The guiding principles of the American Psychiatric Association include the following principle under the heading of Science As Our Foundation: “We ground every decision in evidence and clinical rigor to ensure patient-centered, high-quality care for all.”
I am rereading a book, Chance and Necessity (1970) by the late Jacques Monod who won the 1965 Nobel Prize in Physiology and Medicine. The preface of his book includes the following words by Monod: “Nowadays it is risky for a man of science to use the word ‘philosophy,’ even with the qualification ‘natural,’ in the title (or even subtitle) of a book: this is guaranteed to earn it a distrustful reception from other scientists, and from philosophers at best a condescending one. I have only one excuse, but I believe it is sound: the duty, today more imperative than ever, which is incumbent on scientists to consider their discipline within the larger framework of modern culture, with a view to enriching the latter not only with technically important findings, but also with what they may feel to be humanly significant ideas arising from their area of special concern.”
Of course there are areas of scientific and philosophical disagreement. But there are also areas of wide agreement that do not require unanimity. I wonder if members of the American Psychiatric Association (APA) have tried to agree on more specific scientific and cultural principles. It would be even better if that could be done in collaboration with members of other professional groups (e.g., psychologists, social workers, attorneys) with the best interests of patients in mind.
I agree, Monod is one of those writers who makes you stop mid-page and just sit with a sentence for a while. Chance and Necessity is a masterpiece not because of what it says about molecular biology but because of what it dares to say about meaning, purpose, and the responsibility scientists carry when they step into the public square. The fact that he had to apologize in his preface just for using the word philosophy tells you everything about how defensive science had already become by 1970.
And that defensiveness hasn't gone away. If anything it's gotten worse in psychiatry, where the pressure to look like hard science, to look like cardiology or oncology, has pushed us further and further from the very thing that makes our field matter: the human being sitting across from us.
The APA principle you cite is not wrong. Evidence matters enormously. Clinical rigor matters. But rigor without cultural and philosophical grounding is just a very precise way of missing the point. We can measure symptom reduction on a rating scale with exquisite accuracy and still send someone home to an empty apartment with no connection to community, no sense of purpose, no reason to get up tomorrow. That's not high quality care. That's a clean data set.
The APA has not always had the courage to stand behind strong opinions when it mattered most. That's just a fact. And that gap between stated principles and actual moral courage is exactly what Monod was warning about. His point wasn't just that scientists should be curious. It was that they have a duty, a real one, to bring humanly significant ideas into the larger culture even when it's uncomfortable. Science as foundation only means something if the people holding it are willing to follow it somewhere difficult.
That is the thing you cannot write into a principle statement. You either have it or you don't.
It's almost as if the 'critical camps' are unaware of the international (and primarily non-American) field called "philosophy of psychiatry", which now has well over 60 volumes filled to the brim with 'dissenters', many with their own rather interesting metaphysics that are anti-reductionist and some even anti-physicalist. Many of those volumes published decades ago are now integrated into mainstream cognitive science (e.g. the growing popularity of panpsychism). If the critical folk simply expanded their horizon away from pure constructivism (which is basically anti-foundationalist) then we wouldn't be watching these "back and forth" fights.
But when their starting point is "Objective truth is a social construct" (aka, anti-foundationalism) then any philosophical discussion becomes an automatic non-starter. Imagine your first premise being "Objective truth is a social construct" and then proceeding to making truth-claims about human suffering, DSM, oppression and such and such. Notice that the first premise automatically cancels out all other premises. Just like eliminativism, it is self-defeating from the start.
“It's almost as if the 'critical camps' are unaware of the international (and primarily non-American) field called "philosophy of psychiatry"”… Bingo! You hit the nail on the head!
I'd read your blog about Szaszians and MAHA, and the Bob Whitaker's MIA post characterizing you (sort of) as if designated by the APA to pounce on critical psychiatry ( one of many terms which are used mostly as the user sees fit), and now this one. I comment on some MIA offerings and have written 3 of my own; I recall after the first one, we had an exchange in which you noted that I was perhaps too soft on them! And I believe you opted to withdraw from engaging with MIA.
