COMPLEXITIES FOR PSYCHIATRY’S IDENTITY AS A MEDICAL SPECIALTY

Even though psychiatry is a medical speciality, it is a special medical speciality. This arises from its subject matter, ordinarily conceived of as mental health conditions or disorders, to be contrasted with physical health conditions or disorders. Psychiatry deals with the mind not working as it should while ophthalmology, for example, deals with the ophthalmic system not working as it should. The nature of its subject matter raises certain complexities for psychiatry that, in extreme, are sometimes taken to suggest that psychiatry’s positioning as a medical speciality is suspect; these include the normative nature of psychiatric judgements, the explanatory limitations of psychiatric theories, and the classificatory inaccuracies that beset the discipline. In this post, I examine these complexities, asking whether or not they are fatal to psychiatry’s identity as a medical speciality.

Normative Complexity

When doctors refer to an organ or system not working as it should they do not intend this judgement in a moralistic sense; what they mean is that the organ or system is not functioning in the way they expect it to given the purpose for which it was designed, or that it is not functioning as it does for the majority of people in an appropriately defined population, or that its anatomy or histology is grossly distorted. These three naturalistic takes on dysfunction (which are not the only possible ones) correspond, respectively, to evolutionary theory, bio-statistical theory, and lesion theory. There is now a huge literature both in the philosophy of medicine and the philosophy of psychiatry on the concept of dysfunction and on the possibility of defining it in value-free terms (e.g. Boorse 2011; Bolton 2008, 2013a; Varga 2015; Kingma 2013). A key intuition driving this debate seems to be that if we cannot define dysfunction in value-free terms then it becomes harder to distinguish proper clinical judgement from the moralistic interjections of zealous clinicians. The debate continues and I will not venture into it, partly because it is not directly the subject of this post, and partly for the reason that in many cases that distinction does not really matter: clinical judgement and moralistic judgement collapse into each other when all parties are (broadly) in agreement that something is not working as it should, and that that thing is an appropriate target for medical intervention; i.e. there are known treatments and a known prognosis; it is a condition that doctors treat as opposed to, say, a spiritual malady. When disagreements arise, clinical and moralistic judgements come apart and clinical intervention is problematised. Note that from the perspective of the patient, the doctor’s alleged moralistic judgement can go both ways: the doctor can judge that you have an organ or a system that is not functioning as it should, whereas you think that it is; conversely, the doctor can judge that the organ or system is functioning as it should, whereas you think that it is not. In the former case you reject medical diagnosis and intervention, and in the latter case you seek them but they are denied. In addition, there is a variant of the first possibility where someone else – perhaps a relative – deems that something about you is not working as it should, a judgement with which the doctor agrees but which you reject.

As doctors and patients know, these possibilities for disagreement are not uncommon in medical practice. For example, you experience pain in your acromio-clavicular joints when you exercise; you visit an orthopaedic doctor who tells you that this is consistent with age: “there’s nothing wrong with you”, the doctor says, an explanation that you refuse to accept. Conversely, the doctor examines you and prescribes anti-hypertensive medication which you refuse to take as you feel well and do not believe that you have problems with your blood pressure. In psychiatry, discrepancies in judgements of this sort are more intractable, more common, and, given the power that psychiatrists have to detain individuals, more serious in their implications. This intractability arises from the fact that psychiatry deals with the mind not working as it should. The normative judgements involved in such a determination are more complex than those involved in determining, say, whether or not the ophthalmic system is working as it should. This complexity, in turn, creates considerable possibilities for disagreement. This is to be expected: belief, reasoning, emotion, and perception – to name a few faculties of mind – permit a wide range of evaluations and demonstrate a high degree of “observer-relativity” (Bolton and Hill 2004, p. 99; see also Bolton and Banner 2012, p. 83). To agree on what it is to have true belief, valid reasoning, appropriate emotion, and veridical perception is more complicated than it is to agree on what it is to have good visual acuity, even after we account for the fact that for a fighter pilot a 0.1 drop in vision is life-changing, whereas for a drummer it is not.

Negotiating the intractable disagreements that arise in psychiatric practice means that psychiatry, like – but more than – other medical specialities, has to be aware of differences in values among the various stakeholders, and of the cultural beliefs that constitute the profession itself as well as those that persons bring to the consultation. Given the magnitude of these challenges, it is not surprising that theoretical and now also practical endeavours have taken psychiatry as the paradigm case of the complexity of the clinical encounter and therefore also as the target for developing and testing solutions that can benefit clinical practice irrespective of specialty.[1] Far from undermining the identity of psychiatry as a medical speciality, the normative complexity inherent in psychiatry demonstrates that it shares the same problems other specialities have to deal with, only in psychiatry these problems are more common and challenging.

Explanatory Complexity

The subject matter of psychiatry is the ‘mind not working as it should’. As a medical speciality, psychiatry aims to relate the various failures of mind to underpinning biological substrates in the brain. One position in this respect is to reduce those failures to specific brain dysfunctions. Mental disorders, on this view, are nothing but brain disorders; as some authors have put it, “there are only brain disorders that psychiatrists prefer to treat and other brain disorders that neurologists (and neurosurgeons) prefer to treat” (Baker and Menken 2001). Biological reductionism goes back a long way; historians of medicine identify a shift to purely somatic explanations of ‘madness’ towards the end of the 19th century in Europe (e.g. Scull 1975), a shift that persists among some practitioners and researchers. Yet it is fair to say that biological reductionism is not a popular view today, with many practitioners and researchers adopting a multifactorial, non-reductionist view of causation of mental disorders, the well-known biopsychosocial model.

