Critical and Integrative Pluralism
Critical and Integrative Pluralism
Points of disagreement with "critical psychiatry"
Conversations in Critical Psychiatry (Oxford University Press, 2024), edited by me, brings together a selection of interviews published in the Psychiatric Times from 2019 to 2022, updated with new and previously unpublished material (including a foreword by Sir Robin Murray and a detailed introductory chapter). These interviews explore critical and philosophical perspectives in psychiatry by engaging with prominent commentators within and outside the profession who have made meaningful criticisms of the status quo.
Conversations in Critical Psychiatry is officially out in the UK and can be purchased in both print and eBook format. It will be available for print orders in the US very soon and currently can be purchased in Kindle format.
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In the introductory chapter, Psychiatry and the Critical Landscape, I endorse a position that I characterize as “critical and integrative pluralism,” and I describe points of convergence and divergence from the standard positions of critical psychiatry (taking views from the critical psychiatry network as representative). The discussion is summarized in a table in the chapter that I am reproducing here. There is a lot of conceptual detail condensed in the table, and the relevant issues are unpacked in the book and elsewhere. Some of the differences highlighted in the table may seem subtle, but they have significant downstream consequences, generating the sorts of debates that I’ve been covering on this Substack since its inception. Check out the chapter in the book for more details!
Since Substack still doesn’t have the option to create tables within posts (!), I'm posting snapshots from the table and the free text below it.
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Critical and integrative pluralism: Mental health problems are heterogenous. In different instances, they may be better understood as faulty physiological or psychological mechanisms, extremes of dimensional variations, mismatches between evolutionary design and environment, problems of living, maladaptive learning behaviours, evolutionary adaptations, disabilities resulting from poor social accommodations, psychological conflicts, responses to and sequalae of trauma, and various sorts of psychological adaptations to interpersonal and psychosocial stressors, among other possibilities.
Critical psychiatry: In critical psychiatry there is often insufficient appreciation of the heterogeneity of mental health problems and the emphasis is on characterizing them as responses of various sorts to societal and structural arrangements (often at the expense of other perspectives). There is also a tendency to dismiss the causal role of various neurophysiological and neuropathological factors (even as components of a more complex, multifactorial etiology).
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Critical and integrative pluralism: Mental health problems are complex, value-laden, and multidimensional to a degree that medical problems are typically not, but there is no fundamental discontinuity between problems in psychiatry and problems in the rest of medicine. Mental health problems cannot be mapped and categorized sufficiently by a simple categorical system, and require a pluralistic, multiperspective approach that takes into account their dimensional, developmental, and idiographic aspects. But they can nonetheless be mapped and categorized in pragmatic ways that have clinical utility and scientific validity.
Critical psychiatry: There is a tendency to see a discontinuity between psychiatry and the rest of medicine, and there is a rejection of the idea that ‘mental health problems can be mapped and categorized with the same causal logic used in the rest of medicine’ (Bracken et al., 2012).
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Critical and integrative pluralism: Psychiatric interventions typically have broad, non-specific, transdiagnostic effects across a range of mental functions. These effects can have therapeutic value and may be studied in clinical trials for a particular diagnosis, but it is not accurate to understand them as targeting specific psychiatric diagnoses. They nonetheless may, and likely do, act in part on mechanisms—mechanisms that are themselves transdiagnostic—that produce and sustain psychiatric symptoms/problems.
Critical psychiatry: There is an assumption that broad, non-specific, transdiagnostic effects can only be understood through a ‘drug-centred’ model which rejects the proposition that psychiatric medications can act on mechanisms that produce psychiatric symptoms/problems (see section ‘An Integrative Psychopharmacology’)
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Critical and integrative pluralism: Biological, psychological, and sociocultural are not ontologically distinct domains with separate essences. They are overlapping ways of talking about a complex reality that requires us to draw on the concepts and languages of multiple disciplines.
The neurophysiological dimension is only one dimension among many (experiential, sociocultural, existential) and it is not always, or even usually, the most important one. However, neurophysiological factors can and do increase the risk (probability) of experiencing mental health problems; furthermore, since neurophysiological mechanisms are involved in mental health problems due to the embodied nature of mind, those mechanisms can be intervened on to produce desired effects, even if they are not ‘dysfunctional’ in any objective sense.
Critical psychiatry: There is a tendency in critical psychiatry to treat biological and social explanations in a binary manner (Moncrieff, 2020; Read & Moncrieff, 2022).
There is also a tendency to see any invocation of biological mechanisms in scientific causal explanations of mental illness (including causal risk factors) as evidence of reductionism: ‘wishful speculation that the findings of neuroscientific research will translate into clinical practice implies that you think that mental health disorders are brain diseases’ (Double, 2015).