The politics of interacting with MIA and critical psychiatry, I'm sadly coming to see, make it close to impossible to engage with those forces in a constructive way. Much as I like to think that our field is, warts and all, not as closed-off as critical psychiatry seems to need to portray us as being; I find them, or at least those who post (hopefully not a representative sample) straining to ever acknowledge that I/we have a valid point in any discussion. It's as if one concession will bankrupt their entire stance. One can speculate about why that is, but the common ground or interests is, let's just say, elusive.
I don't like the idea of just talking to those who are already on board with how we see things and not to those who aren't. It so much parallels what else goes on - or appears to - in our country with separate silos in which both seem so fearful or avoidant of saying the other side has even a point to make. I remain somewhat hopeful that there is more mingling going on than there appears to be.
There is a rich conceptual middle ground and increasingly a middle ground of interests too. There are too many incentives to remain polarized, especially among those who built their careers on this polarization, but I believe there is robust appetite for constructive dialogue (and in some ways this substack is a demonstration of that)
It's encouraging to hear you say that. I look forward to seeing more of that constructive dialogue; feel free to point me and others in the direction of those dialogues. thanks
thanks - I've read some of these, and I'll continue to work my way through more.
I have an interest in the clinical integration of psychiatry and religion, and as I've gotten more connected with religion ( and I don't mean 'spirituality') in my own life, it became another terrific tool in my work. Wonder if any of those interviews touch on that.
One of the reasons I return to this substack is for its humility before its subject matter, its patience and openness with the many contradictions of mental illness and its system of care, and its general independence from any school of advocacy (as you note, there are many micro-tribes in this corner of the world and it isn’t always fun to have conflict with them). Keep it up man.
Awais, I started writing a comment this morning after reading your essay and quickly realized I had more to say than this space would allow. Given the respect I have for your work and the seriousness of the questions you raise, I felt you deserved a more careful response than a few rushed lines in a thread. So I wrote it out as a full piece. I hope you take it in the spirit it is offered, from someone who reads you regularly and admires what you are building here. The link is below for anyone who wants to follow the conversation. https://giovannicolella336816.substack.com/p/when-elegance-replaces-courage
I was reflecting for the hundredth time this year on the feud between Mogens Schou and Michael Shepherd and what it cost science to have two of its greatest thinkers bickering.
Its an extraordinary state of affairs when people can dedicated their lives to a field, give up time with family, risk their own careers and still find room to have a crack at colleagues in the same boat.
I resolved in my heart once more to cease saying foolish things on the internet about people who are clearly in good faith, which most people I believe are. In particular I regret saying nasty things about people interested in the exact same issues I am but with whom I slightly disagree and resolved in my heart once more to instead work together with anyone whose heart is in the right place no matter how much I might disagree with them.
Helen Speyer spoke of the desire for an integrative pluralism in her keynote at this year’s Too Mad to be True conference in Ghent. But I think the counter that there already exists a global conception of mental health which accommodates such a pluralism, means that more problems exist if we think that a future integrated pluralism will suffice. The crises of mental health requires far broader attempts at generalization and universalism than current postmodern conceptions allow; partly narrowed by professional specialization (eg overfocus on psychiatry).
When it comes to testimonies from patients/service users/survivors, I don't think critical psychiatry's problem is that they treat testimony as too sacred, instead of balancing it against other sources of evidence. The big problem is that BOTH critical psychiatry AND reductive and bio-focused versions of psychiatry must dismiss SO MUCH. Because patient/user/survivor experiences of psychiatry and psych med treatments are extremely heterogeneous - something that pluralism can make space for, but not any narrower camp in the debate.
The guiding principles of the American Psychiatric Association include the following principle under the heading of Science As Our Foundation: “We ground every decision in evidence and clinical rigor to ensure patient-centered, high-quality care for all.”
