The ironic thing is that psychiatrists *don't* medicalize human suffering. By the time someone arrives in the psychiatrist's office, they or someone who advised or forced them to go there has already medicalized something they're experiencing. At most, a psychiatrist can refuse to cooperate with the medicalization, perhaps leading an ambivalent or reluctant patient to think "oh, good, this is just normal" and stop medicalizing it, but often leaving the person to seek out a different provider. (And sometimes psychiatrists seize on a different thing to medicalize than what the patient agrees with, which will likely lead to the patient marching away unless they're involuntarily committed, which is presumably rarely the case for the situations of diagnostic expansion this discussion is inspired by.)
I think people who object to the authority of the psychiatrist are usually more specifically mad about the larger power structures that psychiatrists operate within and often collude with. The abusive parents who try nothing but further abuse to correct a child's behavior before taking them to the psychiatrist as a form of chemical control and gaslighting; the racial, class, gender, and cultural biases; the ableist way of affirming that difference is illness even when the people experiencing it say otherwise; and so on. But those power structures show up just as much in what psychiatrists and others consider "ordinary" as in what they consider pathological or unusually pathological ("ordinary" and "medicalized" are obviously overlapping categories--as in COVID, age-related disorders, and some psychiatric diagnoses like anxiety, depression, or ADHD).
For instance, the neurodivergence movement is pretty vocal about underdiagnosis of autism in groups including women and Black people. The distress autistic kids in these groups experience is often considered unworthy of treatment, overlooked as ordinary based on expectations that they *should* suffer more and take up less space in social situations, and/or diagnosed as different mental health conditions that are considered more ordinary for those groups based on negative stereotypes. I've also seen really extreme cases of Black people who were showing clear signs of experiencing psychosis being ignored or identified as criminal, and had my own childhood/adolescent attenuated psychosis dismissed, I think on the basis that "girls" are naturally anxious and hysterical (and my catatonic symptoms were originally misdiagnosed as conversion disorder, which couldn't be more on-the-nose when it comes to underlying sexism). As a lay person, maybe I'm just seeing the lay side of things, but it seems to me like diagnostic expansion is overwhelmingly pushed by people who want access to diagnosis for themselves or their children, not by psychiatrists.
Psychiatrists do literally set the terms of discussion at certain junctures, but we also see that patient groups are perfectly willing to invent terms or seize upon ideas that don't have broad acceptance within psychiatry and bring those into the mainstream of how the culture thinks about mental health conditions. Ideas with more power behind them will proliferate more on average, but entities that aren't psychiatrists such as pharmaceutical and insurance companies probably have much more of that power than actual psychiatrists, and have power over the psychiatrists to boot.
Actually, I'd argue that AA is a lot more prevalent or at least universally familiar than medical treatments for addiction, and that's because it has, for generations, had the force of law behind it, with many people being required to attend a 12-step group in lieu of some other criminal punishment. And many of the criticisms of AA's effectiveness and the ways it can harm members are based in exactly those things that made it appealing to the legal system. As for non-medical groups without that advantage, it is obviously difficult for unfunded, disabled people to self-organize alternative institutions of care in a society where even finding a free space to meet is increasingly difficult, and I don't think that should be seen as evidence that these organizations couldn't do a better job of addressing human suffering than the existing mental healthcare system (hopefully in conjunction with it rather than one having to wipe the other out) if they had enough resources.
More than one of the outspoken critics of psychiatry I've encountered have been people who, at some point in their post-secondary educations, got an ADHD diagnosis and stimulants to continue in an educational environment that was, as you've described, a trait-demand mismatch (and some educational environments would be a trait-demand mismatch for almost everyone without stimulants). So they go on stimulants for years, and over time realize they would have been better off questioning the values that led them to take a drug with significant side-effects than staying on their educational/career path at all costs.
But the thing is, no psychiatrist made them get that ADHD diagnosis or take those stimulants. I was also diagnosed with ADHD as an adult, and that process is a very active choice usually *motivated* by a desire to get stimulants to help with your career (or even just to make your job tolerable). Sure, you might truly (and even accurately) believe that you had all the symptoms of ADHD as a child and have been unnecessarily suffering without a diagnosis, but that narrative is formed in front of a computer screen "doing your own research" on ADHD, or maybe in conversations with friends, or perhaps even with a therapist who refers you to a psychiatrist, all before you ever see the psychiatrist. People who are not psychiatrists valorize this framework, and psychiatrists don't need to put any effort into promoting it--the demands of the school and work environment creating a problem that stimulants might be able to solve is sufficient.
The criticism therefore is not of psychiatrists per se, or even the institution of psychiatry, but of the society that creates the trait-demand mismatch and so much pressure to be successful in a certain way, and that callously devalues the subjective experience of the person who may feel worse-off on stimulants while performing better. And it's also a criticism of the critic's own younger self who wholeheartedly believed in medically molding themself for a specific career. It's easier to project shame over your early self and their vulnerabilities on someone else, in this case the figure of the psychiatrist, than to accept that you once had very different values than you have now.
I think there is some valid seed of pain around the idea that maybe the right mental health practitioner could have dissuaded them from taking stimulants to continue down a career path that was a sure route to burnout, but it's obvious that such an attempt would likely have been unsuccessful, and is just as likely to provoke anger at psychiatrists from people who (rightly or wrongly) perceive themselves as truly needing the diagnosis and medications.
