Psychiatry and its Critics
This blogpost is in response to a blogpost by James Barnes on Mad in the UK: Are critics of psychiatry stranded in a ‘Jurassic world?’
I am not interested in framing my response as a refutation. I am not interested in any claims of victory or proclamations along the lines of “Hah! Arguments by critics of psychiatry have been refuted!” That would be the wrong way to think about this. I think there are many valid criticisms of psychiatry to be made, and it is important and essential to engage with criticisms. As I explain below, any framing that frames this discussion in terms of psychiatry vs its critics is problematic in my view. Refutations and counter-refutations are neither the best way to advance a debate nor the best way to learn from each other. My hope, in offering this as a response, is that we can move away from having the same arguments over and over again.
1) Psychiatry and the Critics of Psychiatry
First thing I want to note is the framing of debate, the way the title sets up the opposing parties as being "psychiatry" vs "critics of psychiatry". Thinking in terms of such a polarity actually sets us up for failure from the very beginning. This is because there are many different traditions of criticism, and many different traditions within psychiatry, and the two overlap. In fact, depending on the context, the same individual can be a defender of psychiatry or a critic of psychiatry. A prominent example would be Allen Frances. I also see myself as occupying a dual role in this regard, sometimes a critic, sometimes a defender, depending on the issue at hand.
So it is important to have some conception of what is the object of one's criticism. Is it "biomedical psychiatry"? Is it the down-and-dirty reality of how psychiatry is currently being practiced in clinics and hospitals? Is it psychiatry how it exists in academia and in professional guidelines? Is it about psychiatry as it currently exists, as it has existed in the past, or is it also about any shape and form that psychiatry can take in the future? Is it just "psychiatry" or is it broadly the psy-professions? Is it the societal understanding of psychiatric conditions? Some of these? All of these?
These are not simply rhetorical question. What we are criticizing is intimately connected to what we hope to accomplish, the sort of change we want to see in the world.
For instance, I criticize the many deficiencies I see in contemporary psychiatric practices and the conceptual limitations of existing ways of thinking, but this is because I have a different conception of what psychiatry could be and should be. If I criticize reductionism in psychiatry, it is because I can envision a psychiatry which is not reductionist. I defend the ability of psychiatry to grow, to change, to learn from its critics. I defend psychiatry's existence because I believe psychiatry will continue to be relevant and continue to be essential, regardless of who emerges as the “winner” in inter-professional politics and who enjoys greater power and authority.
That is a very different relationship to psychiatric criticism compared to a hypothetical critic who believes that "psychiatry" should effectively be abolished, that the profession should no longer exist, that psychiatry is condemned to always be reductionist, that psychiatry is condemned to always be biomedical, that it will never be something other than what it is now.
I am not saying there are actual psychiatric critics who endorse this position; I wouldn't be surprised if someone somewhere does, but I don't think this is a common position. I'm not using this to attack a strawman. I am using this to illustrate the spectrum of relationships one can have as a critic to psychiatry.
This does, however, raise an interesting point. I don’t quite know what James Barnes and his associates seek from their critique of “biomedical” psychiatry. Do they wish to reform psychiatry so that it is no longer “biomedical” but is something else, something better? Do they seek better integration of multidisciplinary perspectives? Are they okay with psychiatry “existing” as a profession but they would rather see it deprived of its authority in the power hierarchy of psy- professions? Or do they think that “psychiatry” is beyond hope? Is this a project for reform or abolition? I think it would be helpful to know.
2) The Critical, Eliminative View of Mental Disorder
This also brings a related issue of the critical, eliminative view of “mental disorder”. The view that “mental disorder” doesn’t exist, that the very idea is incoherent and a category error, that when it comes to the “meaningful, purposeful experience in the world”, there can be no such thing as a “disorder”.
There are obviously many different ways of understanding “disorder” as well as more specifically “mental disorder”. The critical position often begins with a certain view of disorder as being an inextricably physical phenomena, and if the argument was that “disorder”, when understood in a certain way, is incoherent, a category error, doesn’t exist, etc. then there wouldn’t be much of a problem. But the argument seems to assume the attitude that all philosophical and conceptual notions of “disorder” are problematic and flawed, and that all of them suffer from fatal errors when applied to the realm of the experiential. I don’t know for sure if that is really the position that is being advanced, but that is certainly the impression one gets at times. This latter attitude also sets itself up for opposing any and all philosophical notions of “mental disorder”.
It would be one thing to confidently oppose a “biomedical” understanding of “mental disorder” or to oppose the popular societal understanding of mental disorders (say, in terms of simple biological dysfunctions)… but to oppose the notion of “mental disorder” in all its possible philosophical meanings is a very different undertaking.
