Psychiatry and Medical Authority

Back to the Future

In my corner of twitterverse, the philosophical challenge to psychiatry’s medical authority is seeing a new resurgence, reminiscent of the 1960s. The philosopher Justin Garson, for example, who is a wonderful colleague and whose work I greatly admire, has (unfortunately) argued the following:

“I take it that what’s essential to Psychiatry is that it’s a branch of medicine; as such, it must see mental disorders as medical problems if it’s to have any purchase. If it turns out they’re not medical problems, that’s… kind of an issue.” (tweet)

“My view is that psychiatry has the authority it does, as a branch of medicine, because it’s seen as treating diseases. The more we see mental disorders as non-diseases, the more folks will wonder what psychiatry has to do with them.” (tweet)

“I think mental health problems are real & there’s always going to be a need for mental health professionals. The problem is with psychiatry as a branch of medicine. Medicine’s job is to treat diseases. If people stop seeing mental disorders as diseases, that’s a problem for them.” (tweet)

A lot of this discussion echoes arguments offered by Thomas Szasz and other psychiatry critics from the 1960s and 1970s. The neo-Kraepelinian psychiatrists and Robert Spitzer were particularly concerned with this threat and responded by asserting the identity of psychiatry as a branch of medicine and mental disorders as being a subset of medical disorders. Jerome Wakefield later sought to philosophically fortify this neo-Kraepelinian and Spitzerian defense by developing his “harmful dysfunction” account of medical disorder based on evolutionary considerations. The philosophical debate has subsequently continued in a smoldering fashion, more of interest to philosophers rather than psychiatrists. Recent developments in psychiatry – problems with validating DSM constructs in neurobiological terms, the popularity of dimensional frameworks, a vocal emphasis by some groups on viewing mental disorders as “understandable” reactions to life circumstances, seeing some mental illnesses as evolutionary adaptations, and the collapse of the “chemical imbalance” narrative – have all contributed to the resurgence of this debate.  

Given this context, it’s helpful for us to revisit the antipsychiatric challenge to psychiatry’s medical authority and the philosophical ways in which we can respond to this challenge. Wakefield’s understanding of this debate provides a useful starting point. He covers some of this territory in a 2022 article for World Psychiatry.

Wakefield writes: “Antipsychiatrists argued that psychiatry used bogus medical categories to justify the use of medical authority and technology for the social control of disapproved behavior. In an unlikely alliance with antipsychiatrists, behaviorists, who were a powerful constituency within psychology at the time, argued that deviant behavior is shaped by normal learning processes in deviant environments and thus that “mental disorders” are not literally medical disorders but merely socially disapproved behavioral outcomes.”

He notes that psychiatrists from those years also offered a similar framing of the antipsychiatry argument:

“According to this view, psychiatric diagnosis is merely a way that society labels its deviants… and only serves as a means of social control” (Samuel Guze) and “… common to these schools of criticism is an attack on the basic concept that mental illnesses… are appropriately treated within the medical model and that psychiatry and its treatments… are legitimate medical activities” (Gerald Klerman)

Wakefield clarifies further: “Psychiatry is obviously a branch of medicine in a sociological or organizational sense. However, what is being raised is a conceptual question about whether psychiatry deals with medical disorders, which is the essential defining mission of medicine, whatever else it does.”

According to Wakefield, what is needed is an account of what constitutes “genuine medical disorders” and then to demonstrate that there are conditions we currently call mental illnesses that meet the requirement for being a “medical disorder.”

Wakefield, and psychiatrists such as Spitzer and Klerman, distinguish between establishing the existence of mental disorders as a subset of medical disorders, and the question ‘what can medicine/psychiatry legitimately treat?’ The answer to the latter question is broader than the issue of mental/medical disorder because these commentators all recognize that physicians and psychiatrists can justifiably apply their skills to non-disordered conditions for treating distress/suffering and for enhancing human well-being. However, in their view the legitimacy of the discipline is contingent upon the existence of its essential domain – medical disorders – without which the role of medicine in the extended domain would become illegitimate as well.

Natural Dysfunction

Wakefield’s solution to this is his account of disorder as “harmful dysfunction”, requiring a value component (harm) and a factual component (dysfunction). For Wakefield, it is dysfunction that performs of crucial role of rebutting the antipsychiatric challenge. He defines dysfunction in evolutionary terms as “failure of some internal mechanism to perform a function for which it was biologically designed (i.e., naturally selected).” According to Wakefield, DSM’s thresholds are too liberal and include many false positives that do not involve natural dysfunction, but for paradigmatic psychiatric cases, he sees good reasons to infer the existence of probable evolutionary dysfunction.