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Critical and integrative pluralism: A priori assumptions to privilege technological or hermeneutic aspects of mental illness are problematic; the solution has to be Jasperian—both ‘causal explanation’ and ‘meaningful understanding’ are necessary, and their application and relevance will vary from case to case and context to context. We will require a plurality of perspectives that includes the perspectives of disease, dimensions, behaviour, and life story (see interview with McHugh, Chapter 15).
Critical psychiatry: According to critical psychiatry, ethical and hermeneutic aspects take primacy over scientific aspects, and social, cultural, economic, and political aspects take primacy over neurophysiological and psychological aspects.
‘… position the ethical and hermeneutic aspects of our work as primary, thereby highlighting the importance of examining values, relationships, politics and the ethical basis of care and caring’ (Bracken et al., 2012).
‘If mental illness is not a brain disease, there is no need to specify an underlying brain problem. Instead the focus is on understanding the person and why they have presented with the problems they have in the context of their life situation’ (Double, 2019).
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Critical and integrative pluralism: Psychiatric medications produce intended therapeutic effects by intervening on mechanisms and processes that underlie and/or constitute mental functioning and are involved in the production and maintenance of psychiatric symptoms. These mechanisms and processes may not be classifiable as ‘normal’ or ‘abnormal’ in any straightforward factual sense. Explanations of how therapeutic effects of psychotropics are produced will require explanatory pluralism—multiple causal interactions between the effects of medications and psychiatric symptoms at multiple levels of explanation (Aftab & Stein, 2022).
Critical psychiatry: Psychiatric medications do not act on mechanisms and processes involved in the production of psychiatric symptoms. Instead, ‘psychiatric drugs are psychoactive substances that modify symptoms through the characteristic alterations they produce in normal mental processes, emotion and behaviour … psychiatric drugs should be understood as producing altered states that may sometimes be useful in suppressing certain mental symptoms or unwanted behaviours’ (Yeomans et al., 2015).
References:
Aftab, A., & Stein, D. J. (2022). Psychopharmacology and explanatory pluralism. JAMA Psychiatry, 79(6), 522–523.
Bracken, P., Thomas, P., Timimi, S., et al. (2012). Psychiatry beyond the current paradigm. British Journal of Psychiatry, 201(6), 430–434.
Double, D. (2015). Giving up the disease model. Lancet Psychiatry, 2(8), 682.
Double, D. B. (2019). Twenty years of the Critical Psychiatry Network. British Journal of Psychiatry, 214(2), 61–62.
Moncrieff, J. (2020). ‘ It was the brain tumor that done it!’: Szasz and Wittgenstein on the importance of distinguishing disease from behavior and implications for the nature of mental disorder. Philosophy, Psychiatry, & Psychology, 27(2), 169–181.
Read, J., & Moncrieff, J. (2022). Depression: why drugs and electricity are not the answer. Psychological Medicine, 52(8), 1401–1410.
Yeomans, D., Moncrieff, J., & Huws, R. (2015). Drug-centred psychopharmacology: a non-diagnostic framework for drug treatment. BJPsych Advances, 21(4), 229–236.
See also:
I agree with most of your points versus the critical movement, with the exception of the very last one. Although my heart often aligns with the critical movement on the basis of being anti-mechanistic, anti-reductionist, and libertarian, I have yet to find a voice there that has a consistent metaphysics grounded in either western or eastern philosophy. There is too much "social constructivism" in the critical movement. They are both anti-God, anti-idealism, anti-physicalist, anti-mechanistic, and anti-dynamicist, and thus are incoherent. It's as if they're anti-everything and thereby occupy an "epistemic no man's land", where no one actually doubles-down and commits to an established tradition. They are too circumstantial.
Jasper's, on the other hand, atleast understood what an Aristotelian and Platonic form was. He at least understood the importance of self-transcendence across the lifespan and hence it's effects on the personality system (self-governance and moral reasoning), along with the limits of potentiality (as in the limits of altered states of consciousness and the limits of meaning). Although I despise Jaspers because he's another Kantian, I will give him more credit than the modern critical movement.
Since you have endorsed integrative pluralism, does this now mean you will place the (emergentist) Temperament & Character Inventory by Cloninger on equal footings to the (reductionist) Big 5? Because last i checked, the TCI contextualizes each person across the lifespan from by grounding it in complexity science, self-organization, and autonomous action, whereby persons are operationalized as possessing irreducible properties or being self-causing "non-Heaps". Whereas the Big 5 instead approaches persons as "heaps" qua lists of summable factors that behave in billiard-ball fashion, that is, without form.