Critics and Their Psychiatry

This is a guest post by James Barnes, who offers a response here to my earlier blog post Psychiatry and its Critics.

Your response-blog was much appreciated and clarifying. I wanted to respond in kind to some of what you said, partly to explore certain misunderstandings and identify differences, but also to highlight degrees of agreement.

I do want to just say, though, that I disagree with your premise. I do not think this should be characterized as a conversation that is being had “over and over again.” The implication is that what is/has been missing is some sort of better appreciation of a set of facts about what psychiatry actually is or does. I think that is a serious underestimation of what is going on.

Ultimately, this debate concerns a clash of ‘world views.’ Similar themes can of course be traced back to the “antipsychiatrists” of the 1960’s — though they are not simply regurgitations of those arguments — but that movement itself can and should be located within the perennial clash between the reductive, positivistic (and technological) approaches to the human condition and those that vehemently reject such aspirations as dangerously flawed. This broader clash goes back to the very beginnings of the Enlightenment, only arguably having reached its climax in recent times — especially well illustrated in the case of (the demise of) biomedical psychiatry. 

Far from this being a matter of clearing up technical distinctions, the dialectic going on underneath this will only be ‘resolved’ when something genuinely new and different emerges — from forces in all likelihood far outside the ‘academic halls.’ That is my take anyway. 

In any event, to get to the technical distinctions: 

You say: 

“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.”  

Yes, I am of course not saying that every psychiatrist is reductionistic. The ‘critical psychiatrists’ are a case in point. I will put the point another way: the vast majority of psychiatrists, biopsychosocial or otherwise (yourself included, correct me if I am wrong) are in the day-to-day business of prescribing psychiatric drugs as the first-line, primary intervention. This suggest to me that the term ‘biopsychosocial’ is being used inappropriately, irrespective of how one personally justifies it theoretically. An approach true to the term’s equivalence of levels — and true to Engel's vision as I understand it — should preclude the almost invariable priority that the biological level is given in treatment. 

Biopsychosocial should mean that for a non-insignificant amount of the time interventions at the biological level are not indicated and only those at the psychological and/or social are. That clearly is not born out in current practice. I acknowledge, of course, that psychiatrists make referrals to psychologists and/or social workers, and some also provide psychotherapy themselves. But if that only happens some of the time, whereas prescribing is almost guaranteed, then it is clear that it is bio- first (and foremost) and psychosocial as a secondary thought. It is clearly not integrated in practice either, then. The fact that there is an “integration problem” in theory, serves to strengthen the point here. If there is such indeterminacy and confusion at the theoretical level, we should not generally find an inflexible assuredness with intervening at the biological level. 

So, while I respect and appreciate the aspirations, I do not think it makes sense or is right to justify current practice based on such things. 

“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.” 

It is not about hostility as psychiatry is in the position of power; if it were not, it is not hard to imagine that it might emerge. In any event, I certainly acknowledge that the benefits of psychotherapy and social interventions are recognized — not least because the evidence of their efficacy would be very unwise to ignore. How their role is understood, however, is just as important.

Following what I wrote in the blog, interventions at these levels are generally considered as having an effect on or mitigating the ‘triggers’ and ‘stressors’ of otherwise biologically determined process. This means that they are not understood as addressing ‘the problem,’ but only ‘risk factors’ and such. Helpful, yes, welcome even — but considered capable of taking the place of psychiatric drugs (i.e., capable of equivalence with the bio- as biopsychosocial implies)? Clearly not. Rather, it is a very impoverished understanding of the role they actually play, and within the current power structure it is no surprise that such interventions are viewed positively. When understood in this way, they do not pose much of a threat to the dominant model (whereas if understood correctly, they do). As such, the fact that there is such an attitude has little bearing on the arguments. 

“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.”

Well, assuming that medical disorders need not involve identifiable physical components, as the practical kind analysis does, is also begging the question, which I think is instructive. I would argue that this is a natural result of the term being emptied of specific content as a result of ‘mental disorders’ (that have no demonstrable physical components) being included in the category. 

To reiterate a point from the blog, the fact is that psychiatry as an institution has done its level best to find such physical components. Evidently this path was pursued precisely because verifying them as the physical disorders it fully expected them to be was considered paramount — Kendler for example writes about his own such dashed hopes. The fact that no ‘physical components’ were properly identified consequently problematized a concept of disorder that was otherwise unproblematic. Without ‘mental disorders’ that have no specific physical components, there would be no problem of how we define the concept of disorder (i.e., in terms of physical components). It is disingenuous, therefore, to imply that this is an issue written into the concept of disorder. 

Thus, while we may well both be begging the question, it is psychiatry that has deviated from the accepted, common sense notion of disease/disorder due to the problems it encountered, creating a question to be begged in the process. In truth the critical argument is begging the history of modern medicine. The onus, as such, is on psychiatry. 