It is this line of reasoning by Wakefield that provides one opportunity for some critics to attack the medical status of psychiatry. Justin Garson, for example, broadly favors an adaptationist view: mental illnesses are evolutionary adaptations. If they are not evolutionary dysfunctions, then they are not medical disorders, and hence not within the purview of medicine, and psychiatry’s status as a “medical specialty” is on unsteady ground.

Now, I am not a proponent of Wakefield’s account. I personally don’t conceptualize medical or mental disorders as evolutionary dysfunctions, and there has been a prominent shift in philosophy of psychiatry (at least the circles in which I hang out) in moving away from this style of thinking about disorders. But the account remains influential, and so for people who do broadly work within a Wakefieldian framework, I want to highlight that there are good reasons to accept the medical legitimacy of psychiatry.

Recall that the Wakefield/Spitzer view of psychiatric legitimacy depends on establishing a core domain of mental disorders and then an extended domain in which the tools of the medical professions are employed in service of alleviating other forms of distress and for enhancing human well-being. From this it follows that in order to challenge psychiatric legitimacy, one would have to make the radical claim that there are no evolutionary dysfunctions in psychiatry. Because as long as there are some mental dysfunctions, there is an essential domain of psychiatry which can be extended into other areas based on pragmatic grounds and therapeutic needs.

It is very difficult to demonstrate on evolutionary grounds that there are no psychiatric dysfunctions. Saying that many conditions considered to be disordered may be evolutionary adaptations doesn’t suffice – that’s a quibble over the boundary of disorder as natural dysfunction, not a challenge to the medical legitimacy of psychiatry.

Randolph Nesse, one of the founders of the field of evolutionary medicine, is very clear on this point. There are psychiatric disorders:

“Viewing Diseases As Adaptations (VDAA) is the most common and most serious mistake in evolutionary medicine. So several cautions bear repeating. Diseases themselves do not have evolutionary explanations. They are not adaptations shaped by natural selection. Genes or traits associated with some diseases provide advantages and disadvantages that influence natural selection. However, proposals about the utility of diseases themselves, such as schizophrenia, addiction, autism, and bipolar disorders, are wrong before they start. The correct question is Why did natural selection shape traits that make us vulnerable to disease?” (italics in original, bold emphasis is mine) (Nesse, Good Reasons for Bad Feelings, page 41)

and

“Humans are fascinated by function and seduced by simplicity. These tendencies are major obstacles to progress in evolutionary psychiatry. It is tempting to view disorders as if they are adaptations and to look for possible benefits that could provide simple explanations. But disorders in themselves are not adaptations shaped by natural selection… Proposals abound for possible fitness benefits thought to explain depression, eating disorders, addiction, attention deficit hyperactivity disorder (ADHD), autism and even schizophrenia. One reason why this mistake is common is that some conditions frequently considered to be disorders or diseases are actually adaptations; pain, anxiety and low mood are examples. Another reason is that individuals at the tails of trait distributions where diseases become likely experience benefits as well as costs. A third reason is that explanations that propose a possible function for a disease often make good memes that spread fast irrespective of their veracity.” (Why Do Mental Disorders Persist?)

Anyone making the radical argument that there are no evolutionary dysfunctions in psychiatry has a lot of work to do to overturn current scientific thinking in evolutionary medicine, and as long as there is a domain of evolutionary dysfunctions in psychiatry, whatever its size, the fundamental legitimacy of psychiatry is secure in the Wakefieldian worldview.

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Wakefield’s response is not the only strategy available to us to counter the antipsychiatric challenge. As I mentioned, I personally do not think of mental disorders in terms of evolutionary dysfunctions, so I will review some of the other strategies available to us here.

While Guze/Spitzer/Wakefield focus on the notion of “medical disorder” as a way of responding to Szaszian claims, other strategies include focusing on the existence of biological mechanisms, developing accounts of dysfunction that don’t invoke social norms in the sense alleged by the antipsychiatry arguments, and identifying the role of values in preventing diagnostic abuses in psychiatry. The common theme here is that there is more to psychiatric kinds than mere labelling of social deviance.

Biological Mechanisms and Homeostatic Property Clusters

Instead of focusing on diseases or dysfunctions, we can focus on biological kinds. This is the strategy taken by the philosopher Jonathan Tsou (2021).

