Are critics of psychiatry stranded in a ‘Jurassic world?’

In a recent Psychiatric Times interview with Lucy Johnstone,¹ the interviewer took the very unusual step of seeking ‘clarification’ from two psychiatrists that she mentioned in the interview. These ‘clarifications’ were then published at the end of the interview. One of these psychiatrists, the eminent professor Sir Robin Murray, concluded with the following statement:

‘Sadly, a few psychologists appear to have been stranded in a Jurassic world where they spend their energies railing against a type of psychiatry which became extinct years ago.’

This is a bold statement. It is also an increasingly common example of psychiatry’s critics being dismissed out of hand for allegedly being ‘out of touch’ with the theory and practice of modern psychiatry.

In times past, the standard rebuttal to those who highlighted the lack of evidence for biomedically caused ‘mental disorders’ was some version of ‘yes, but we will obviously find evidence of this causation eventually’ which affirmed the approach but denied that there was a problem. It is increasingly common in current times, however, for critics to be dismissed on the grounds that psychiatry is not, as it apparently turns out, committed to biomedical causation/explanation after all. This is often accompanied by suggestions that such critics have not understood what psychiatry — and indeed medicine at large — actually does, and/or that psychiatric theory has evolved philosophically from its biomedical days and the conceptual naivety of the past has matured. Sir Robin Murray seems to be alluding to this kind of position.

If true, this would obviously pose a problem for those critics of psychiatry. So, it would seem proper to examine the arguments behind these sorts of statements in order to see whether the critics are now in fact the naïve ones, or whether the charges brought against psychiatry remain valid. I will look at 3 core arguments below.

1. The Critical arguments about psychiatry argue against a ‘straw man’; we are ‘all biopsychosocial now.’

The first and the most common argument suggests that few psychiatrists (if any, according to some) actually practise the biomedical model of psychiatry. Rather, it will be said, psychiatrists (in the UK, at least) have been using the ‘biopsychosocial model’ for the past 40 years or so — since Engel’s seminal 1977 paper that birthed the term.² Far from an exclusive focus on biological causes and treatments, the modern, practical application of Engel’s descriptive position purports to integrate the biological, psychological and social levels of experience in its psychiatric explanations and treatments. If this is indeed the norm, then it can be claimed that the ‘critical position’ is arguing against a straw man.

Leaving aside the fact that the vast majority of psychiatric research to this very day concerns biomedical causes/explanations/treatments and that billions of dollars have been spent on such failed science over the last few decades; that claims such as ‘mental disorders are medical conditions just like heart disease or diabetes’, ‘mental disorders are brain disorders’, or ‘mental disorders are related to problems with chemistry in your brain’ are ubiquitous (found, for example, on the American Psychiatric Association website³); and that psychiatrists — despite allegedly thinking in this complex and integrative way for 40 years or so — are still rarely anything other than in the business of 15-minute ‘med reviews’, which cover status examinations, symptom/side effect descriptions, and/or changing from one drug to another — it’s important to understand what is actually being conveyed by the term, especially with regards to the ‘social’ aspect.

The chief intended purpose of the term ‘biopsychosocial’ is to assert that unlike in the biomedical era ‘social causes’ are now permitted a place in the causal chains that psychiatry sees as leading to its ‘mental disorders.’ And it is true, psychiatry has indeed conceded such a causal role for some time now. To be fair, there is also an increasing emphasis on discussing social factors. But when one understands what the ‘social’ means in this context, the continuing allegiance to biomedical explanation becomes clear.

For a model that purports to integrate social experiences, it is very strange that their lived, meaningful dimensions and idiosyncratic character are absent from the causal explanations. The ‘social’ in biopsychosocial in fact only features in terms of external ‘triggers’ or’ stressors.’ So, when it is claimed that the model accounts for the social world of the person, what is meant is that it acknowledges external pressures that contribute to otherwise biologically determined processes. The actual personal, meaning-pervaded social experiences we are all immersed in are, as such, irrelevant to the model, or at least without any causal efficacy. A ‘social cause’ within this model is simply a quantity of external force on the biological system, which is then where the disorder is located and expressed.

