The Users and Abusers of Psychiatric Criticism
This post continues the dialogue between James Barnes and me on the topic of criticisms of psychiatry. See last post by Barnes here.
I am going to respond to some of the specific points raised by Barnes, but in order for this exchange to be more meaningful, I want to do so in the context of some larger theses about the common ways in which criticisms of psychiatry can be problematic. In line with my previous post, the intention is not to shut down or suppress criticisms, but rather to encourage more thoughtful and more nuanced criticisms.
1) On analysis, many (certainly not all) criticisms about psychiatry are actually about the current system of mental health care, but these criticisms are often directed at psychiatry as a medical specialty. By conflating the two, critics often ignore or downplay the “market forces” and systemic influences in shaping contemporary practice.
2) Many criticisms that apply to psychiatry also apply to psychology, but psychiatry is typically singled out in a way that psychology is not. While critics would admit that criticisms also apply to psychology, this is typically admitted in the fine print, while the rhetoric remains focused on psychiatry (which also partly explains why such criticisms are often perceived as being ‘antipsychiatry’ or reflective of interprofessional ‘guild’ conflict).
3) It is common to see exchanges in which both sides stick to their talking points, when it is clear that the talking points do not represent the messy reality. Sticking to the talking points is an example of having the same arguments over and over, because no progress is made. Progress is made when it is realized that talking points fail to do justice to the reality, and we advance to more nuanced positions. “Psychiatry is biomedical” and “psychiatry is biopsychosocial” are examples of such talking points because psychiatry is biomedical in some respects and biopsychosocial in others (vague as the terms are).
4) When it comes to philosophical discussions, there is a continual tendency to confuse/conflate “disorder” as an abstract category with specific disorders. Saying that “disorder” as a category doesn’t exist out there in the world doesn’t mean that specific conditions we characterize as disorders cannot be located out there in the world or do not have biological contributions to etiology.
5) There is a mistaken tendency to see psychiatric power as arising from a specific notion of mental disorder. That in my opinion represents a profound misunderstanding of what the exercise of psychiatric power (primarily involuntary commitment and involuntary treatment) is really about. It is not about a philosophical disagreement over how to define concepts. It is fundamentally about considerations of risks (at least in the US), i.e. risk of harm to self (which includes suicidality but also inability to care for self) and risk of harm to others (severe agitation, violence, homicidality, or behavior that, to use the legal language from Ohio Revised Code, “creates a grave and imminent risk to substantial rights of others”). To exercise this power is a responsibility that is enshrined in the law and is placed on the shoulders of the mental health professionals.
I will elaborate on these points further during the course of the commentary.
Psychiatry
and the System
As I see it, there are three different ways in which psychiatry is presented as a target of criticisms:
1) Psychiatry as a medical specialty, perceived to concern itself (rightly or wrongly) with biological causes of psychiatric conditions and biological treatments, distinct from clinical psychology and social work
2) Psychiatry as representative of the current state of psy-professions as well as aspects of primary care/general practice, representing scientific and technological approaches to the human condition, and encompassing psychological approaches such as CBT and psychoanalysis
3) Psychiatry as representative of the systemic forces shaping mental health care and discourse, including laws, funding organizations, health insurance agencies, pharmaceutical companies, and social narratives, among other things.
It is my impression that the target of the criticisms keeps shifting between the three modes, yet the differences are not clearly acknowledged such that the target always appears to be psychiatry as a medical profession. This is important because it sets up psychiatry the medical specialty as the scapegoat for all the systematic wrongs, even though psychiatry as a medical specialty is also a victim of the systemic forces in many ways. Targeting psychiatry this way serves a rhetorical function; it intentionally or unintentionally plays into the rhetoric of guild conflict; and it ignores that even if psychology possessed the power and prestige that psychiatry as a medical specialty enjoys currently, a lot of the systemic problems would still exist, just in a different form.
I think any well-intentioned and fair critic should not scapegoat psychiatry (as a medical specialty) and should make it clear wherever applicable that what is being criticized is a larger system with many moving parts which also includes psychology, social work, pharma, law, society, politics, capitalism, and everything else that makes mental health care what it is right now.
Biopsychosocial
Practice
It is important to clarify that the biopsychosocial framework by itself doesn’t dictate which treatments should be used: what it does is that it emphasizes the importance of incorporating all the relevant variables across the bio-psycho-social spectrum into a comprehensive explanation and of targeting those relevant variables by appropriate means.
The determination of what treatments to utilize comes from integrating empirical evidence and in practice is often determined by various practice guidelines, such as by NICE. It is the task of guidelines to synthesize existing evidence for various biological and psychosocial interventions, and to guide clinicians regarding what works best. Any bio/psycho/social treatment can be recommended provided it has enough evidence to justify the recommendation.