My stance is that there are views of “mental disorder” that are highly problematic, and that many problematic views of “mental disorder” are actually quite prevalent in our societies and in psy-professions, and that it is our ethical and intellectual responsibility to challenge such problematic views. But I also think that there are views of “mental disorder” that are less problematic, that are more philosophically robust, which cannot be easily dismissed. I also think that we are not wedded to the category of “mental disorder” for eternity. I think the notion of “mental disorder” will continue to evolve and change, just as the notions of “madness” evolved into present day notions of “mental disorder”. I think each specific notion of mental disorder has to be evaluated on its own merits.
3) Biopsychosocial Psychiatry
In Barnes’s discussion of biomedical vs biopsychosocial psychiatry, the charges against psychiatry seem to be:
i) The practice of psychiatry remains biomedical in reality even though it purports to be biopsychosocial.
ii) The biopsychosocial model doesn't prevent biomedical reductionism
Here's the more complex reality, the way I see it
i) Psychiatry has and continues to aspire to be biopsychosocial in its approach. This is fundamentally a pluralistic and integrative aspiration. This is an admirable aspiration. At the very least this reflects psychiatry’s ideological vision of what it wants to be, even if that is not what it is right now.
ii) The biopsychosocial approach is already reflective in many existing practices of psychiatry. At the very minimum, I see little antagonism among my psychiatric colleagues towards other non-biological treatments. Most psychiatrists I know have a positive view of psychotherapy and social interventions. Most psychiatrists I know want better access to psychotherapy and social interventions for their patients. There is no mainstream hostility towards psychotherapy or social interventions. As an illustrative example, the new guidelines for the treatment of schizophrenia by American Psychiatric Association explicitly recommend cognitive-behavioral therapy for psychosis, psychoeducation and supported employment services, as well as coordinated specialty care program for patients experiencing a first episode of psychosis. If psychiatry as a profession were committed to a biomedical approach, it certainly could be doing a much better job at it.
iii) There are many practices of psychiatry that either fall short of biopsychosocial aspiration or still reflect the on-going presence of biomedical mindset and norms. I see no reason to deny that. This is in fact quite commonly acknowledged by many within the professions. And why the practice of psychiatry falls short of biopsychosocial is a complex question, involving many larger system issues and limitations imposed by healthcare social structures. What I find problematic is a common assumption that psychiatry falls short of biopsychosocial approach because the biopsychosocial approach is really just lip service while psychiatry as a profession remains committed to biomedical model. I am not sure if Barnes believes this or alleges this, but that's the charge which a lot of psychiatrists are trying to defend against. Psychiatrists like myself don't deny the failings of the system or the failure of psychiatry to live up to aspirations, but what we deny is a cynical interpretation of why this is so. To acknowledge that there are unmet aspirations, as I do, means that we can work towards them, get better, and we can work towards a realistic assessment of the complex reasons for why this has proven so difficult. To believe that these aspirations are simply convenient fabrications designed to fend off critics is a very different thing.
iv) The biopsychosocial model doesn't necessarily prevent biomedical reductionism. I agree with that. In fact I made a very similar point in my exchange with Sanneke de Haan. I have also been vocal about my dissatisfactions with biopsychosocial model as philosophical theory and I have advocated for the need for better and more robust pluralistic approaches. Recognizing that biopsychosocial model doesn't necessarily prevent biomedical reductionism also doesn't imply that all biopsychosocial approaches in psychiatry are de facto reductionist. The integration problem in philosophy of psychiatry is complex. Lack of a satisfactory philosophical account of how this integration happens doesn't indicate that there is a lack of commitment to the integrative aspiration itself. Focusing only on biopsychosocial model also misses the point that there are other pluralistic models being proposed and discussed, which needs to be taken into account if one aims to be fair towards the ideological commitments of psychiatry.
v) Biopsychosocial thinking also enjoys support from the critical community. A prominent example would be the psychiatrist Duncan Double of the UK Critical Psychiatry Network, who has expressed his ideological support for Engel's biopsychosocial model numerous times, and sees the critical psychiatry position to be broadly consistent with that aspiration. Such overlaps suggest the need for more nuanced dialogue and also again illustrates why talking about "critics of psychiatry" as a monolith is simplistic and misleading.
vi) The fact that many psychiatrists don't practice psychotherapy or psychosocial interventions themselves by itself doesn't suggest a commitment towards biomedical reductionism. This is akin to saying that internal medicine physicians are anti-surgery or don't really believe in the value of surgery because they don't do surgery themselves. First of all, many psychiatrists I know actually do practice psychotherapy (including some who are trained psychoanalysts), even though they are in minority. Secondly, even psychiatrists who restrict their role to evaluations and psychopharmacological management can nonetheless be biopsychosocial in their approach by working as part of interdisciplinary teams, by referring patients to their psychology and social work colleagues, and by recommending psychosocial interventions to their patients.