While admitting a causal role to social factors is of course an improvement on the purely biomedical model, if that role is limited to a position in a causal chain that leads inexorably to biological processes, then we have not moved past the biomedical model in any meaningful way. We have just stretched it out a bit. While the biopsychosocial model is not pure biological reductionism or determinism, we are nevertheless talking about experiences that are only relevant in their effect on biological processes which then determine the ‘disorder.’ It is these processes that remain the focus — the main treatments (e.g. drugs, ECT) have remained the same — evidencing the supposed incorporation of the social world is nothing of the sort. The actual meaningful dimensions of our social experience remain absent from the explanations and, as result, from the primary interventions.

The problem exists, as such, unchanged. The critical argument updated to reflect this change would assert that, without justification for doing so, (biopsychosocial) psychiatry still explains distressing emotional experiences biologically, by reducing non-biological events to quantities that only have ultimate relevance in terms of the biology of the person.

2. It is not necessary for mental disorders to have biomarkers as there are other general medical disorders that do not.

The perennial failure to find ‘biomarkers’ (measurable indicators of a biological state or condition used to identify disorders/diseases in medicine) for the vast majority of ‘mental disorders’ has led critics over the decades to conclude that the experiences in question are not legitimate medical disorders/diseases. The argument put in defence is as follows: as there are some uncontested diseases/disorders in general medicine that do not have established biomarkers, then biomarkers are not necessary for something to be considered a disease/disorder. Therefore, it will be suggested, the presence of biomarkers is not relevant to establishing whether these experiences are medical disorders or not.

So, has a flaw been found in the critical position? No.

The fact is that the vast majority of uncontested physical diseases/disorders do have known biomarkers and the vast majority (arguably all) of purported ‘mental disorders’ do not. When it is the case that, say, 95% of entities in one category fit a definition and 95% in another do not, does it really make sense to argue that they are, in fact, a single category because there is a minuscule overlap? Clearly not. The employment of biological tests/physical examinations that identify anatomical and biomedical markers is obviously vital to almost every instance of medicine. Indeed, it is this above all else that is arguably responsible for medicine emerging from the so-called dark ages.

The argument, as such, is deceptive. Biomarkers are at the very heart of what modern medicine is and how it functions. In the case of psychiatry, however, they are entirely absent for the vast majority of ‘mental disorders,’ despite monumental efforts to discover them. While their absence does not technically disqualify psychiatry’s ‘disorders’ from the rest of medicine, it nevertheless puts it at categorically odds with it. Because modern medicine would cease to be modern medicine if biomarkers are considered dispensable elements of disease/disorder, the problem for psychiatry remains.

The argument, in fact, is not even about disorder/diseases, psychiatry or medicine. There are always exceptions to the rule in almost any definition, because discerning ‘necessary and sufficient conditions’ for something is extremely rare. It is, as such, a highly pedantic argument that forgoes common sense to make a logical point, and in doing so alienates itself from the actual practice of medicine, which is of course what we are all concerned with. There is nothing unique at all about the definition of disease/disorder in this regard, so we might also consider it disingenuous to invoke a general philosophical problem about knowledge as if it were specific to this situation. The application of this philosophical problem, ironically, is what occupies the third argument.

This argument and others like it serve to occlude the categorical difference between the experiences that come to be diagnosed as mental disorders and the disorders of general medicine (known in psychiatry as functional/psychiatric vs. organic/somatic disorders). Any number of pedantic distinctions can be put forward to try and conflate or collapse this difference, but the fact remains that the 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, if there is any allusion at all.

This is a crucial difference. In being fundamental in this way, the world (and the others we relate to in it) are implicated in distressful emotional/psychological experiences in the same primary sense as brains/bodies are in somatic or organic disorders. It follows from this that pathologising the individual in terms of their brain/body is wholly inappropriate in the case of emotional/psychological distress. It is no surprise, therefore, that biomarkers are not forthcoming if the search for them rests on this category error. It is this — not some form of caricatured ‘mind-body dualism’ — that is at the root of the critical stance, something which is largely ignored in favor of addressing straw-man arguments not in fact held by such critics.