He argues that “the naturalistic requirement of biological dysfunction (which implies mental disorders are diseases) is too demanding. A more useful and empirically ascertainable naturalistic requirement is that mental disorders should be biological kinds. Hence, mental disorders are biological kinds whose effects lead to harmful consequences.… I argue that some mental disorders (e.g., schizophrenia, depression) are HPC [homeostatic property cluster] kinds: classes of abnormal behavior constituted by a set of stable biological mechanisms. The naturalistic requirement that HPC kinds are underwritten by intrinsic biological mechanisms ensures that HPC kinds are relatively stable objects of classification and their classifications yield projectable inferences (i.e., reliable predictions about kind members).”

And

“Skeptics argue that mental disorders are not diseases or biological kinds, and they suggest that mental disorders are best explained in terms of social factors. For example, Szasz and Laing contend that ‘schizophrenia’ is not a disease, but an oppressive label used to explain socially deviant behavior. I counter these claims by appealing to scientific evidence indicating that schizophrenia and depression are underwritten by identifiable biological mechanisms.”

Appeals to homeostatic or mechanistic property clusters [MPCs] are common in philosophy of psychiatry these days. Tim Thornton summarizes this debate in a recent volume (2022):

“I have explored two opposing general intuitions about mental illness. One takes the various dissimilarities between mental illnesses and paradigmatic physical illnesses to be a reason to deny the former illness status. The other holds that there are sufficient underlying similarities, despite the apparent differences, for mental illnesses properly to count as illnesses. The former view denies particular illness kinds a real, objective, or natural status. The latter holds that while not essentialist kinds, the sort that seems to fit chemistry, they could be genuine, objective, or natural kinds of a more relaxed form such as MPCs, in which the tying together of stable properties in law-like ways helps sustain inductive generalisations for explanation and prediction.”

The presence of homeostatic property clusters and biological mechanisms allow for the possibility of medical intervention, but they are not sufficient to establish that we should. That reason comes from the harm criterion. It is when the HPCs are associated with relevant forms of distress and disability that they become targets of clinical attention.   

I noted in a recent commentary with colleagues:

“The involvement of biological factors can take many different forms in explanations of depression: i) biological dysfunctions (e.g. hypothyroidism, stroke, HPA axis abnormalities, etc); ii) biological risk factors (e.g. genetic variants, inflammatory processes, etc), iii) biological mechanisms (e.g. brain circuits involved in the regulation of mood). There is extensive literature that supports this… The exact nature of involvement will vary from person to person; for some individuals there may very well be no biological dysfunctions or biological risk factors, but due to the embodied nature of mind, there will still be biological mechanisms involved. Understanding biology in this manner also provides a rationale for biological intervention that doesn’t necessarily rely on disease processes; biological mechanisms do not have to be dysfunctional for us to successfully intervene on them to produce desired effects.” (Aftab et al. 2022)

The desired effects are, of course, enmeshed with value judgments that require further scrutiny.

Functional Norms

One of my favorite attempts at defining mental disorder comes from Kristopher Nielsen and Tony Ward (2020), who are also motivated to fend off the Szaszian challenge. They offer the following definition:

“What counts as mentally dysfunctional is any set of behaviors (inclusive of cognition, perception, or anything the organism does) performed by an organism that significantly violates its own functional norms, in that it is acting counter to its own self-maintenance and adaption needs. The persistence of this pattern of behavior thereby threatens the organism’s organizational autonomy and as such should be considered disordered.”

“… this is a significant strength as the act of diagnosis is then justifiable by reference to individuals and their needs, staving off Szaszian claims (unlike strong evaluativism) while also not ignoring how culture shapes many of those needs in the first place (as per weak evaluativism).”

They also highlight how such a way of thinking is congruent with a medical understanding of physical illness:

“A significant violation of the functional norms of an organism system at a biological scale essentially constitutes an injury or medical condition. Similarly, on our view, a significant and continued violation of functional norms of the organism system at a behavioral or psychological scale is a psychological disorder.”

Nielsen and Ward are working within an embodied, embedded, and enactive framework, and the embodied nature of mind necessities that mental dysfunctions possess a neurophysiological dimension, which again allows for the possibility of pharmacological and other medical interventions.