Non-reductionist views are held even by those who wish to end the distinction between mental disorders and brain disorders in favour of the latter. White and colleagues, for example, make a number of arguments in this regard, one of which is the empirical point that psychosocial factors “interact strongly” with neurological disorders, while “disorders of the mind are rooted in dysfunction of the brain” (White et al. 2012: 1). Their point is that psychological, social, and biological causal and risk factors run across all medical conditions, whether mental or physical. If so, then there might not be much sense insisting on the distinction between mental disorders and brain disorders, especially, they argue, in light of recent advances pertaining to the neurological and genetic bases of mental disorders. Part of the authors’ motivation in advancing this proposal is to foreground psychiatry’s identity as a medical speciality. This, they point out, can improve recruitment into the profession, for if psychiatry is more explicitly aligned with neurology it may become more attractive to medical students. On the other hand, a more medicalised psychiatry would be able to define more clearly its distinctive contribution to mental health care relative to allied professions such as clinical psychology and mental health social work. Standing in contrast to White and colleagues’ proposal is a position paper by Bracken and colleagues that advances a similarly non-reductionist position but rejects the suggested equivalence between psychiatry and neurology: “psychiatry is not neurology; it is not a medicine of the brain. Although mental health problems undoubtedly have a biological dimension, in their very nature they reach beyond the brain to involve social, cultural  and psychological dimensions” (Bracken et al. 2012: 432).

There is no doubt that both mental and physical health conditions demonstrate “multifactorial pathways”, nevertheless psychosocial factors appear to be more prominent in mental disorders across a range of dimensions (Bolton 2013b: 25). To the extent that this is the case, psychiatry differs from many other medical specialties in that it “has particular expertise in the management of psychosocial factors as well as internal biological factors” (ibid.). One could take this observation to support the view that we should not collapse the distinction between mental disorders and brain disorders. Or one could decide that the terms of the debate are out of keeping with developments in the new mental health sciences. These “new sciences do not work with ideological battles between the biological, the psychological, and the social … rather they work with all of these factors and the diversity of interplay between them” (ibid.). There is much work to be done, both empirical and conceptual, to understand how the different social, psychological, and biological factors interact in specific conditions. However – and this is key – that work applies to physical health as well as mental health conditions (see, for example, Hernandez and Blazer 2006, and Bolton in press). Even though psychiatry, relative to other medical specialities, is more heavily involved in the psychosocial dimensions of the conditions of interest, the model of causation, risk, prevention, and treatment that applies in psychiatry, as it does across all of medicine, is biopsychosocial.

Classificatory Complexity

In the foregoing, the notion of the mind not working as it should was explicated in terms of the various faculties of mind. The issue, therefore, is that a particular faculty – belief, emotion, perception, reasoning, will – is not working as it should. These faculties are interrelated, and from its inception psychiatry sought to recognise patterns of symptoms and signs and to construct diagnostic categories on that basis. So a particular condition, say schizophrenia, comprises dysfunctions in multiple faculties of mind; e.g. paranoid delusions (belief), blunted affect (emotion), ambivalence (will), and auditory hallucinations (perception). It is now accepted that psychiatry’s classifications of its subject matter into discrete conditions is much more controversial than, say, ophthalmology’s classifications. Often this is expressed by saying that psychiatric categories lack validity, which in turn is often taken to mean that they do not “map onto any entity discernible in the real world” (Kinderman et al. 2013: 2). We can refer to this position as medical realism, the view that the validity of disease categories rests on the extent to which they “represent features of the underlying structure of the world” (Simon 2011: 66). In order to do so, the categories in question, typically, need to satisfy two conditions: (1) the category has to be separated from related categories by a “zone of rarity”; (2) the category has to be “associated with explanatory variables of deeper structural significance” such as “causal factors [and] pathogenetic mechanisms” (Jablensky 2016: 27; see also Kendell and Jablensky 2003). Accordingly, in light of a medical realist view, a valid disease entity is a ‘natural kind’.[2]

With a few notable exceptions such as the dementias and conditions such as Huntington’s Chorea, it is questionable whether current psychiatric categories can satisfy the two aforementioned requirements. Consider, first, the requirement for a zone of rarity surrounding the condition. In clinical medicine, a zone of rarity can be established on two grounds: clinical state and biomarkers. Clinical state refers to the symptoms and signs established during a clinical examination and by which the patient is determined to have a condition that is discontinuous with the ordinary functioning of the organ or system in question. For example, myocardial infarction is separated by a zone of rarity on the basis of clinical state: the experience of chest pain is qualitatively different from a healthy heart. On the other hand, a biomarker refers to a biological “characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention”.[3] In accordance with this definition, myocardial infarction is associated with a host of biomarkers such as Troponin and Creatine Kinase that, together with clinical state and other investigations, establish a zone of rarity surrounding the condition. Biomarkers can play  a key role in diagnosis, prognosis, and classification.

Moving on to psychiatry, there is now ample literature that casts doubt on the ability of current psychiatric classifications to establish a zone of rarity surrounding their putative conditions. In the philosophy of psychiatry literature, the assumption that psychiatric categories are natural kinds has long been questioned (e.g. Zachar 2015, 2000; Haslam 2002; cf. Cooper 2013). On the basis of clinical state, it has proven difficult to draw categorical distinctions between one disorder and another, and between disorder and its absence. Symptoms of schizophrenia and symptoms of bipolar disorder overlap, necessitating awkward constructions such as schizoaffective disorder or mania with psychotic symptoms. And the boundary between clinical depression and intense grief has been critiqued as indeterminate, with the distinction between the two made on the seemingly arbitrary specification of the number of weeks during which a person can feel low before a diagnosis is made (see Horwitz and Wakefield 2007).[4] And things are not better on the biomarker front; despite vigorous research, limited progress has been made in identifying biomarkers of clinical relevance, whether diagnostic, prognostic, or predictive (see Venkatasubramanian and Keshavan 2016; Kobeissy et al. 2013; Rose and Singh 2009). All of this indicates that there are difficulties in establishing a zone of rarity around key psychiatric categories.