“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? “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.”

Firstly, as above, there is only a problem with the term ‘disorder’ because emotional/psychological distress has been included under it. If we removed that domain then the problem evaporates, which is what some critics advocate for.

Having said that, I personally do not in principle have an issue with expanding the term ‘disorder’ to include emotional/psychological distress if it incorporates the world(s) that the emotional/psychological distress in question is inextricably interwoven with.

As I alluded to in the blog (and went into our conversation here), my position — and I think, in one form or another, the position of many critics of psychiatry — is that meaningful, purposeful experience necessarily implies the world as constitutive of that experience. That is very different from reducing the world to a causal object that somehow triggers biological processes somehow distinct from it, which is positivistic (and dualistic) type of thinking that does not and cannot incorporate meaningful experience of the world.

If the world is constitutive of the experiences, then any notion of ‘disorder’ applied to such experiences would have to necessarily include the world within the explanation of what is disordered. If that is the case, then we would have to be talking about ‘individual-world disorders,’ or some such thing, where the person’s world is in principle as implicated and intervened in as the individual. This, of course, is not on the table, as psychiatry and medicine at large are in the business of pathologies of the individual organism a priori (which is a central issue). 

The reason why the term ‘disorder’ or ‘disease’ is rejected as a description/explanation of emotional/psychological suffering is that it currently only applies (non-metaphorically) to the individual organism. If we can use ‘disorder’ to literally describe the persons world in tandem, then that is personally fine with me. But if we did that then the phenomena of psychiatry would be acknowledged to be inherently non-medical in the process — that is, unless we consider the world/society to be under the remit of medicine too — which is the reason why doing so is not on the table. Sometimes it seems like this is an aspiration, but I’m imagining that is not a step you’d be willing to make. So, I turn the question back on you: why must ‘disorder’ be something limited to the individual? Now that disorder need not apply to physical components, why must it only apply to the individual? So far as I can see, the only reason is because you are/psychiatry is constrained by an a priori commitment to individual pathology. 

As an aside, I take the basic idea of the world’s constitutive involvement to be central to R.D Laing’s vision, who is much more of a forefather to modern critical approaches than Szasz. Laing’s position itself was indebted to the phenomenological-existential philosophical tradition, which, far from this being a thing of the past, is now very much en vogue, as your interest in 4E illustrates. Without being constrained by positivism as psychiatry (and much of academic psychology) are one ends up with much more of a Laingian position than a 4E position. I take the PTMF and Lucy Johnstone’s brilliantly argued position across her papers/talks to be modern incarnations/variations of the Laingian analysis in this sense, though of course not limited to it. 

“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. 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.” 

There are clear assumptions in the DSM, none of which allow the disorder to be anything but some sort of dysfunction of the individual. As a result, it commits to a particular conception of what mind is that is reducible to the individual (brain). Allowing disorders to be “psychological dysfunctions” is therefore misleading if such dysfunctions are directly (or in a convoluted way) reducible to biologically processes. 

I personally, as well as many critics, reject this kind of philosophy of mind, taking a view that mind is relationally/socially generated and located. The PTMF and Lucy Johnstone, for example, are patently not talking about ‘mind or ‘mental’ in a sense that can be reduced to the individual. As ‘power’ and ‘threat’ are integral to the experiences described, clearly we are talking about a domain that has the events of the world inherent, not incidental, to it. Claims that this debate is about the discipline of Psychology wrestling for power are similarly confused, as like psychiatry, it is also a largely positivistic, individual focused enterprise. This talk by Mary Boyle (PTMF co-author along with Lucy Johnstone) I think illustrates this view well (https://www.youtube.com/watch?v=Kt4JcTDPUoc&ab_channel=TheBritishPsychologicalSociety)

This matters, to reiterate the point, because under such a view minds cannot be disordered/dysfunctional when these terms are limited to the individual. If we call these experiences disordered, we are immediately and necessarily also calling the (person’s) world disordered.

“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.”

Yes, I agree with this. As I’ve said before, I am not against the use of psychiatric drugs in principle. The key issue is the misleading narrative that has been employed around them and how they are sold — metaphorically and literally — which has led to disastrous consequences. I know you are in agreement about much of this. The notion that such drugs are intervening in ‘the problem’ (i.e., the biology of the individual) and therefore should be the primary intervention continues to be at the basis of the psychiatry as practiced. I don’t think that is debatable. If they were prescribed using a very different narrative, such as Joanna Moncrieff's ‘Drug Centered Model’, then that would a different story. I do not see that there has been much uptake of this narrative though. On the contrary, I have largely seen antagonism to it, which is telling.