4) Biomarkers and Mental Disorders
The charges against psychiatry here seem to be:
i) The failure to find biomarkers leads to the inevitable conclusion that the experiences in question are not legitimate medical disorders/diseases.
ii) Phenomena under psychiatry fundamentally pertain to meaningful, purposeful experience in the world, inextricably bound up with the world. The disorders of general medicine, by contrast, are almost exclusively focused on the functioning of the body, with only incidental or secondary allusion to the person’s relationship with the world. Therefore, pathologizing the individual in terms of their brain/body is wholly inappropriate in the case of emotional/psychological distress
Here’s how I see this.
i) The notion that biomarkers are essential for “legitimate” medical disorders is simply one way to think about what constitutes a disorder. Critics such as Barnes and associates seem to argue that because all physical disorders have some identifiable physical component, therefore it demonstrates that all disorders must have some identifiable physical component, in the absence of which the condition cannot be considered to be a disorder. But that is simply begging the question. If we have already restricted the starting point of our analysis to physical disorders, it will be no surprise that we conclude that physical markers are necessary. I would like to see a philosophical analysis of the notion of “disorder” that doesn’t start with the assumption that disorders are physical. Why should disorders be physical? What is it about the notion of “disorder” that makes it so? In fact, aside from insisting that real disorders have biomarkers, we have not seen a proposed definition of what a disorder is.
ii) There are many other ways to think about what constitutes a “legitimate” medical condition, in particular ways that focus on the methods of the medical approach when applied to a condition and not on the nature of the condition. This is in fact a complex question in philosophy of medicine, and the fact that Barnes and associates have decided that they are in possession of a settled answer to this philosophical question is rather odd in my view.
My own take on the issue is a broadly pragmatic one. I have written about this a bit on my blog earlier.
iii) The idea that “meaningful, purposeful experiences” cannot be disordered relies on a very narrow definition of disorder. I don’t think anyone really is denying that phenomena under psychiatry fundamentally pertain to meaningful, purposeful experience in the world. I mean, that’s pretty much a given. The whole phenomenological tradition in psychiatry exists for that reason. The question is how to best understand these distressing, impairing, problematic experiences.
iv) The idea that by calling an emotional/experiential/psychological condition as a “disorder”, we are “pathologizing the individual in terms of their brain/body” is incorrect. I do not deny that such an attitude has been expressed commonly, especially by those prone to biological reductionism, but that does by no means exhaust the variety of attitudes that psychiatrists have taken on this matter. For instance, according to the DSM definition of mental disorder, a mental disorder can simply reflect a “psychological dysfunction”. The presence of a “biological dysfunction” is not necessary, and there is no requirement by the DSM that “dysfunction” be understood solely in biological terms. So even by the “official” definition, the integral link between “disorder” and “brain pathology” is disputed.
v) The idea that “disorder” is intrinsically a medical concept is incorrect. Peter Zachar, for instance, is a psychologist (not a medical physician), and when he defends a particular view of “disorder”, he is not defining a notion that he sees as intrinsically medical. Same with Derek Bolton, a psychologist and another prominent commentator in philosophy of psychiatry. I also briefly touched on this in my interview with Kristopher Nielsen, who argues for a notion of “disorder” but does not see it as inherently “medical”.
vi) Barnes and associates also seem to ignore the tradition of “operationalism” in psychiatry and psychology, which seeks to delineate operational entities for the purposes of scientific study without making unnecessary assumptions about the nature of the entities under question.
vii) Just because phenomena fundamentally pertain to meaningful, purposeful experience in the world does not mean that the biological processes involved in the phenomena (and Barnes and associates are keen to admit that obviously all experiences are accompanied by biological changes, because the mind is embodied after all) cannot be identified or cannot be intervened on to make a difference. This remains the case even if the biological phenomena under question have no pathological changes. The fact that meaningful experiences in the world are embodied means that there is in principle an opportunity to exert some sort of modulating influence on those meaningful experiences by intervening on the biological phenomena, the limits of which are to be determined empirically. If an individual is experiencing severe anxiety, this anxiety can be lessened in the short term if the individual, say, drinks some alcohol, or smokes some marijuana, or takes a sedative medication. This will be so regardless of whether the severe anxiety is a “disorder” or not, and regardless of whether the severe anxiety is a “meaningful, purposeful experience” or not. The point is that meaningful, purposeful experiences can nonetheless be influenced through biological means, and the question is not whether we can do so, but whether it is a good thing to do so, and how to balance the risks and benefits of such an intervention. Meaningful, purposeful experiences do not preclude the possibility that biological interventions can be beneficial or helpful.