I am rereading a book, Chance and Necessity (1970) by the late Jacques Monod who won the 1965 Nobel Prize in Physiology and Medicine. The preface of his book includes the following words by Monod: “Nowadays it is risky for a man of science to use the word ‘philosophy,’ even with the qualification ‘natural,’ in the title (or even subtitle) of a book: this is guaranteed to earn it a distrustful reception from other scientists, and from philosophers at best a condescending one. I have only one excuse, but I believe it is sound: the duty, today more imperative than ever, which is incumbent on scientists to consider their discipline within the larger framework of modern culture, with a view to enriching the latter not only with technically important findings, but also with what they may feel to be humanly significant ideas arising from their area of special concern.”
Of course there are areas of scientific and philosophical disagreement. But there are also areas of wide agreement that do not require unanimity. I wonder if members of the American Psychiatric Association (APA) have tried to agree on more specific scientific and cultural principles. It would be even better if that could be done in collaboration with members of other professional groups (e.g., psychologists, social workers, attorneys) with the best interests of patients in mind.
Thanks Joseph! Good suggestion. And I wasn’t familiar with Monod, so that’s useful!
I agree, Monod is one of those writers who makes you stop mid-page and just sit with a sentence for a while. Chance and Necessity is a masterpiece not because of what it says about molecular biology but because of what it dares to say about meaning, purpose, and the responsibility scientists carry when they step into the public square. The fact that he had to apologize in his preface just for using the word philosophy tells you everything about how defensive science had already become by 1970.
And that defensiveness hasn't gone away. If anything it's gotten worse in psychiatry, where the pressure to look like hard science, to look like cardiology or oncology, has pushed us further and further from the very thing that makes our field matter: the human being sitting across from us.
The APA principle you cite is not wrong. Evidence matters enormously. Clinical rigor matters. But rigor without cultural and philosophical grounding is just a very precise way of missing the point. We can measure symptom reduction on a rating scale with exquisite accuracy and still send someone home to an empty apartment with no connection to community, no sense of purpose, no reason to get up tomorrow. That's not high quality care. That's a clean data set.
The APA has not always had the courage to stand behind strong opinions when it mattered most. That's just a fact. And that gap between stated principles and actual moral courage is exactly what Monod was warning about. His point wasn't just that scientists should be curious. It was that they have a duty, a real one, to bring humanly significant ideas into the larger culture even when it's uncomfortable. Science as foundation only means something if the people holding it are willing to follow it somewhere difficult.
That is the thing you cannot write into a principle statement. You either have it or you don't.
On the issue of defensiveness, something I wrote for Psych Times a few years ago: https://www.psychiatrictimes.com/view/its-time-for-us-to-stop-being-so-defensive-about-criticisms-of-psychiatry
It's almost as if the 'critical camps' are unaware of the international (and primarily non-American) field called "philosophy of psychiatry", which now has well over 60 volumes filled to the brim with 'dissenters', many with their own rather interesting metaphysics that are anti-reductionist and some even anti-physicalist. Many of those volumes published decades ago are now integrated into mainstream cognitive science (e.g. the growing popularity of panpsychism). If the critical folk simply expanded their horizon away from pure constructivism (which is basically anti-foundationalist) then we wouldn't be watching these "back and forth" fights.
But when their starting point is "Objective truth is a social construct" (aka, anti-foundationalism) then any philosophical discussion becomes an automatic non-starter. Imagine your first premise being "Objective truth is a social construct" and then proceeding to making truth-claims about human suffering, DSM, oppression and such and such. Notice that the first premise automatically cancels out all other premises. Just like eliminativism, it is self-defeating from the start.
“It's almost as if the 'critical camps' are unaware of the international (and primarily non-American) field called "philosophy of psychiatry"”… Bingo! You hit the nail on the head!