Moving on to the second requirement identified earlier for a condition to constitute a natural kind – the requirement that the category is associated with distinctive aetiological and pathogenetic mechanisms – we find similar problems. Even though some progress has been made towards understanding the pathophysiology of schizophrenia, bipolar disorder, and depression, our understanding of the aetiology of these conditions remains at best provisional, with a multitude of non-specific factors interacting in complex ways over a long period of time. For example, research on molecular genetics – which has seen significant advancement in recent years with the use of whole-genome studies and large samples – has only been able to identify genetic commonalities that stretch across multiple psychiatric categories (see Jablensky 2016).

In summary, the majority of psychiatric conditions cannot properly meet the requirements for a medical realist view. Some critics of psychiatry take this conclusion to imply that psychiatric categories lack validity (e.g. Kinderman et al. 2013, Timimi 2014, all the way back to Szasz 1960). But all the critics can really assert is that current psychiatric categories do not meet the requirements for medical realism about disorder: they are not natural kinds. And that is not a problem for the identity of psychiatry as a medical speciality for three reasons: (1) Defenders of a medical realist view of psychiatric categories can simply point out that more work needs to be done to refine the existing categories and to improve the science and the research on biomarkers, aetiology, and pathogenesis.[5] (2) Alternatively, one could respond to the aforementioned critics by pointing out that there are many medical conditions that do not fully meet the requirements for medical realism yet are regarded as valid conditions that merit clinical attention and treatment. For example, the condition known as essential hypertension is not separated from normotension by a zone of rarity but is continuous with it, and neither is its causation entirely understood, hence its classification as ‘essential’ (or primary or idiopathic). Rheumatoid arthritis, while satisfying the zone of rarity requirement, is an autoimmune disorder whose aetiology is not understood. And some types of anaemia, while satisfying the aetiology requirement, are continuous with normal red blood cell size and number. (3) Finally, one could point out to the critics that medical realism is not the only option in medical ontology, another option being medical anti-realism.

Medical anti-realists reject the view that the diseases “we identify are either part of, or given to us by, the underlying structure of the world” (Simon 2011: 84). In contrast to medical realists, anti-realists do not accept the assumption of a mind-independent world that gives us our disease categories, rather such categories are pragmatic constructions driven by a range of criteria and stakeholders (see Simon 2011: 89-92).[6] Among the criteria that enter into recognising a set of symptoms and signs as a disease category are the ability of the category to give useful information on prognosis, to enable doctors to affect the course of the patient’s condition, to explain the patient’s prior condition, and to be therapeutically modifiable. Other criteria can be of a utilitarian and economic nature whereby disease categories are recognised if doing so would benefit society as a whole, or would be economically productive or viable. For example, the cut-off point for treating essential hypertension has to achieve a balance between expected treatment benefit (by reducing the risk of cardiovascular disease) and the economic considerations of offering this treatment in a national health system.

The aforementioned criteria are emphasised differently by the different stakeholders. Doctors, researchers, governments, pharmaceutical companies, and patient groups each have their own interests and varying abilities to influence the construction of disease categories. This creates the possibility for disagreement over the legitimacy of certain conditions, something we can see playing out in the ongoing debates surrounding Chronic Fatigue Syndrome, a condition that “receives much more attention from its sufferers and their supporters than from the medical community” (Simon 2011: 91). And, in psychiatry, it has long been noted that some major pharmaceutical companies influence the construction of disorder in order to create a market for the psychotropic drugs they manufacture. From the perspective of medical anti-realism (in the constructivist form presented here), these influences are no longer seen as a hindrance to the supposedly objective, ‘natural kind’ status of disease categories, but as key factors involved in their construction. Thus, the lobbying power of the American Psychiatric Association, the vested interests of pharmaceutical companies, and the desire of psychiatrists as a group to maintain their prestige do not undermine the identity of psychiatry as a medical specialty; what they do is highlight the importance of emphasising the interests of patient groups as well as utilitarian and economic criteria to counteract and respond to the other interests. Medical constructivism is not a uniquely psychiatric ontology, it is a medicine-wide ontology; it applies to schizophrenia as it does to hypertension, appendicitis, and heart disease. Owing to the normative complexity of psychiatry (outlined earlier) and to the fact that loss of freedom is often involved in psychiatric practice, the vested interests involved in psychiatry are more complex and harder to resolve than in many other medical specialties. But that in itself is not a hindrance to psychiatry’s identity as a medical speciality.

 *

We can see that on the normative, explanatory, and classificatory fronts, there is much that psychiatry can concede to its critics and still be able to able to maintain its identity as a medical speciality. It can concede the normative complexity of the psychiatric encounter while pointing out that this is a more challenging instance of the normative complexity of the general clinical encounter: values-based practice (alongside evidence-based practice) applies to all medical specialities. It can concede that it is more heavily invested in the psychosocial dimensions of the conditions of interest but that, like all medical specialities, it works within a biopsychosocial framework: the causality of all disorders is complex, across multiple levels. It can concede that a range of vested interests influences the construction of its disease categories, while pointing out that this is merely a more involved example of what occurs in all medical specialities.

References

Baker, M., and Menken, M. 2001. Time to Abandon the Term Mental Illness. BMJ 322: 937.

Biomarkers Definition Working Group. 2001. Biomarkers and Surrogate Endpoints: Preferred Definition and Conceptual Framework. Clinical Pharmacology and Therapeutics 69(3): 89-95.

Boorse, C. 2011. Concepts of Health and Disease. In Philosophy of Medicine (pp. ­13-64), F. Gifford (ed). Amsterdam: Elsevier.

Bolton, D. 2008. What is Mental Disorder? An Essay in Philosophy, Science and Values. Oxford: Oxford University Press.