Such a narrative as Moncrieff's also involves a very different vision of psychiatry, one in which psychiatric drugs are not routinely prescribed precisely because their non-specific mode of action and highly particular role in relieving distress are center stage, along with the harms of the drugs of course. I think it is pretty clear that if people had proper informed consent in this regard there would be a great reduction in their use. I think psychiatry would also naturally have to become simply a specialty among many, to which referrals would be made if deemed necessary by someone primarily trained in psycho-social (spiritual) matters — not biology and positivistic science — as befits the phenomena in question. It would, in other words, involve a significant relinquishing of practical and ideological power, which is presumably why there has been limited uptake of such a narrative.

“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.”

That makes sense, though I don’t think the confusion is mine. It seems to me that people who have used this term often use it in a sort of ‘perspectival realism’ way, i.e., as representing some partial reality that is not entirely a construction. I did not understand it as ‘does not’ correspond to, as you have said, but as ‘needn’t correspond’, thus leaving some room, at least, for a degree of objective reality. If you are saying that a pragmatic kind literally means that such things “don’t correspond to anything “out there,”” then I cannot but conclude that we are entirely in agreement: ‘mental disorders’ are essentially the artifice of psychiatry. However, Kendler and Pies clearly believe that psychiatry is about physical/brain abnormalities, only ones that we cannot (yet) determine. So, there seems to be a disconnect.

From what you personally are saying, however, it follows that the edifice of psychiatry is based entirely on (inter)subjective constructions. It should also then follow that we are all entirely welcome to reject the notion of ‘mental disorders,’ and also therefore psychiatry as a medical discipline. More to the point, if this is so, when are mandatory inpatients going to be notified that they didn’t lack ‘insight’ after all — perhaps even had a more sophisticated appreciation of the problem than did their psychiatrists — and informed that they are free to go? If ‘mental disorders’ do not correspond to anything in the world, then it would seem impossible to justify the powers that psychiatry has. It seems that this literal version of the practical kind analysis serves, as such, to exactly undermine the taken-for-granted power structures that psychiatry rests on. If this is the result, then I am also in agreement.

The confusion arises because no such radical conclusions are drawn by any of the practical kind theorists, at least to my knowledge. The analyses are put forward as theoretical justifications for psychiatry as currently practiced, which the literal form of pragmatic kinds do not support. Given that it appears as if they do not follow the consequences of their arguments, it feels very relevant to address what they are doing with their arguments, rather than what they may or may not be technically saying.

“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.”

Again, if this is the case, psychiatry has no right to diagnose, treat or determine the fate of anyone except those who willfully request it to do so. Psychiatry's status, power and responsibility are predicated on it treating things “out there,” as in the rest of medicine. If it is not doing so, then by these standards those roles should be relinquished.

“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?”

I’m glad that you brought this up. The terms ‘arbitrary’ and ‘subjective’ here are relative to psychiatry’s presumption of an objective, independent reality. If there is an objective world, then the pragmatic analysis is ‘subjective’ and if that world is ordered logically, then such an analysis is ‘arbitrary.’ I am, as such, characterizing it from the point of view of its own philosophical mode.

In direct contrast, the PTMF — in my understanding at least — explicitly rejects positivism’s reach in this domain, preferring a notion of truth and reality as the product of shared meaning-making and co-constructed narrative. These terms lose their meaning in this context, as from this perspective it is both true that everything is subjective and arbitrary and also nothing is simply subjective or arbitrary (this is very different from saying that there cannot be empirical research – quantitative and qualitative — that validates the PTMF). This indeterminacy is central, in other words. Indeed, it is the focus. It is psychiatry that has pretentions to an ‘objective science’ and therefore psychiatry that is falling foul of its own claims. The very fact of psychiatry having ended up in a subjective and arbitrary place by its own admission, in fact, should be evidence and good cause for dropping its pretentions to a positivistic science. Instead, it might do well to embrace a conceptual position such as the PTMF that centralizes the inherently qualitative nature of the phenomena.

In conclusion, what you say seems largely very valid to me. The result, however, is that we are left with a psychiatry that seems to bear little resemblance to how the vast majority of psychiatrists currently practice and understand their practice, including, so far as I can see, the authors I cited in my blog and yourself. You said at the beginning of your blog that it was not a refutation (of my blog), but I think what you have said does result in a refutation, only a refutation of the current practice and status of psychiatry. The common ground we can find, then, is that psychiatry needs to radically change. This, for me, would involve a drastic shift away from medicine with all the invokes and towards something that is centered on human and social concerns. I’m for that version of psychiatry, though I am not sure it would be similar enough to current the current version to preserve the name!

 

[Awais Aftab: I am grateful to James Barnes for engaging with my post and for the continued dialogue. You can read my response here.]