3. Disorder/disease is a ‘practical kind’ not a ‘natural kind.’

Given the paucity of evidence for biological disease processes and given psychiatry’s non-negotiable commitment to distressing psychological/emotional experiences being the remit of medicine, some psychiatrists have turned to the distinctions of philosophy in order to attempt a new theoretical case for psychiatry. The ‘solution’ has not been to think again about whether distressing psychological/emotional states are best thought of as medical diseases/disorders — which would seem to be the obvious option given the problem — but to (re)define the concept of ‘disease/disorder’ itself.

Central to these positions is the philosophical concept of ‘natural kinds.’ To say that something is a ‘natural kind’ is to say that it corresponds to a type of thing that exists in the world independent of human concerns and requirements. ‘Mental disorders’ have been seen as natural kinds by virtue of referring to some sort of yet-to-be-discovered biological disease process — like other diseases/disorders in medicine. The increasing tendency now, however, is to effectively say “Actually, we were wrong about mental disorders being ‘natural kinds.’” Now that proper philosophical analysis has been done, so the story goes, what psychiatry meant to say all along was that mental disorders/diseases are in fact pragmatic entities or ‘practical kinds’ (e.g. Zachar, 2000).⁴

The positions that follow this line of thinking, though different, share the general notion that (mental) diseases/disorders no longer need to refer to things out there in the world independent of human affairs, but only to groups of things that tend to cluster together in (medical) practice. The entities that result from a given grouping are ‘practical kinds.’ Therefore, it is suggested, it does not matter that ‘mental disorders’ have no identifiable biological disease processes because under this more general, pragmatic definition there is no requirement for them to do so. It is a way of effectively reverse engineering the definition so that it encompasses what is already treated medically, including of course emotional/psychological distress. As such, it simply represents a version of ‘mental disease/disorders are what psychiatrists treat.’ Supposedly this circumvents the critical arguments.

This general stance is held in common by the most influential protagonists in the debate — Ronald Pies, Kenneth Kendler and Peter Zachar.

To take one such example, Ronald Pies, writes:

‘Serious mental illnesses (SMI) like schizophrenia, bipolar disorder, and major depression are rightly grouped in the broad family of disease entities not because they are “equivalent” to diabetes or pneumonia, but because.. there are “family resemblances” between SMI and certain conventionally “medical” disease states’⁵

Getting more specific he says:

“The most clinically relevant family resemblance among members of the class called “disease entities” is the presence of prolonged or substantial suffering (or distress) and incapacity (or impairment); and these issues constitute the central focus of clinical care and treatment.”⁶

Disease/disorder accordingly does not to refer to a biologically caused illness, nor does it require any sort of biomarker or test. It simply describes a family theme of ‘suffering and impairment,’ which both psychiatric disorders and all other medical disorders, happily, share in common. Thus, in a more complex version of the second argument above, supposedly there is no longer a problem. Critics are now recast as taking issue with an erroneous, outdated conception of what ‘mental disorders’ are actually referring to, something now updated by psychiatry. As the only requirements that need to be satisfied to legitimately call the experiences disorders/disease are now the involvement of prolonged suffering and impairment — for Pies at least — the critical arguments are now considered ‘old hat.’

Problem solved? No.

The issue is that this and other similar arguments put forward by psychiatry already presuppose psychiatric disorders as valid, real entities in the first instance. In the case of the vast majority of other disorders/diseases this can be empirically demonstrated, so there is no issue. However, this is not the case for the vast majority of psychiatric disorders, which is the very problem. 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.’⁷ 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.’

A given ‘mental disorder’ is only a description of phenomena. While the phenomena described, such as feelings of extreme distress, are actually, empirically there, as the chair is, the existence of those phenomena as a mental disorder is only inferred. The problem with the chair analogy is that it relies on  something we already know exists; the problem with a ‘mental disorder’ is whether it exists over and above the phenomena in the first place (given the lack of empirical evidence). Only then is there a problem of defining it. This is an important distinction, because the critical argument is not that psychiatry mis-explains what mental disorders are, or that we should think about mental disorders in a different, perhaps psychosocial way (as is often suggested). On the contrary, 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.

Given this, an argument that shifts the ‘kind’ status of mental disorders so as to make the critical argument redundant, itself turns out to be redundant. It begs the very question of whether the phenomena are in fact ‘mental disorders’ in the first place, which is precisely the question that the critical position is addressing. It is, to put it formally, an epistemological dog in an ontological fight. It ignores the fact that the lack of biomarkers leads to doubt that mental disorders are kinds at all.This remains entirely unaddressed by this philosophical move, and therefore fails to address the critical charge.