The difficulty of implementing biopsychosocial treatment has to do a great deal with the fractured nature of services: we have different professionals assigned different roles within the system. Psychotherapy as a treatment, for instance, shows up a consistent recommendation in guidelines. Why doesn’t it happen more often in practice?
Let’s look at some numbers. In 2010 Olfson and Marcus reported that the percentage of Americans who use psychotherapy each year has remained remarkably stable: 3.24% in 1987, 3.37% in 1998, and 3.19% in 2007. They also noted that among individuals receiving outpatient mental health care, the percentage of individuals receiving psychotropic medication only had increased, such that in 2007, 57.4% of individuals in outpatient mental healthcare were on medication only, 32.1% were receiving both medication and psychotherapy, and 10.5% were receiving only psychotherapy. Even though majority were receiving medications, 43% of individuals receiving psychotherapy, with or without medications, is not an insignificant number.
Olfson and Marcus identified several factors that may have contributed to the shifting distribution of treatment modalities.
1) The
pharmaceutical industry spends billions of dollars each year promoting
medications to physicians and the general public but there is no entity of
comparable influence or visibility to advocate psychotherapy.
2) No federal
agency or prominent national organization certifies the effectiveness of individual
psychotherapies or psychotherapists, like FDA does for medications
3) Reliable
information about medications is far more readily available to the public than
is information about psychotherapy.
4) Ideological
disagreements among psychotherapists may have an effect on public acceptance of
psychotherapy.
5) Primary care
physicians account for a great majority of psychotropic medication prescriptions
in the United States, but psychotherapy typically is restricted to mental
health specialists
6) For some
practitioners, especially psychiatrists, there are financial disincentives to
providing psychotherapy.
7) Unlike
pharmacotherapy, psychotherapy requires a considerable time commitment from
patients.
How is all this the fault of an individual psychiatrist, who may very much want to practice psychotherapy or refer patients for psychotherapy, but is unable to because of systemic forces? This system failure is as much a failure of psychology as it is a failure of psychiatry. My intention is not to defend the current practices; certainly a lot needs to be changed. But it is problematic to think that the burden of biopsychosocial practice falls entirely on the shoulders of the psychiatrists when clearly the psychologists are as much a part of this system as anyone else.
The Notion
of Disorder
Barnes writes that the accepted, historical, common-sense notion of “disorder” is one that defines “disorder” in terms of physical abnormalities. I think Barnes is reacting to the notion of disorder that he perhaps grew up with and that he sees prevalent in the society around him, but that is far from the overarching historical reality. The adoption of “disorder” as a term in psychiatry itself signified a break from older, more common terms such as “disease” and “illness”. It was intended to be a category with less conceptual baggage, one that was not inherently medical, and therefore also suitable for use in psychological contexts. As I mentioned in the last post, DSM-III allowed for an understanding of “disorder” in terms of psychological dysfunction. The usage of the term disorder as way of implying functional rather than structural abnormalities is also quite old. This has been the case since at least the late 1800s, when the Lexicon of Medicine and Allied Sciences stated that disorder is “a term frequently used in medicine to imply functional disturbance, in opposition to manifest structural change.” (source)
I’m not here to privilege dictionary definitions as truth, nor am I supporting the supporting the functional/structural distinction per se. My point is that Barnes has a very specific story in his mind. The story is along the lines of: it was commonly accepted that disorder refers to a physical abnormality, therefore psychiatry spent decades searching for physical abnormalities, and when it was unable to find these abnormalities, psychiatry then sought for other creative ways to interpret the notion of disorder to come up with one which doesn’t rely on physical abnormalities.
As any good historian can tell you, this story is extremely simplistic and misleading. Such a story also fails to take into account various notions of psychopathology that have existed in psychiatry over the years, such as Jasperian, Meyerian and Freudian notions of psychopathology. The notion of disorder that Barnes sees as common sense and widely accepted is, in its current iteration, a recent historical development, heavily influenced by the contemporary rise of biological psychiatry and pharmaceutical propaganda (“chemical imbalance”) that peaked in the 1990s and 2000s
The only thing I can say is: give it up, it is a rhetorical fiction, and grapple with the complex reality of ways in which concepts of disease/disorder/illness/psychopathology have evolved over the course of history. This lack of historical consciousness wouldn’t be much of a problem if Barnes and associates were to admit that the target of their criticism is a specific historical conception of mental disorder that is prevalent in our societies, but that makes for a far less appealing narrative.
Furthermore, philosophical analysis of concepts is not necessarily bound to history. Whatever the history of concepts, philosophy can challenge those histories, reveal inconsistencies and problems, and force us to think differently. This is a continuous, open-ended project. We are not wedded to our concepts. The philosopher Lisa Bortolotti for instance has recently argued against the idea that if there are no mental disorders then the status of psychiatry as a medical field is challenged. I myself favor an attitude of what I call “conceptual humility”, the recognition that philosophical problems are open-ended questions and rarely settled conclusively.
