves or others needed to be quantified rather than mitigated with yes/no.

Acute emotional distress, bizarre motives, bizarre drunkenness, and atypical forms of persistent stubbornness often characterized by bizarre manipulations, egotistical disregard for others, and other personality disorders. should be distinguished from serious mental health problems, some of which can lead to dangerous and dangerous conditions. deadly act. People who mutilated themselves, drove stakes through their victims’ hearts, murdered their brothers, and performed freak strangulations were also hospitalized. Some suicidal incidents have been associated with overt side effects of antidepressants, various forms of akathisia, and acute dissociative stress disorder.

Revisiting the dichotomous caveat at the outset, are homicidal behaviors the result of the presence of acute psychopathological conditions such as delusions and hallucinations? Or, on the contrary, do they represent enduring traits of lack of mental health with enduring interpersonal coldness and hostility?

Acute and chronic conditions can co-exist in the same person, under the same circumstances. For example, her new-onset heart failure with STEMI and her persistent type 1 diabetes with acute ketoacidosis. The mental health example shows that although acute paranoid schizophrenia is not a personality disorder, it can be characterized by long-lasting erratic patterns.

In this regard, the horrific predatory violence now befalling our country cannot be reduced to an either-or solution. The latest attack in Allen, Texas, will be the country’s 22nd mass murder (defined as an attack in which at least four people, excluding the killer, are killed) in 2023. The first question many people have after these horrific events undoubtedly represents yet another dichotomy. Expression: “Did mental health play any role?”

Dimensional expression of A/B

As an example, violence can be identified by point A, absence point B, and writing AB. Of course, this ignores dimensions, and taking into account: A … … … B.

In a more precise formulation, if AB represents the crossfactor product, there are not only midpoints between A and B, but also dimension points above and below the line. Thus, the vast space of self- or predatory ideas and behaviors contains many intersections such as age, gender, race and ethnicity, religion, shame and humiliation, family history, nonpsychopathies, neurological disorders, medications, parents, and so on. There are coordinates to Authoritarian style or overprotection, legal issues, alcohol or substance abuse, early-onset behavioral disorders, availability of firearms or other lethal means. The list goes on.

Murder of self or others by a police officer, and the final act of suicide

A healthy and adaptable personality requires the ability to holistically understand the plight of the less fortunate. This develops in children by emphasizing the legitimacy of their feelings and offering a consistent self and unconditional caring love. A temperament in which empathy is not integrated becomes a mixture that reinforces impulsiveness, grandiosity, and heartlessness. In other words, they lack a conscience and harbor cognitive contradictions, persistent maladaptive biases, and persistent irresponsibility. The common and unique acute and chronic features of integrated narcissistic sociopaths (narcissistic and antisocial personalities) can be particularly challenging and potentially dangerous.

Children who are raised with hostility or who are viewed as indifferent by their caregivers are taught that love and affection fade when they fail. A child’s sad experiences of abuse, exclusion, abandonment, and/or humiliation may recapitulate early narcissistic injury when re-experienced by shaming after adolescence or in adolescence. This internalized trauma can be dimensionally projected (i.e. external and homicidal), often unnoticed or unexpected by family, friends, clinicians and teachers. to others, inwardly or brutally to oneself, or both).


  1. Yes/no binary thinking is especially dangerous in the fields of medicine and mental health.
  2. Severe mental illnesses, including psychosis, are less reliable predictors of mass murder.
  3. Many mass shooters take their own lives at the scene (final act) or are killed by law enforcement (police suicide).
  4. A common characteristic of narcissistic sociopaths is that they are extremely dangerous.
  5. A personality trait in which empathy is not integrated is a mixture that leads to enhanced impulsiveness, grandiosity, and callousness.


  1. Be suspicious of simplified single-plane analysis.
  2. We focus on early familial and social factors as significant facilitators of violence in individuals when combined with experienced or threatened interpersonal shaming, regardless of the ‘pure’ diagnosis.
  3. Background checks for “mental deficiencies” in federal law are outdated, vague, and need an upgraded, comprehensive definition.
  4. Raise the judicial burden of proof for “clear and persuasive” red flag legislation, a standard consistent with civil commitments on mental health, beyond resource limitations and safe deposit.
  5. Universal and synchronous mental health background studies for all guns, including soft ballistic and premium ballistic armor sales, point to potential solutions to some categories of gun violence.

Increased coordination of schools, mental health and legal agencies, and additional training and screening for aberrant violent phenotypes, could reasonably reduce the incidence and severe burden of fatal self-harm and other forms of violence. It should be possible to interrupt and mitigate

Russell Coplan, M.D., retired, lives in Pensacola, Florida. He graduated from Stanford University and UCLA School of Medicine. He is trained in neurosurgery and has completed psychiatric emergency department residencies and fellowships at the University of California, Irvine and the University of Colorado, Denver. An academic psychiatric reviewer and founder and distributor of non-profit violence assessments, he is the founder of eMed Logic. Coplan is also a speaker for the National Association of School Psychologists (NASP) Speakers Bureau and a consultant for the American Society of Suicide.

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