Bolton, D. 2013a. What is Mental Illness. In The Oxford Handbook of Philosophy and Psychiatry (pp. 434-450), K.W.M. Fulford, M. Davies, R. Gipps, G. Graham, J. Sadler, G. Stanghellini, and T. Thornton (eds). Oxford: Oxford University Press.

Bolton, D. 2013b. Should Mental Disorder be Regarded as Brain Disorders? 21st Century Mental Health Sciences and Implications for Research and Training. World Psychiatry 12(1): 24-25.

Bolton, D. FORTHCOMING. The Biopsychosocial Model. Palgrave.

Bolton, D., and J. Hill. 2004. Mind, Meaning and Mental Disorder. Oxford: Oxford University Press.

Bolton, D., and N. Banner. 2012. Does Mental Disorder Involve Loss of Personal Autonomy? In Autonomy and Mental Disorder (pp. 77-99), L. Radoilska (ed.). Oxford: Oxford University Press.

Bracken, P., Thomas, P., Timimi, S., Asen, E., Behr, G., Beuster, C., Bhunnoo, S., Browne, I., Chhina, N., Double, D., Downer, S., Evans, C., Fernando, S., Garland, M., Hopkins, W., Huw, R., Johnson, B., Martindale, B., Middleton, H., Moldavsky, D., Moncrieff, J., Mullins, S., Nelki, J., Pizzo, M., Rodger, J., Smyth, M., Summerfield, D., Wallace, J., and Yeomans, D. 2012. Psychiatry Beyond the Current Paradigm. British Journal of Psychiatry 201: 430-434.

Cooper, R. 2013. Natural Kinds. In The Oxford Handbook of Philosophy and Psychiatry (pp. 950-965), K.W.M. Fulford, M. Davies, R. Gipps, G. Graham, J. Sadler, G. Stanghellini, and T. Thornton (eds.). Oxford: Oxford University Press.

Fulford, K., van Staden, C. W., and Crisp, R. 2013. Values-based practice: Topsy-turvy take-home messages from ordinary language philosophy (and a few next steps). In The Oxford handbook of philosophy and psychiatry (pp. 385-412), K. Fulford, M. Davies, R. Gipps, G. Graham, J. Sadler, G. Stanghellini, and T. Thornton (eds.). Oxford: Oxford University Press.

Ghaemi, N. 2016. Utility without Validity is Useless. Current Opinion in Psychiatry 15(1): 35-37.

Haslam, N. 2002. Kinds of Kinds: A Conceptual Taxonomy of Psychiatric Categories. Philosophy, Psychiatry and Psychology 9, 203-217

Hernandez, L., and Blazer, D. 2006. Genes, Behaviour, and the Social Environment: Moving Beyond the Nature/Nurture Debate. Washington, D.C.: The National Academics Press.

Horwitz, A., and Wakefield, J. 2007. The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder. Oxford: Oxford University Press.

Jablensky, A. 2016. Psychiatric Classifications: Validity and Utility. World Psychiatry 15(1): 26-31.

Kendell, R., and Jablensky, A. 2003. Distinguishing Between the Validity and Utility of Psychiatric Diagnoses. American Journal of Psychiatry 160(1): 4-12. ­

Keil, G., Keuck, L., and Hauswald, R. 2017. Vagueness in Psychiatry: An Overview. In Vagueness in Psychiatry. G. Keil, L. Keuck, and R. Hauswald (eds.). Oxford: Oxford University Press.

Kinderman, P., Read, J., Moncrieff, J., and Bentall, R. 2013. Drop the Language of Disorder. Evidence Based Mental Health 16: 2-3.

Kingma, E. 2013. Naturalist Accounts of Mental Disorder. In The Oxford Handbook of Philosophy and Psychiatry (pp. 363-384), K.W.M. Fulford, M. Davies, R. Gipps, G. Graham, J. Sadler, G. Stanghellini, and T. Thornton (eds.). Oxford: Oxford University Press.

Kobeissy, F., Alawieh, A., Mondello, S., Boustany, R., and Gold, M. 2013. Biomarkers in Psychiatry: How Close Are We? Frontiers in Psychiatry 3(114): 1-2.

Rose, N., and Singh, I. 2009. Biomarkers in Psychiatry. Nature 460: 202-207.

Scull, A. 1975. From Madness to Mental Illness: Medical Men as Moral Entrepreneurs. European Journal of Sociology 16: 219-261.

Simon, J. 2011. Medical Ontology. In Philosophy of Medicine (pp. ­65-114), F. Gifford (ed). Amsterdam: Elsevier.

Szasz, T. 1960. The Myth of Mental Illness. American Psychologist 15: 113-118.

Timimi, S. 2014. No More Psychiatric Labels: Why Formal Psychiatric Diagnostic Systems Should be Abolished. International Journal of Clinical and Health Psychology 14: 208-215.

Varga, S. 2015. Naturalism, Interpretation, and Mental Disorder. Oxford: Oxford University Press.

Venkatasubramanian, G., and Keshavan, M. 2016. Biomarkers in Psychiatry – A Critique. Annals of Neurosciences 23(1): 3-5.

White, P. D., Rickards, H., and Zeman, A. 2012. Time to End the Distinction Between Mental and Neurological Illnesses. BMJ 344: e3454.

Zachar, P. 2000. Psychiatric Disorders Are Not Natural Kinds. Philosophy, Psychiatry and Psychology 7: 167-182.

Zachar, P. 2015. Psychiatric Disorders: Natural Kinds Made by the World or Practical Kinds Made by Us? World Psychiatry 14(3), 288-290.

*

[1] Values-based practice is one such solution (see Fulford and Van Staden 2013).