Whether “disorder” can or cannot be meaningfully applied to individuals, or whether we are forced to speak of individuals in relationship with their environments, or some radical notion of Heideggerian “individual-world” entities, is an interesting and important philosophical question, but one that has little to do with legitimacy of psychiatry. I favor the enactive position at the moment but what is clear to me is that a relational approach is consistent with many different metaphysical views about the nature of experiences. There are many different ways to take a relational approach, and I don’t think any profession as a whole can really commit to a specific metaphysics of a relational approach. Even PTMF, as far as I can tell, doesn’t commit to the sort of metaphysics that Barnes has in mind.
Mental
Disorder as Pragmatic Kind
Barnes: “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.”
What I am saying is that not just psychiatry but also medicine is based on concepts of health and disease that are essentially pragmatic and these concepts don’t correspond to “anything out there”. I still think that Barnes continues to confuse abstract (pragmatic) categories with specific instances of those categories. For instance, frontotemporal dementia is a disease, but the biological materiality of frontotemporal dementia does not by itself contradict the pragmatic nature of the construct of disease or disorder.
We are welcome to adopt different concepts, but in order to do so we have to grapple with the functions these concepts serve. Concepts can be hard to change because we collectively rely on them to perform certain functions, and it is only in the presence of (better) alternatives that we exchange one concept for another.
Practical kind approach has a lot of critical potential. As Robert Chapman recently commented on twitter: “I think critics of psychiatry should embrace the concept of pragmatic kinds. It follows from the ontology of pragmatic kinds that they *should* change (even be abandoned in some cases) if they aren't working well. So the concept can be empowering and fruitful. It also legitimises questions such as "*who* is this kind pragmatic for?" and "who *should* it be pragmatic for?". Accepting it as a helpful ontology opens more space for acknowledging the political elements of classification.” I completely agree with him.
I lean towards conceptualizing mental disorders as pragmatic kinds, but I certainly don’t think that it is the only philosophical position of merit. I personally favor a pluralism which welcomes multiple different philosophical perspectives. The reason practical kind often comes up in discussion with the version of critical psychiatry/psychology advocated by Barnes and associates is because the concept of “disorder” that Barnes and associates still hold is one that has been almost completely insulated from the developments in philosophy of psychiatry over the last 2 decades. And this brings me back to a point I have made repeatedly. It is one thing to criticize a specific biomedical notion of disorder that has dominated societal thinking over the last three decades. If that was all what Barnes and associates were saying, I wouldn’t have much of a problem with it. But there seems to be pervasive reluctance to acknowledge that there are viable notions other than the biomedical one, and the sense one gets is that the critics think they have successfully criticized any and all notions of disorder that psychiatry may employ. This latter attitude makes an unnecessary enemy of various philosophical approaches such as enactivism/3E and practical kinds.
The Exercise
of Psychiatric Power
Barnes writes: “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.”
This is a mistaken view. As I said, the pragmatic kinds analysis applies to all of medicine, not just psychiatry. The concept of “disease” in rest of medicine is no more “out there” than “mental disorder”. Saying that “disorder” as a category doesn’t exist out there in the world doesn’t mean that specific conditions we characterize as disorders cannot be located out there in the world.
Secondly, this is a rather naïve view of social construction (pragmatic kinds are a special instance of social construction). Our laws are socially constructed, is everyone free to just reject them? The boundaries of nations are socially constructed. Money is socially constructed. The rules governing exercise of psychiatric power are complex socially constructed entities; recognizing them as socially constructed is not enough to just wish them away. It requires making sense of the complex collective functions they serve. Psychiatric power is a function of legal responsibilities and societal expectations of professional roles, and these fundamentally have to do more with considerations of risk (risk to self, to others) than any particular philosophical notion of mental disorder. This is again a reminder that psychiatry as a medical profession exists as part of a larger societal system. The rules governing exercise of psychiatric power can be changed, with great effort, but not merely by philosophical analysis.
Furthermore, the laws and practices regarding exercise of psychiatric power extend beyond psychiatry as a medical discipline. For instance, in the US it is very common for me to see cases where a social worker or a psychologist conducts an evaluation in the emergency room and recommends/initiates the process for involuntary psychiatric care. This is because the legal responsibilities of clinical risk assessment don’t apply merely to psychiatrists but also to other physicians as well as mental health professionals such as psychologists. It is wishful thinking that these larger legal and professional responsibilities will disappear if psychiatry as a medical profession were to be dismantled or if we abandoned the idea of mental disorder.
