The Ground Beneath the Clinic
On the scope of medical authority
My friend and collaborator Alan Levinovitz recently posed a question to me that, slightly paraphrased, goes something like this… It’s relatively easy to argue against the hyperbolic view that mental illness doesn’t exist. What’s much harder is defining “disorder” in a way that draws clear boundaries around the scope of medical and psychiatric expertise; it’s hard enough in general medicine, significantly harder in mental health. The strongest version of the critique isn’t the claim that there’s no such thing as mental illness but rather something along the lines of: Mental health professionals have no good way to define the scope of their expertise, and so they have expanded that scope, along with the domain of “disorder,” in ways that amount to the over-medicalization of suffering and invite skepticism about this claimed authority.
I think Alan is right that this is the more important argument. It’s also an argument that cannot be answered by pointing to brain scans, genetic studies, or DSM criteria. It requires a different kind of answer altogether, and I believe, in the process of answering it, we have to relinquish certain comforting illusions about what grounds the authority of clinicians.
Here is the core of what I want to say: There is no objective or a priori way of determining the authority of medicine and clinical disciplines, and the scope of these disciplines is pragmatic and institutional in nature. It is historically contingent, pluralistic, uncertain, open-ended, subject to revision, and sensitive to the presence of other viable institutional alternatives.
While this may sound deflating to some, I myself find it liberating as well as a more honest and more defensible answer.
Getting the Order of Things Right
The standard move when defending the legitimacy of psychiatry is to argue that psychiatric disorders are real… that they are, in some sense, natural kinds or at least track genuine dysfunctions in the organism. The implicit logic is: disorders exist in nature → medicine is the discipline that treats disorders → therefore psychiatry is legitimate because it treats real disorders.
I believe that this gets the order of things backwards. The attempt to fix medicine’s legitimacy with reference to “disorder” as a fact of nature, to anchor the scope of clinical authority in an objective demarcation between the normal and the pathological, has not succeeded. The philosophical complexity surrounding “dysfunction” and “disorder” is, at this point, well-documented, and I won’t rehearse the debate here. I take it for granted that the project of defining the authority of medicine and clinical disciplines in terms of disorder concepts on the basis of objective, value-free facts has failed. We need a different account of what grounds clinical legitimacy.
Clinical and Pragmatic Justification
So if “disorder” doesn’t do the foundational work, what does? The legitimacy of medicine rests on a constellation of pragmatic and institutional considerations: the presence of suffering, impairment, and harm that exceed our ordinary capacities and the ordinary personal and social resources available to us; the illness experience, which constitutes a call to action for the healing professions; medicine’s ability to accurately understand the nature of, and effectively treat, instances of vulnerability and suffering, and to undertake research where understanding and treatment are lacking; medicine’s accountability to science and society, and the social and scientific standing of its professional training.
In other words, we don’t first define “disorder” and then determine the scope of medicine. Rather, people suffer in various ways, and that suffering arrives at the doorsteps of various institutions (medicine, psychology, social work, education, law, religion…) and the question arises: which institutions have something meaningful to offer, and under what circumstances?
Let’s bypass the philosophical labyrinth of “dysfunction” and consider the matter practically. Experiences and behaviors become problematic in a particular context, and then these problems are brought to clinical attention.
Why do some experiences and behaviors emerge as “problems”? Typically because they are distressing, disabling, or disruptive, and because they are understood (usually on the basis of largely common-sensical, folk-psychological judgments) to be excessive, disproportionate to the circumstances, unintelligible, lacking meaningful connections to the person’s situation, persisting beyond sociocultural expectations, and so on.
Why do some problems come to clinical attention? Because ordinary personal and social resources available to us have failed to address them, and we have reasons to think that healthcare clinicians can do something about them in a way that other social institutions cannot.
This is a thoroughly pragmatic and institutional picture. And when these processes of problem recognition and clinical attention occur transparently, scientifically, democratically, and with good intentions, they go reasonably well.
The Scope of Institutions
It’s worth pausing here to notice that the question about the scope of authority is a question that can be asked of any social institution, and the answer is rarely clean and circumscribed.
What is the scope of Law? There is no essence of “the legal” that determines, in advance and for all time, which human conflicts and behaviors fall within the jurisdiction of legal institutions and which do not. The boundaries of law have shifted enormously across history: marital rape was once outside the law’s concern; blasphemy was once firmly within it. We do not think this historical contingency makes law illegitimate. We understand, implicitly, that the scope of legal authority is negotiated through democratic processes, responsive to social values, shaped by the availability of alternative dispute-resolution mechanisms, and revisable as circumstances change.
What is the scope of Education? There is no natural fact that tells us whether sex education, financial literacy, or civic responsibility are “really” educational matters or matters for families and communities to address outside of formal educational institutions. The answer varies by era, by culture, by political climate, based on reasons that can be good or bad, with advantages and disadvantages. The scope of educational institutes is determined by a society’s collective and pragmatic judgment about what schools can usefully accomplish and what other institutions are available to accomplish the rest.