[2] A ‘natural kind’ is a philosophical concept which refers to entities that exist in nature and are categorically distinct from each other. The observable features of a natural kind arise from its internal structure which is also the condition for membership of the kind. For example, any compound that has two molecules of hydrogen and one molecule of oxygen is water, irrespective of its observable features (which in the case of H2O can be ice, liquid, or gas).

[3] Biomarkers Definition Working Group (2001: 91).

[4] Indeterminacies of this kind have been discussed recently under the concept of ‘vagueness’; the notion that psychiatric classifications are imprecise with no sharp distinctions possible between those phenomena to which they apply and those to which they do not (Keil, Keuck, and Hauswald 2017). One possible implication of vagueness is a gradualist approach to mental health. For example, Sullivan-Bissett and colleagues (2017) argue that delusional and non-delusional beliefs differ in degree, not kind, a point that can also apply to the distinction between clinical depression and intense grief.

[5] An example of such attempts at refinement is the framework of the Research Domain Criteria (RDoC). See also Ghaemi (2016) and Bingham and Rashed (2014).

[6] As can be seen, the realist/anti-realist debate taps into fundamental issues in epistemology concerning our conception of truth. In the text I am not so much concerned with the status of that debate but simply with pointing out that there are alternatives to medical realism.

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In Defense of Madness: The Problem of Disability

By developing a perspective on the social model of disability and by appealing to the concept of intelligiblity, I respond to arguments against Mad Pride activism. You can access the articlm_covere HERE.

Abstract: At a time when different groups in society are achieving notable gains in respect and rights, activists in mental health and proponents of mad positive approaches, such as Mad Pride, are coming up against considerable challenges. A particular issue is the commonly held view that madness is inherently disabling and cannot form the grounds for identity or culture. This paper responds to the challenge by developing two bulwarks against the tendency to assume too readily the view that madness is inherently disabling: the first arises from the normative nature of disability judgments, and the second arises from the implications of political activism in terms of being a social subject. In the process of arguing for these two bulwarks, the paper explores the basic structure of the social model of disability in the context of debates on naturalism and normativism, the applicability of the social model to madness, and the difference between physical and mental disabilities in terms of the unintelligibility often attributed to the latter.

Mad Activism and Mental Health Practice

On the 6th of August 2018 I delivered a live webinar that was part of a Mad Studies series organised by Mad in America. The aim of the webinar was to explore ways of incroporating ideas from Mad activism into clinical practice. The full recording of the webinar and the accompanying slides can be found below.

The Identity of Psychiatry in the Aftermath of Mad Activism

[Introduction to an essay I am working on for a special issue of the Journal of Medicine & Philosophy with the title ‘The Crisis in Psychiatric Science’]

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THE IDENTITY OF PSYCHIATRY IN THE AFTERMATH OF MAD ACTIVISM

  1. INTRODUCTION

 Psychiatry has an identity in the sense that it is constituted by certain understandings of what it is and what it is for. The key element in this identity, and the element from where other features arise, is that psychiatry is a medical speciality. Upon completion of their medical education and during the early years of their training, medical students – now budding doctors – make a choice about the speciality they want to pursue. Psychiatry is one of them, and so is ophthalmology, cardiology, gynaecology, and paediatrics. Modern medical specialities share some fundamental features: they treat conditions, disorders, or diseases; they aspire to be evidence-based in the care and treatments they offer; they are grounded in basic sciences such as physiology, anatomy, histology, and biochemistry; and they employ technology in investigations, research, and development of treatments. All of this ought to occur (and in the best of cases does occur) in a holistic manner, taking account of the whole person and not just of an isolated organ or a system; i.e. person-centred medicine (e.g. Cox, Campbell, and Fulford 2007). In addition, it is increasingly recognised that the arts and humanities have a role to play in medical education, training, and practice. Literature, theatre, film, history, and the various arts, it is argued, can help develop the capacity for good judgement, and can broaden the ability of clinicians to understand and empathise with patients (e.g. Cook 2010, McManus 1995). None of the above, I will assume in this essay, is particularly controversial.

Even though psychiatry is a medical speciality, it is a special medical speciality. This arises from its subject matter, ordinarily conceived of as mental health conditions or disorders, to be contrasted with physical health conditions or disorders. Psychiatry deals with the mind not working as it should while ophthalmology, for example, deals with the ophthalmic system not working as it should. The nature of its subject matter raises certain complexities for psychiatry that, in extreme, are sometimes taken to suggest that psychiatry’s positioning as a medical speciality is suspect; these include the normative nature of psychiatric judgements, the explanatory limitations of psychiatric theories, and the classificatory inaccuracies that beset the discipline.[1] Another challenge to psychiatry’s identity as a medical speciality comes from particular approaches in mental health activism. Mad Pride and mad-positive activism (henceforth Mad activism) rejects the language of ‘mental illness’ and ‘mental disorder’, and rejects the assumption that people have a ‘condition’ that is the subject of treatment. The idea that medicine treats ‘things’ that people ‘have’ is fundamental to medical practice and theory and hence is fundamental to psychiatry in so far as it wishes to continue understanding itself as a branch of medicine. Mad activism, therefore, challenges psychiatry’s identity as a medical speciality.

In this essay, I argue that among these four challenges, only the fourth requires of psychiatry to rethink its identity. By contrast, as I demonstrate in section 2, neither the normative, nor the explanatory, or the classificatory complexities undermine psychiatry’s identity as a medical speciality. This is primarily for the reason that the aforementioned complexities obtain in medicine as a whole, and are not unique to psychiatry even if they are more common and intractable. On the other hand, the challenge of Mad activism is a serious problem. In order to understand what the challenge amounts to, I develop in section 3 the notion of the hypostatic abstraction, a logical and semantic operation which I consider to lie at the heart of medical practice and theory. It distinguishes medicine from other social institutions concerned with human suffering such as religious and some therapeutic institutions. In section 4 I demonstrate how Mad activism challenges the hypostatic abstraction. And in section 5 I discuss a range of ways in which psychiatry can respond to this challenge, and the modifications to its identity that may be necessary.