But let’s imagine that we do accept this kind of pragmatic definition and see what follows practically. Well, now that the concept of disorder/disease has been untethered from its ties to biomedical disease processes, it has also been relieved of its connection with an objective, ‘hard’ science and therefore also of the authority it claims in virtue of this link. The very reason for tying itself to biomedical explanation in the first place (and presumably also the reason, rather than not spending enough time on philosophical reflection, for the billions and decades spent pursuing biomarkers) was that it was in biology that it hoped to find the evidence, justification and objective criteria needed for it to function as the science it presents itself to be. If the link is removed, one is left with little more than conjecture and biased consensus, not very different from the Freudianism of early 20^th psychiatry that was dispensed with — and ridiculed in some quarters — precisely on the grounds that it was those very things.

Under such a theory of disorder, more to the point, psychiatry becomes something that not only strays into the socio-political domain but firmly camps itself smack in the middle of it. If disease/disorder only needs to satisfy the criteria of ‘prolonged or substantial suffering (or distress) and incapacity (or impairment)’ then clearly all sorts of sociocultural experiences — e.g. being subject to racism in a racist society, being in relative poverty, living under an oppressive regime etc. — fall under the remit of psychiatry. And, of course, ‘medications’ are then indicated. This was, again, precisely what modern psychiatry was supposed to be eliminating in its move away from Freudianism and toward the objectivity of biology. Ironically, in being even less specific about what constitutes a disorder, it becomes even more subjective and arbitrary than Freudian psychopathology. And we must not forget that for Freudian psychiatry homosexuality was agreed to be a mental disorder.

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.’⁸ Theoretically, then, every aspect of our lives could now fall under the umbrella of medicine. That is indeed concerning. Of course, it will be argued that one can be differentiated from the other — but how? Certainly not objectively or scientifically. Zachar concludes that it is an ‘open ended conceptual-philosophical issue and will likely remain so.’ Will there be a philosopher at every act of detainment under the mental health act to discern whether it is a medical disorder or not? I suspect not.

To sum up, there were/are two options when presented with the lack of evidence for a medical explanation of emotional/psychological suffering: 1. rethink whether these experiences should be legitimately considered the remit of medicine, or 2. rework the concept of disease/disorder so as to make to make them fit with medicine. The second option has been taken by many defenders of psychiatry. In putting the chips down in this way so as to preserve psychiatry’s authority over matters of emotional distress, psychiatry — in the form of Pies’ argument at least — opens itself up to the much more serious charge that it is an inherently sociopolitical enterprise in the business of arbitrarily deciding what is a pathology and what isn’t, without a basis in science.⁹

In the same article quoted above, Robert Pies says that ‘The physician’s chief concern is with determining who is experiencing suffering and incapacity (in varying proportions); identifying a likely cause, whenever possible (it often isn’t!); and relieving the patient’s misery safely and effectively.’ Given that causes for ‘psychiatric disorders’ are exactly what is at issue we can remove the middle sentence. We can also remove the ‘safely and effectively,’ which in the case of psychiatry’s treatments is being increasingly recognised as highly debatable. A more accurate reading now seems to be that the psychiatrist’s chief concern is with ‘determining who is experiencing suffering and incapacity and relieving the patient’s misery,’ which cuts through a lot of the conceptual convolutedness above. Given the explicit lack of evidence and justification for doing this through psychiatry and given that there is no real limit on what and who can be brought under this umbrella, the critical concern remains as vital as ever.

In conclusion, these arguments do nothing to address the critical arguments, nor to assuage the critics’ anxiety about psychiatry’s de facto authority in treating matters of emotional/psychological distress. If anything, there is reason for us all to be more concerned. In a candid claim that I think represents what’s going on beneath all of this well, Kendler remarks ‘In my scientific worldview, the mind is part of the body and its disorders are just as real. It would be inconsistent, or an admission of defeat, to regard psychiatric disorders as being of a different status than classical physical-medical disorders.’¹⁰ The threat, then, is the defeat of a worldview, and what we are witnessing here, I believe, is largely ad hoc evasiveness in the face of the increasing evidence of that very defeat.