What is the scope of Counseling and Psychotherapy? This question has been live and contentious for over a century now. The boundaries between psychotherapy, pastoral care, life coaching, peer support, and self-help have been unstable. Clinical psychology has an uncomfortable relationship with medicine; many clinical psychologists work in hospitals, hold appointments in medical departments, serve on multidisciplinary medical teams, but many psychologists also can’t really stop bashing what they understand to be the “medical model” and feel strongly that psychology shouldn’t emulate medicine. Spitzer’s initial proposed definition for DSM-III defined “mental illness” as a subset of “medical illness,” and American psychologists objected strenuously, arguing that conditions acquired through learning experiences and lacking demonstrated organic etiology had no justification for a medical label. The DSM-III task force yielded and created the more agnostic definition of “mental disorder” that we’ve inherited. Rather than an empirical clarification about the boundaries of medicine, it was a negotiation between professional communities.
The scope of these institutions, all institutions, is determined pragmatically, historically, and in negotiation with other institutions that serve overlapping but not identical functions. The question “What is the scope of medicine?” is not categorically different. It only feels different because medicine, more than law or education, has invested its self-understanding in the idea that its jurisdiction is carved at the joints of nature by the concept of “disease” or “disorder.”
Contingency Without Catastrophe
The scope of medicine is contingent, and so is the scope of things like clinical psychology and social work. Tim Thornton captures this well when he writes that “it can seem a contingent matter that a number of conditions have come to be classed as illnesses. That is, it is conceivable that they might not have done.”
We can choose to draw the boundaries differently, and that we can, in principle, choose not to employ medical concepts at all for certain forms of human suffering, but these choices are (or at least should be) informed by relevant facts at hand and the reasons in favor or against these choices can be examined and supported or disputed. Contingency is not the same as arbitrariness, because it is contingency within the space of reasons and within the historical evolution of institutions.
Consider a peculiar but illustrative example. After Ivan Illich, the author of Medical Nemesis, was diagnosed with cancer in 1983, he refused all treatment. As the tumor on his cheek grew, he reportedly declared: “I am not ill, it’s not an illness. It is something completely different—a very complicated relationship.” (source) Illich could accept the physiological reality of the tumor, the reality of the uncontrolled cellular proliferation, while denying the conceptual characterization of it as an “illness,” because of his unique and extreme embrace of the art of suffering.
This is an attitude that is not shared by the vast majority of people, which is why the characterization of malignancy as illness is, for all practical purposes, basically uncontested. In the realm of psychiatry, however, there are fewer facts at hand to constrain possible disagreements, and there is much more diversity in the values that people hold. This is what makes the boundaries of psychiatric authority contested in ways that the boundaries of oncology are not.
Communities as Justification
I find it helpful to draw on the pragmatist tradition and the insight that communities play a constitutive role in establishing norms and reasons. As Jules Gleeson writes in the context of discussing Robert Brandom’s philosophy: “We are obliged to make sense of the world, and have no ‘given’ that we can depend on across every context. But we are never left attempting this alone. Reasons both arise from communities and are appeals to them.”
Along similar lines, we are obliged to make sense of the domain of distress, disability, risk, and harm that comes to clinical attention. We have no universal “givens” to fall back on, no foundational truths in the form of pristine “disorder” concepts. But there are legitimate reasons for medicine (and psychology, and social work, and service users…) to tackle this domain with the tools it has at its disposal. These reasons arise from and are justified by the norms of the medical community, what it has to offer, the particular history in which it exists, and the relationships it has with other communities.
In this sense, over-medicalization is a question about institutional and social relationships and the negotiation of boundaries.
Pluralism
Something can be within the domain of mental health disciplines and yet not be exclusively within the domain of healthcare. A “medical problem” is not just a medical problem, because this characterization is not something intrinsic to it. The same condition can also be an interpersonal problem, an existential problem, a problem of living, a spiritual problem, one that may be addressed successfully by non-clinical interventions. The medical perspective is simply one way of conceptualizing a condition, and it is not always or not necessarily the best way to view or help every problem.
This raises the obvious question: When should the characterization of a condition as a medical or clinical problem dominate over other forms of characterization? And how should competing conceptualizations coexist?
My answer is that these are questions that cannot be settled a priori. They are settled, provisionally, imperfectly, revisably, through ongoing negotiation between institutions, informed by empirical evidence, constrained by values, and responsive to the experiences and preferences of the people these institutions serve.
Clinical conceptualizations and treatments are not universally helpful. For some people they will be useless, and for some harmful. Some people are better off trying to understand and manage their suffering through non-clinical approaches: self-help, spiritual practices, lifestyle changes, coaching, political engagement, financial support, existential reflection, peer support, and so on. The problem is that we don’t have a good way of knowing in advance who will benefit from the clinical approach and who will not, so we clinicians end up casting and people end up accepting a wide net, albeit with some ambivalence and resistance.