[1] These are not the only complexities; there are, for example, well-known difficulties and controversies surrounding the efficacy and risks of anti-depressant and anti-psychotic medication. In addition, psychiatry faces distinctive ethical complexities arising from the fact that mental health patients can be particularly vulnerable which raises questions of capacity not ordinarily raised in other medical specialities (see Radden and Sadler 2010).

 

The Meaning of Madness

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Excerpt from Chapter 1 of my book “Madness and the Demand for Recognition”. Forthcoming with Oxford University Press, 2018

Mad with a capital m refers to one way in which an individual can identify, and in this respect it stands similar to other social identities such as Maori, African-Caribbean, or Deaf. If someone asks why a person identifies as Mad or as Maori, the simplest answer that can be offered is to state that he identifies so because he is mad or Maori. And if this answer is to be anything more than a tautology – he identifies as Mad because he identifies as Mad – the is must refer to something over and above that person’s identification; i.e. to that person’s ‘madness’ or ‘Maoriness’. Such an answer has the implication that if one is considered to be Maori yet identifies as Anglo-Saxon – or white and identifies as Black – they would be wrong in a fundamental way about their own nature. And this final word – nature – is precisely the difficulty with this way of talking, and underpins the criticism that such a take on identity is ‘essentialist’.

Essentialism, in philosophy, is the idea that some objects may have essential properties, which are properties without which the object would not be what it is; for example, it is an essential property of a planet that it orbits around a star. In social and political discussions, essentialism means something somewhat wider: it is invoked as a criticism of the claim that one’s identity falls back on immutable, given, ‘natural’ features that incline one – and the group with which one shares those features – to behave in certain ways, and to have certain predispositions. The critique of certain discourses as essentialist has been made in several domains including race and queer studies, and in feminist theory; as Heyes (2000, p. 21) points out, contemporary North American feminist theory now takes it as a given that to refer to “women’s experience” is merely to engage in an essentialist generalisation from what is actually the experience of “middle-class white feminists”. The problem seems to be the construction of a category – ‘women’ or ‘black’ or ‘mad’ – all members of which supposedly share something deep that is part of their nature: being female, being a certain race, being mad. In terms of the categories, there appears to be no basis for supposing either gender essentialism (the claim that women, in virtue of being women, have a shared and distinctive experience of the world: see Stone (2004) for an overview), or the existence of discrete races (e.g. Appiah 1994a, pp. 98-101), or a discrete category of experience and behaviour that we can refer to as ‘madness’ (or ‘schizophrenia’ or any other psychiatric condition for this purpose). Evidence for the latter claim is growing rapidly as the following overview indicates.

There is a body of literature in philosophy and psychiatry that critiques essentialist thinking about ‘mental disorder’, usually by rebutting the claim that psychiatric categories can be natural kinds (see Zachar 2015, 2000; Haslam 2002; Cooper 2013 is more optimistic). A ‘natural kind’ is a philosophical concept which refers to entities that exist in nature and are categorically distinct from each other. The observable features of a natural kind arise from its internal structure which also is the condition for membership of the kind. For example, any compound that has two molecules of hydrogen and one molecule of oxygen is water, irrespective of its observable features (which in the case of H2O can be ice, liquid, or gas). Natural kind thinking informs typical scientific and medical approaches to mental disorder, evident in the following assumptions (see Haslam 2000, pp. 1033-1034): (1) different disorders are categorically distinct from each other (schizophrenia is one thing, bipolar disorder another); (2) you either have a disorder or not – a disorder is a discrete category; (3) the observable features of a disorder (symptoms and signs) are causally produced by its internal structure (underlying abnormalities); (4) diagnosis is a determination of the kind (the disorder) which the individual instantiates.

If this picture of strong essentialism appears as a straw-man it is because thinking about mental disorder has moved on or is in the process of doing so. All of the assumptions listed here have been challenged (see Zachar 2015): in many cases it’s not possible to draw categorical distinctions between one disorder and another, and between disorder and its absence; fuzzy boundaries predominate. Symptoms of schizophrenia and of bipolar disorder overlap, necessitating awkward constructions such as schizoaffective disorder or mania with psychotic symptoms. Similarly, the boundary between clinical depression and intense grief has been critiqued as indeterminate. In addition, the reductive causal picture implied by the natural kind view seems naive in the case of mental disorder: it is now a truism that what we call psychiatric symptoms are the product of multiple interacting factors (biological, social, cultural, psychological). And diagnosis is not a process of matching the patient’s report with an existing category, but a complicated interaction between two parties in which one side – the clinician – constantly reinterprets what the patient is saying in the language of psychiatry, a process which the activist literature has repeatedly pointed out permits the exercise of power over the patient.

The difficulties in demarcating health from disorder and disorders from each other have been debated recently under the concept of ‘vagueness’; the idea that psychiatric concepts and classifications are imprecise with no sharp distinctions possible between those phenomena to which they apply and those to which they do not (Keil, Keuck, and Hauswald 2017). Vagueness in psychiatry does not automatically eliminate the quest for more precision – it may be the case, for example, that we need to improve our science – but it does strongly suggest a formulation of states of health and forms of experience in terms of degrees rather than categorically, i.e. a gradualist approach to mental health. Gradualism is one possible implication of vagueness, and there is good evidence to support it as a thesis. For example, Sullivan-Bissett and colleagues (2017) have convincingly argued that delusional and non-delusional beliefs differ in degree, not kind: non-delusional beliefs exhibit the same epistemic short-comings attributed to delusions: resistance to counterevidence, resistance to abandoning the belief, and the influence of biases and motivational factors on belief formation. Similarly, as pointed out earlier, the distinction between normal sadness and clinical depression is difficult to make on principled grounds, and relies on an arbitrary specification of the number of weeks during which a person can feel low in mood before a diagnosis can be given (see Horwitz and Wakefield 2007). Another related problem is the non-specificity of symptoms: auditory hallucinations, thought insertion, and other passivity phenomena which are considered pathognomonic of schizophrenia, can be found in the non-patient population as well as other conditions (e.g. Jackson 2007).