I'd read your blog about Szaszians and MAHA, and the Bob Whitaker's MIA post characterizing you (sort of) as if designated by the APA to pounce on critical psychiatry ( one of many terms which are used mostly as the user sees fit), and now this one. I comment on some MIA offerings and have written 3 of my own; I recall after the first one, we had an exchange in which you noted that I was perhaps too soft on them! And I believe you opted to withdraw from engaging with MIA.
The politics of interacting with MIA and critical psychiatry, I'm sadly coming to see, make it close to impossible to engage with those forces in a constructive way. Much as I like to think that our field is, warts and all, not as closed-off as critical psychiatry seems to need to portray us as being; I find them, or at least those who post (hopefully not a representative sample) straining to ever acknowledge that I/we have a valid point in any discussion. It's as if one concession will bankrupt their entire stance. One can speculate about why that is, but the common ground or interests is, let's just say, elusive.
I don't like the idea of just talking to those who are already on board with how we see things and not to those who aren't. It so much parallels what else goes on - or appears to - in our country with separate silos in which both seem so fearful or avoidant of saying the other side has even a point to make. I remain somewhat hopeful that there is more mingling going on than there appears to be.
There is a rich conceptual middle ground and increasingly a middle ground of interests too. There are too many incentives to remain polarized, especially among those who built their careers on this polarization, but I believe there is robust appetite for constructive dialogue (and in some ways this substack is a demonstration of that)
It's encouraging to hear you say that. I look forward to seeing more of that constructive dialogue; feel free to point me and others in the direction of those dialogues. thanks
https://www.psychiatrymargins.com/p/interviews
thanks - I've read some of these, and I'll continue to work my way through more.
I have an interest in the clinical integration of psychiatry and religion, and as I've gotten more connected with religion ( and I don't mean 'spirituality') in my own life, it became another terrific tool in my work. Wonder if any of those interviews touch on that.
One of the reasons I return to this substack is for its humility before its subject matter, its patience and openness with the many contradictions of mental illness and its system of care, and its general independence from any school of advocacy (as you note, there are many micro-tribes in this corner of the world and it isn’t always fun to have conflict with them). Keep it up man.
Thank you! I really appreciate that.
Awais, I started writing a comment this morning after reading your essay and quickly realized I had more to say than this space would allow. Given the respect I have for your work and the seriousness of the questions you raise, I felt you deserved a more careful response than a few rushed lines in a thread. So I wrote it out as a full piece. I hope you take it in the spirit it is offered, from someone who reads you regularly and admires what you are building here. The link is below for anyone who wants to follow the conversation. https://giovannicolella336816.substack.com/p/when-elegance-replaces-courage
Thanks Giovanni, I left a comment 😊
I was reflecting for the hundredth time this year on the feud between Mogens Schou and Michael Shepherd and what it cost science to have two of its greatest thinkers bickering.
Its an extraordinary state of affairs when people can dedicated their lives to a field, give up time with family, risk their own careers and still find room to have a crack at colleagues in the same boat.
I resolved in my heart once more to cease saying foolish things on the internet about people who are clearly in good faith, which most people I believe are. In particular I regret saying nasty things about people interested in the exact same issues I am but with whom I slightly disagree and resolved in my heart once more to instead work together with anyone whose heart is in the right place no matter how much I might disagree with them.
Helen Speyer spoke of the desire for an integrative pluralism in her keynote at this year’s Too Mad to be True conference in Ghent. But I think the counter that there already exists a global conception of mental health which accommodates such a pluralism, means that more problems exist if we think that a future integrated pluralism will suffice. The crises of mental health requires far broader attempts at generalization and universalism than current postmodern conceptions allow; partly narrowed by professional specialization (eg overfocus on psychiatry).
When it comes to testimonies from patients/service users/survivors, I don't think critical psychiatry's problem is that they treat testimony as too sacred, instead of balancing it against other sources of evidence. The big problem is that BOTH critical psychiatry AND reductive and bio-focused versions of psychiatry must dismiss SO MUCH. Because patient/user/survivor experiences of psychiatry and psych med treatments are extremely heterogeneous - something that pluralism can make space for, but not any narrower camp in the debate.