Values and Social Objectivity

Dependence on human interests and values with regards to notions of dysfunction is seen as a red flag by some critics who think that any such dependence offers no defense against the Szaszian charge of medicalizing social deviance. However, there are philosophical resources available to us to address this. An emphasis on individual’s functional norms pertaining to self-maintenance and adaption (vs social norms) is one strategy. Another parallel strategy is to allow for meaningful critique of the values involved to ensure “social objectivity” and to identify problematic value judgments. Anne-Marie Gagné-Julien (2021) explores this strategy in the context of Robert Cummins’s causal role approach to function. Cummins approach to function/dysfunction is considered to be too dependent on human interests. Gagné-Julien argues that this can be remedied by the existence of social mechanisms that “ensure that problematic interests and values influencing functional attributions in psychiatry are identified, criticized and regulated.”

“Social objectivity is the view that instead of trying to reach a value-free science, our efforts should be devoted to creating structural mechanisms to make explicit values and interests at play in scientific knowledge production. Those mechanisms should allow for values and interests to be discussed and criticized… this kind of approach would be a good framework to make sense of the interaction of facts and values in the definition of mental disorder.”

A similar sort of point, although not in the language of social objectivity, is made by Derek Bolton in What is Mental Disorder? (2008):

Much of the rationale for naturalist definitions of mental disorder was based on the reasoning that “unless some such definition is valid, there is apparently no defense against the charge that psychiatry is a form of social control. One important form this problem has taken is the perceived necessity of being able to give a principled reason why frank political abuse of psychiatry – for example several decades ago in the then Soviet Union – is wrong and illegitimate. So far as I can see the response… has to be that the principled reason, the nature of the error and the illegitimacy, is not going to be made out in the philosophy or in the science of medicine and psychiatry, but has to be interpreted in terms of human rights legislation and the other principles and institutions of democracy.”

It is noteworthy here that in practice, given our current state of scientific knowledge, evolutionary notions of dysfunction do not offer much protection against the pathologization of cases such as homosexuality and transgender identity. There is no scientific consensus on the evolutionary origins of either homosexuality or transgender identity. Certainly, in the early 70s when homosexuality was taken out of the DSM, there was no clarity on the presence or absence of evolutionary dysfunction. The decision was taken by the American Psychiatric Association based on considerations of harm. Appealing to evolutionary function or dysfunction would’ve meant little. Even now, appeals to evolutionary function/dysfunction are often on shaky grounds in terms of falsifiability and vulnerable to sociopolitical misuse. While progress has been made, evolutionary psychiatry still has a long way to go in terms of providing convincing empirical evidence in support of specific hypotheses.

(Also relevant here: building on the work of Subrena Smith, Hane Maung has argued that evolutionary psychiatry may very well lack the epistemic resources to empirically distinguish between the competing hypotheses of psychiatric conditions as natural dysfunctions, adaptations, or as evolutionarily neutral.)

The problem is compounded by the fact that pathologization of masturbation, homosexuality etc. in the past were not simply a matter of imposition of discriminatory social values. Rather, the scientific understanding of these conditions itself was deeply problematic. Depathologization involved recognition of scientific errors as much as it involved recognition of the role of problematic values. Therefore, the value of an abstract, speculative natural dysfunction criterion as a remedy for inappropriate real-world pathologization of cases such as homosexuality is, to my mind, dubious. [Bingham and Banner have provocatively said that “if candidate definitions of mental disorder are unable to exclude homosexuality, it might perhaps be preferable not to attempt a definition at all.”]

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In part 2 of this post, I will integrate some of the points made above with a clinical and pragmatic argument for the legitimacy of medicine that departs from an understanding of medical disorders as possessing a natural essence. To fix medicine’s legitimacy with reference to “disease” as a fact of nature gets the order of things wrong. The legitimacy of medicine comes from the presence of suffering/impairment/harm, from the illness experience, from a call to action to the profession, from medicine's ability to accurately understand the nature of and effectively treat instances of suffering, undertake research where necessary to do so, medicine's accountability to science and society, and the social and scientific standing of its professional training. I will also highlight how such a pragmatic conception of medicine necessitates a pluralism of perspectives in psychiatry.

For now, I will end by bringing up, in words of Lisa Bortolotti, the possibility of doctors without disorders: “Recognizing that the notion of disorder is not central to demarcating medical practice prompts some further questions about the need for a notion of disorder. It is liberating to realize that the difficulties in arriving at a coherent and useful notion of disorder can be explored without undermining the role of medicine in our lives.” (Bortolotti, 2020) (catchy paper title suggested by Anneli Jefferson)

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Part 2 has not yet been published.

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