Vagueness in mental health concepts and gradualism with regards to psychological phenomena undermine the idea that there are discrete categories underpinned by an underlying essence and that go with labels such as schizophrenia, bipolar disorder, or madness. But people continue to identify as Women, African-American, Maori, Gay, and Mad. Are they wrong to do so? To say they are wrong is to mistake the nature of social identities. To prefigure a discussion that will occupy a major part of Chapters 4 and 5, identity is a person’s understanding of who he or she is, and that understanding always appeals to existing collective categories: to identify is to place oneself in some sort of relation to those categories. To identify as Mad is to place oneself in some sort of relation to madness; to identify as Maori is to place oneself in some sort of relation to Maori culture. Now those categories may not be essential in the sense of falling back on some immutable principle, but they are nevertheless out there in the social world and their meaning and continued existence does not depend on one person rejecting them (nor can one person alone maintain a social category even if he or she can play a major role in conceiving it). Being social in nature they are open to redefinition, hence collective activism to reclaim certain categories and redefine them in positive ways. In fact, the argument that a particular category has fuzzy boundaries and is not underpinned by an essence may enter into its redefinition. But demonstrating this cannot be expected to eliminate people’s identification with that category: the inessentiality of race, to give an example, is not going to be sufficient by itself to end people’s identification as White or Black.

In the context of activism, to identify as Mad is to have a stake in how madness is defined, and the key issue becomes the meaning of madness. To illustrate the range of ways in which madness has been defined, I appeal to some key views that have been voiced in a recent, important anthology: Mad Matters: A Critical Reader in Canadian Mad Studies (2013). A key point to begin with is that Mad identity tends to be anchored in experiences of mistreatment and labelling by others. By Mad, Poole and Ward (2013, p. 96) write, “we are referring to a term reclaimed by those who have been pathologised/ psychiatrised as ‘mentally ill,'”. Similarly, Fabris (2013, p. 139) proposes Mad “to mean the group of us considered crazy or deemed ill by sanists … and are politically conscious of this”. These definitions remind us that a group frequently comes into being when certain individuals experience discrimination or oppression that is then attributed by them as arising from some features that they share, no matter how loosely. Those features have come to define the social category of madness. Menzies, LeFrancois, and Reaume (2013, p. 10) write:

Once a reviled term that signalled the worst kinds of bigotry and abuse, madness has come to represent a critical alternative to ‘mental illness’ or ‘disorder’ as a way of naming and responding to emotional, spiritual, and neuro-diversity. … Following other social movements including queer, black, and fat activism, madness talk and text invert the language of oppression, reclaiming disparaged identities and restoring dignity and pride to difference.

In a similar fashion, Liegghio (2013, p. 122) writes:

madness refers to a range of experiences – thoughts, moods, behaviours – that are different from and challenge, resist, or do not conform to dominant, psychiatric constructions of ‘normal’ versus ‘disordered’ or ‘ill’ mental health. Rather than adopting dominant psy constructions of mental health as a negative condition to alter, control, or repair, I view madness as a social category among other categories like race, class, gender, sexuality, age, or ability that define our identities and experiences.

Mad activism may start with shared experiences of oppression, stigma and mistreatment, it continues with the rejection of biomedical language and reclamation of the term mad, and then proceeds by developing positive content to madness and hence to Mad identity. As Burstow (2013, p. 84) comments:

 What the community is doing is essentially turning these words around, using them to connote, alternately, cultural difference, alternate ways of thinking and processing, wisdom that speaks a truth not recognised …, the creative subterranean that figures in all of our minds. In reclaiming them, the community is affirming psychic diversity and repositioning ‘madness’ as a quality to embrace; hence the frequency with which the word ‘Mad’ and ‘pride’ are associated.

In Defence of Madness: The Problem of Disability

My essay, about to be published in the Journal of Medicine & Philosophy.

I write defending mad positive approaches against the tendency to adopt a medical view of the limitations associated with madness. Unlike most debates that deal with similar issues – for example the debate between critical psychiatrists and biological psychiatrists, or between proponents of the social model of disability versus those who endorse the medical model of disability – my essay is not a polemical adoption of one or other side, but a philosophical examination of how we can talk about disability in general, and madness in particular.

You can read the essay here: IN DEFENCE OF MADNESS

And here is the abstract: At a time when different groups in society are achieving notable gains in respect and rights, activists in mental health and proponents of mad positive approaches, such as Mad Pride, are coming up against considerable challenges. A particular issue is the commonly held view that madness is inherently disabling and cannot form the grounds for identity or culture. This paper responds to the challenge by developing two bulwarks against the tendency to assume too readily the view that madness is inherently disabling: the first arises from the normative nature of disability judgements, and the second from the implications of political activism in terms of being a social subject. In the process of arguing for these two bulwarks, the paper explores the basic structure of the social model of disability in the context of debates on naturalism and normativism; the applicability of the social model to madness; and the difference between physical and mental disabilities in terms of the unintelligibility often attributed to the latter

Beyond Dysfunction: Distress & the Distinction Between Social Deviance & Mental Disorder

Over the course of last year I have been working on a small project with Rachel Bingham examining the possibility of distinguishing ‘social deviance’ from ‘mental disorder’ in light of recent work on concepts of health. The result was an essay published recently in the journal Philosophy, Psychiatry & Psychology (21:3-September 2014).