If clinical diagnosis and treatment are understood as one way of conceptualizing and helping a condition, and not necessarily the only way, and not automatically the best way of helping to achieve all or indeed any desired outcomes, then this necessitates a robust pluralism of conceptualization and intervention. Diagnosis is a partial perspective on a person’s challenges. The clinical lens is appealing because it offers a useful hermeneutic framework through which to look at our problems. But it remains one hermeneutic framework among many that can address individual distress in different contexts. Recognizing this plurality does not negate the value of medical thinking, which remains essential. But to reduce this plurality of perspectives to a single dominant narrative, whatever that may be, is to impoverish our existence and to deprive us of the tools we need to make sense of ourselves in relation to our worlds.
Where Things Go Wrong
Because these processes of problem recognition and clinical categorization are value-laden, socioculturally dependent, and susceptible to various biases, they can be distorted. When the guiding values are corrupted, when clinical services are wielded by the state for confinement and control or when benign states of distress are encouraged to be conceptualized as diseases requiring medications by pharmaceutical companies, we get the clearest perversions of the process. But subtler forms of distortion are all present: when guild interests shape diagnostic boundaries or psychotherapy is recommended as the default response to all life distress, or when the absence of viable or accessible non-medical alternatives creates a vacuum.
The answer to these problems, though, is not to search for an incorruptible, naturalist definition of the scope of medicine that will hold the line against medicalization. No such definition exists. Nor is the answer to artificially restrict the use of the clinical lens and deny people access to clinical care they want and could benefit from. If we are over-relying on the medical framework, the more productive response is to develop other frameworks that can offer people similar or better utility and facilitate more informed and mindful use of the medical lens. The answer is better processes: more transparency, more democratic participation (including the participation of those who receive care), more accountability, more genuine pluralism in the institutions available to people in distress, and more epistemic humility about the limits of any single framework. The answers I ultimately advocate for are thoughtfulness, conceptual clarity, person-centered care, pluralism, and realistic expectations around clinical treatments.
When a problem is inadequately or unsatisfactorily addressed by clinical disciplines and the problem is such that some sort of specialized response is needed or asked for, by all means, create alternative non-clinical institutions that are helpful and accountable. Build frameworks that address the distress and disability more effectively, more humanely, with fewer unintended effects and less epistemic overreach than healthcare currently manages. The future is open-ended, and there is nothing in principle that prevents the development of such alternatives. Indeed, some already exist in nascent form in peer support networks (e.g. those organized around psychotropic withdrawal and tapering, and the Hearing Voices Network), in certain models of community care and peer crisis support, in traditions of religious and spiritual support, and even, dare I say, shamanistic healing. Alcoholics Anonymous and 12-step programs are probably the most established examples.
But there are good reasons why alternatives are scarce and why they haven’t displaced healthcare disciplines. It is difficult to outperform and dislodge professions that have, at their best, rigorous clinical and scientific training, a commitment to understanding human suffering, effective (if imperfect) interventions, and structures of accountability to the scientific communities as well as the society at large.
See also:
Contextualizing the way we respond to suffering does not happen reflexively, in part probably because the idea outsourcing our response to professionals is so pervasive, which is why essays like this one are so important. With a broader perspective entering public discourse, a perspective that allows us to more explicitly define the scope of various institutions and alternatives to them, perhaps we will be able to intentionally understand how we can awaken and harness the capacity we all have for empathy and encouragement to support one another.
If people are taught from a young age about the range of experiences that come with being human, then at least one dimension of suffering can be decreased as people feel less isolated and ashamed about an experience that is simply part of being human. There can be so much panic around a person having something wrong with them that I believe people can lose sight of the often comparatively minor significance of an aspect of their lives they are having difficulty with that gets blown out of proportion once it is assigned to realm of professions.
Because the current model does have so much legitimacy (despite the critiques), there does not seem to be as much room for other perspectives for how to respond to human suffering, especially when it comes to the kind that does not involve extreme situations which understandably can be more difficult for a lay person to manage. One of the reasons that the Power Threat Meaning Framework seems to be so important is that it does attempt bring in a broader perspective than the current approach and attempts to give voice to people outside the institutions historically assigned as the catch basin for problems that people would rather push away.
I made one failed attempt to start something called the mutual encouragement society as a forum for connecting people who would like to discuss the things that we typically assign to institutions (why we respond the way we do to our experiences and ways we can do so that will help us achieve the goals we have for ourselves) but in a more equitable structure where both people are vulnerable (not necessarily simultaneously) and where both people make explicit the life experiences they have had that inform their biases and shape their world view. I am not sure how to meet with more success than I did before but perhaps in the future, I will try to get it going again.