5) Disorder as Practical Kind
i) I think Barnes misunderstands the application of Zachar’s practical kinds analysis to mental disorders.
Barnes writes: “As an illustration, Zachar (2000) writes, ‘Chairs are not natural kinds [and] there are many reasons for refusing to believe that syndromes, diseases, species, and personality traits are natural kinds as well.’ This is a flawed analogy, as there is no doubt that there is a chair over there that we are trying to define, however problematic that may be — the fact of its existence as a chair is not doubted. We do not infer the existence of a chair; its existence is demonstrably, empirically there. This is unlike ‘a mental disorder.’”
What is being discussed is the abstract category of “chair”… what is demonstrably, empirically there is some kind of an object; the materiality of the object is not under the question. What is under question is the characterization of that object as a “chair”. Is the object a chair in some real, fundamental way? This is a similar situation to the psychological distress/impairment, where what is under the question is not the existence of the psychological distress/impairment, but its characterization as a “mental disorder”.
The practical kinds analysis reveals the nature of the concept of “mental disorder” but it doesn’t tell us if we should adopt the “mental disorder” concept in the first place. That is, it is not inevitable that the concept be applied to what we currently apply it to. (Just as the practical kinds analysis of “chair” doesn’t tell us whether we should use the concept of “chair” or not… it just tells us that if we do use the concept, it would be a practical kind.)
Barnes writes: “the critical argument disputes the very reality of their being a ‘kind’ called ‘mental disorder’ in the first place, over and above the phenomena described.”
This is a really confused argument… what does it mean to say that a “practical kind” category isn't real? Practical kind categories by definition don’t correspond to anything “out there” in the structure of the world. That is precisely why they are practical kinds and not natural kinds.
Perhaps what Barnes wants to say is that there is nothing forcing or obliging critics such as him to talk about things in terms of the category of “mental disorder”. That would be, I believe, correct. The category of “mental disorder” is simply one of the many practical ways we can make sense of these phenomena. However, what is problematic is treating the category of mental disorder as a natural kind and dismissing it based on such criticisms, without grappling with or without acknowledging that criticisms that apply to natural kinds don’t necessarily apply to practical kinds.
Practical kinds analysis is not there to settle the question of whether “the phenomena are in fact ‘mental disorders’ in the first place”. Questions such as “is this really a mental disorder?” reveal a certain misunderstanding of the practical kinds analysis, because if by “really” we mean corresponding to some “natural entity” then the answer is no. What the practical kinds analysis reveals is that there is a coherent, pragmatic way of thinking about the category of mental disorder, not that this way of thinking is “really” true, or that is the only correct way of thinking about a particular phenomenon.
ii) Barnes writes that the practical kinds analysis untethers the concept of mental disorder from its ties to biomedical disease processes, and relieves it of its connection to an objective, hard science, and also of the authority it claims in virtue of this link.
This also shows a profound misunderstanding. Acknowledging that the category of mental disorders is an abstract practical category doesn’t say anything about the involvement of biological processes in individual conditions we call mental disorders. The extent of the involvement of biological processes in any particular condition we call mental disorder is an empirical matter; it doesn’t spring automatically from the definition of mental disorder. Therefore, objective science continues to have a role in the empirical investigation of the specific phenomena classified as mental disorders, although it may not have any necessary role when thinking about the abstract category of mental disorders.
I also dispute that psychiatry claims its authority based on ties to biomedical disease processes. Psychiatry claims its authority based on the application of the medical model to psychiatric conditions. That is an important difference.
I am also surprised at the claim that if the link to “hard sciences” is removed, then one is left with little more than conjecture and biased consensus. The approach to psychology that Barnes advocates, exemplified by the PTMF, has no discernible link to “hard sciences”… does that make it “little more than conjecture and biased consensus” by his own argument?
iii) Barnes points out: “Under this kind of definition, there is no ‘natural limit’ to what is and isn’t a disease/disorder, which Zachar himself calls ‘a cause for concern.’” But the answer to this concern cannot be that we just make up a “natural limit” if one doesn’t exist! That there is no “natural limit” doesn’t mean we cannot have “practical limits” based on scientific, ethical, and pragmatic considerations. An account of such considerations is beyond the current discussion, but it would be a mistake to simply dismiss that such limitations do not exist or do not have a meaningful role to play.
iv) Acknowledging that the notion of mental disorder cannot be fully naturalized and that it remains inevitably practical and value-laden is not a fault, it is not a shortcoming; it is a strength. It permits robust philosophical and ethical discussions of how understandings of violations of psychological norms and experiences of psychological distress/impairment are influenced by social and cultural context, etc. Recognizing this is a sign of philosophical maturity on part of the field, not a regression to something “subjective and arbitrary”.