Johanna Moncrieff and Dan Stein wrote commentaries on our essay to which we responded in a short piece published in the same issue with the original essay.

In our response to Moncrieff and Stein we found it necessary to point out that in the writings of some critical psychiatrists and psychologists there is a problematic conflation of empirical with conceptual issues in relation to ‘mental disorder’. That section is reproduced below. Note that Criterion E is the final clause in the DSM definition of mental disorder. It states that a mental disorder must not solely be a result of social deviance or conflicts with society.

Mental Disorder: Separating Empirical From Conceptual Considerations

Let us begin by revisiting the conceptual basis of attributions of mental disorder. Criterion E is not, as we argued with Stein et al. (2010, 1765), conceptually necessary, but is of ethical and political importance given the historical context. Thus, notwithstanding the other criteria, a condition can only be considered for candidacy for mental disorder if “dysfunction” is present. What is a dysfunction? As Moncrieff puts it, there is a tautology in the definition of mental disorder where it is stated that a mental disorder reflects an “underlying psychobiological dysfunction” (Moncreiff 2014). Moncrieff argues that this is flawed because underlying processes have not been established, which renders the definition tantamount to saying that a dysfunction is a reflection of a dysfunction: a definition that adds nothing to our knowledge.

Here Moncrieff follows Thomas Szasz in finding a lack of resemblance to physical disorder to be the primary problem with the concept of mental disorder (see Fulford et al. 2013).1 In pursuing this, the critical psychiatrist not only fails to see the complexity of the concept of physical disorder, but also commits the same error as the biological psychiatrist. The latter implies that an ever longer awaited complete neurochemistry of mental health conditions would solve the conceptual problems. The former—the critical psychiatrist—implies the converse; that the absence of proof for the “existence of separate and distinct foundational processes,” as Moncrieff (2014) puts it, proves that mental health conditions are not disorders. As we have argued elsewhere, identifying the biological basis for a set of behaviors or symptoms does not in itself pick out what is pathological or disordered: for example, a complete description of the neurochemical states governing sexuality would not permit the inference that homosexuality is a disorder, any more than discovery of the neural correlates of falling in love or criminality would make these mental illnesses (Bingham and Banner 2012). Neurobiological changes—their presence or their absence—tells us about conditions when we find them by other means, but it does not tell us what is or is not a disorder. The same arguments could be run for underlying psychological processes. Consequently, emphasis on scientific progress or failure to progress in understanding the neurobiological correlates of mental health conditions does little to advance the conceptual debates, a point that may help to explain the impasse in the ongoing exchange between critical and biological psychiatrists.

Thus, although Moncrieff is right in pointing out that the term ‘dysfunction’ is redundant in the definition of mental disorder, she is wrong about the reason why this is so. It is not, as she claims, due to the point that no “separate and distinct foundational processes” (2014) that can ground dysfunction have been discovered empirically. After all, this leaves her open to the simple response that they actually have been, a response many biological psychiatrists do offer. The redundancy of the term ‘dysfunction’ in the definition of mental disorder is a result of conceptual analysis (and not empirical evidence), whereby it has not proven possible to define dysfunction in a way that excludes values. Here, we follow Derek Bolton in the view that once we “give up trying to conceptually locate a natural fact of the matter [dysfunction] that underlies illness attribution… then we are left trying to make the whole story run on the basis of something like ‘distress and impairment of functioning’” (2010, 332). We are left then with those things that matter in real life, the reasons that lead to healthcare being sought: usually the presence of significant distress and disability.

This is what the terms ‘dysfunction’ and ‘mental disorder’ pick out once we achieve some clarity on their referents. Stein is clearly aware of the problems inherent in defining dysfunction. However, somewhat surprisingly, the assumption that we can talk of ‘dysfunction’ over and above experienced factors (distress and disability in particular) arises through Stein’s commentary. In other words, although Stein has acknowledged the conceptual problem, in places he still writes as if there were a clear definition of dysfunction, without telling us what this would be. For example, he describes “situations when there is evidence of dysfunction, but an absence of distress and/or impairment” and gives the example of tic disorders which have no “clinical criterion (emphasizing distress and/or impairment)” (Stein 2014). We would argue that, despite the lack of explicit acknowledgement in DSM, tic disorders enter the manual because of their association with clinically significant distress and disability. It is important to avoid confusing the empirical questions (e.g., Why do people have tics? Can people have tics and not be distressed?) with the conceptual questions (e.g., When is a tic a disorder? Can tics be disorders if they do not cause distress or impairment?).

A further potential pitfall is to conflate the technical use of ‘dysfunction’ with the ordinary use of that term. This might occur where, on the one hand, we perceive a ‘dysfunction’ but on the other hand we are unable to say what the dysfunction consists of. When Moncrieff writes that dysfunction and distress are not co-extant, because, “people may neglect themselves and act in other ways that compromise their safety and survival without necessarily being distressed,” she is offering a description of behavior many would consider ‘dysfunctional’ in the lay sense (2014). Considered as a basis for conceptual analysis, however, this does not illuminate any “underlying psychobiological dysfunction”, which previous definitions aspired to do. Indeed, it is somewhat surprising that Moncrieff provides this counterexample rather than sticking to her argument that dysfunction in fact does not exist. In citing safety and survival, Moncrieff’s phrase does resemble the evolutionary theoretic approach (notably described in Wakefield’s Harmful Dysfunction Analysis), which as has been discussed widely elsewhere and noted in our paper, has fallen out of favor owing to problems with evolutionary theory specifically and naturalistic definitions in general. What of importance is left in Moncrieff’s putative definition if not underlying psychobiological and evolutionary dysfunction? We would argue: only the harm or threat of harm experienced by the individual, whether that harm is cashed out as distress and disability or as some other similar negatively evaluated experienced factor.