A fundamental consideration in practice is that involuntary holds and treatments are not a matter of physician choice. In fact, these involuntary holds and treatments are enshrined in law, and upheld by "standards of care", such that if physicians don't follow them, they are putting themselves at tremendous liability if a negative outcome happens (such as suicide or homicide or psychotic violence). There is obviously some wiggle room in the interpretation and application of these laws, hence there is variability in practice among physicians, but the basic principles are pretty widely understood and accepted.
Many psychiatric critics seem to have the simplistic idea that if we abolish "psychiatric diagnosis", the issues of involuntary holds and treatments will disappear. They think that because psychiatric diagnostic constructs are invalid, any decisions based on these constructs cannot be justified, and since involuntary holds/treatments are a consequence of psychiatric diagnosis, then they also cannot be justified. But that is an incorrect understanding. Involuntary holds/treatments are not about diagnosis -- diagnosis is entirely peripheral -- they are instead about considerations of risk, of harm to self and others.
My view on this question is largely in agreement with the psychologist-philosopher Derek Bolton, who writes: "[The issues of social control in psychiatry need] to be interpreted in terms of human rights legislation and the other principles and institutions of democracy. Democracies aim to protect freedom of expression of belief and of action, provided they pose no demonstrable risk to others... Risk to public safety raises problems and require solutions that are quite unlike those associated with medical care and healthcare generally: the control of individuals for the safety of others is fundamentally an activity of the state, not of the medical profession or any other healthcare profession." (What is Mental Disorder? OUP. Page xxvii)
In other words, whether involuntary holds/treatments should be allowed is not fundamentally a matter for psychiatry to decide, but rather an ethical and legal decision to be made by societies and their legislators. Are societies willing to allow deaths from suicide and psychosis in order to preserve human autonomy? Societies can decide how they wish to prioritize these competing values. Psychiatrists are certainly a stakeholder in this discussion, but the decision is not really theirs. Societies can also decide who will enforce involuntary holds/treatments. Currently the law asks physicians to perform this role given their medical knowledge and authority, but there is no reason it has to be physicians. The law can just as well decide that it'll be social workers, or some other newly created profession.
My point is that decisions related to involuntary holds/treatments are issues of ethics, human rights, and public safety, and they should be decided by the state and legislators, using principles of ethics, human rights and public safety. This is not an issue that directly relates to psychiatric diagnosis, although it relates to psychiatric phenomena. These phenomena will remain there regardless of whether they are conceptualized as psychiatric diagnoses or not.
Barnes writes: “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?”
This is also a very naïve view of “insight”. Insight is not about a philosophical disagreement of whether the condition one suffers from should be classified as a disorder or not. If a patient is capable of making such a philosophical argument, in all likelihood they possess insight. A typical dictionary definition of insight is: “Awareness of the nature of one's own psychiatric symptoms with some appreciation of the possible causes or precipitating factors.” Insight is not about disorder status; it is about an appreciation of the condition in question. For instance, an individual with delusions who is incapable of recognizing the nature of his/her beliefs. An individual who thinks that the doctor is a CIA agent sent to torture him lacks insight; this has nothing to do with the philosophical question of whether that delusion should be characterized as a disorder or not.
Critics and Common
Ground
Barnes: “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.”
There is indeed a lot of critical ground. As I have said earlier, I see myself in the role of the critic as well, and it is rather frustrating to me that I have to continually defend psychiatry against criticisms that I perceive to be misplaced instead of advancing the critical agenda that I think is much needed.
I suspect Barnes and associates are not quite sure what to do with psychiatrists such as myself and other psychiatric critics (such as neurodiversity philosopher Robert Chapman), who are critical of the status quo but take different philosophical approaches in response. The presence of such commentators is inconvenient for the black and white narratives which some in critical psychiatry/psychology circles seem to have nurtured. That either you are on the side of biomedical reductionism or you are on the side of meaningful experience. That either you are on the side of “dysfunction” or you are on the side of “understandable reaction”. That either you believe in psychiatric diagnosis or you believe in psychological formulation. Criticizing psychiatry is not black and white; the philosophical options available to us are not exhausted by these dualities. Psychiatry is not a monolith but a rich discipline with diverse traditions. Psychiatry is also a profession that exists in relationship with other medical and psychological professions, and in relationship with larger societal systems. The world we inhabit, and the world we co-create is complex, and we need to approach it with humility.
With this, I want to give the final world to @apospodcast who said on twitter: “The problem of these debates, and why I think they're unresolvable, is they presume the existence of an objective truth. We can't determine the objective truth on how people should make sense of things (problem of the person vs problem in society). Pain is intrinsically contradictory. We can help people make sense of these conflicts, which will always be a provisional sense for all of us, if we take a step back as professionals and deprive our constructs, labels, procedures of power and create some space for dialogue. Where multiple meanings of pain are accepted.”
Let us create space for dialogue and let us accept the plurality of ways in which we make sense of human suffering.