Aftab is right to ground clinical authority in pragmatism, but if legitimacy is “negotiated,” we need to ask: who is doing the negotiating? Contra to the “madness-as-dysfunction” model, I side with Justin Garson’s "madness-as-strategy" model and Sanneke de Haan’s view of disorder as an agentic shift in existential sense-making. For de Haan, this isn’t just cognitivist or "rationalist", it’s rooted in sensorimotor (physical) processes to which only the subject has immediate agential access. If the physician steps in only when their resources are exhausted, they will likely fail to grasp the strategic logic of that sense-making that Garson is trying to explain to us from an agent-causation paradigm.
On the issue of negotiation, I’ve previously written: “Disorder judgments, therefore, require a formal or informal process of negotiation among stakeholders. People with the condition are the most important stakeholders, but there are others as well, such as their families, clinicians, funders who will pay for healthcare and research, the legal system, etc. Just to make it clear: the process is, under ideal circumstances, constrained by the relevant considerations. It is not whimsical; it is not anything-goes relativism, where anything can be a disorder just because we want it to be.” (https://www.psychiatrymargins.com/p/the-politics-of-psychiatric-classification )
I’m partial to de Haan’s account!
I like Garson madness as dysfunction vs design distinction, but I don’t think most mental disorders are instances of madness-as-design.
Evolutionary Psychopathology by Del Giudice, 2018. It's far more sophisticated than Nesse. Give it a look some day. Although, it is missing the dissociative disorders...
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.
Thanks, Awais, for another thoughtful column. I agree with the "core" of your argument, having reached a similar conclusion in an essay published in Philosophy Now. The gist of which was:
"All this leads us to an inescapable conclusion: that unless we have a universally recognized ‘taxon’ – a set whose membership is defined by necessary and sufficient criteria – there is no test to determine what does or does not lie within the bounds of the category ‘disease’ (i.e., as a medical problem). Therefore, arguments about psychiatry’s medicalizing normality cannot be settled through scientific methods. Rather, such debates are essentially political-rhetorical exercises, not arguments about empirically verifiable claims. Of course, this doesn’t mean that the debate is unimportant, or without practical implications for our classification of psychiatric diseases.
Paradoxically, those who argue that psychiatry medicalizes normality but who simultaneously assert that there is no clear demarcation between normality and abnormality effectively refute their own argument. For if there are no absolute, categorical boundaries separating ‘normal’ from ‘abnormal’, then the claim ‘psychiatry is medicalizing normality’ cannot logically be sustained. That is to say, if ‘normality’ has no precise boundary in the medical realm – including psychiatric medicine – then there can be no verifiable medicalization of normality."
Best regards,
Ron
P.S. A William James approach to the scope of medical authority: Next time you are experiencing substernal chest pain, carefully consider the merits of seeking out a philosopher. (Mutatis mutandis: auditory hallucinations, etc.)
It's a curious matter as to who has the problem with psychiatry's authority - and responsibility - to minister/treat/help people who come our way. Much as I have some handle on the critical- or anti-psychiatry people's problems with it, it's still the case that if a person comes in to see us, they're not thinking much about anything other than feeling better. All the details of diagnosis/disorder/condition/whatever can wait. It is, at its core perhaps, pragmatic. Maybe it's different outside the USA, but pragmatism has been a more uniquely American value for a long time, and there's wisdom in that. It's not a blank check, and all psychiatrist-patient matters are negotiations, but within the context of an atheoretical or a-philosophical stance by most patients who are feeling bad. Conflicts come up, and they are often related to values or power; unless we step over some line, society cedes us this authority (and responsibility), just as you say, as it is with law or education.
Nobody can fill the vacuum that'd be left if we weren't given that by society, so there's an implicit buy-in. I think some wish we should have some kind of a vote on the matter. We have to work to maintain society's trust, but the buy-in is already there (if we don't screw it up).
The ironic thing is that psychiatrists *don't* medicalize human suffering. By the time someone arrives in the psychiatrist's office, they or someone who advised or forced them to go there has already medicalized something they're experiencing. At most, a psychiatrist can refuse to cooperate with the medicalization, perhaps leading an ambivalent or reluctant patient to think "oh, good, this is just normal" and stop medicalizing it, but often leaving the person to seek out a different provider. (And sometimes psychiatrists seize on a different thing to medicalize than what the patient agrees with, which will likely lead to the patient marching away unless they're involuntarily committed, which is presumably rarely the case for the situations of diagnostic expansion this discussion is inspired by.)
I think people who object to the authority of the psychiatrist are usually more specifically mad about the larger power structures that psychiatrists operate within and often collude with. The abusive parents who try nothing but further abuse to correct a child's behavior before taking them to the psychiatrist as a form of chemical control and gaslighting; the racial, class, gender, and cultural biases; the ableist way of affirming that difference is illness even when the people experiencing it say otherwise; and so on. But those power structures show up just as much in what psychiatrists and others consider "ordinary" as in what they consider pathological or unusually pathological ("ordinary" and "medicalized" are obviously overlapping categories--as in COVID, age-related disorders, and some psychiatric diagnoses like anxiety, depression, or ADHD).
For instance, the neurodivergence movement is pretty vocal about underdiagnosis of autism in groups including women and Black people. The distress autistic kids in these groups experience is often considered unworthy of treatment, overlooked as ordinary based on expectations that they *should* suffer more and take up less space in social situations, and/or diagnosed as different mental health conditions that are considered more ordinary for those groups based on negative stereotypes. I've also seen really extreme cases of Black people who were showing clear signs of experiencing psychosis being ignored or identified as criminal, and had my own childhood/adolescent attenuated psychosis dismissed, I think on the basis that "girls" are naturally anxious and hysterical (and my catatonic symptoms were originally misdiagnosed as conversion disorder, which couldn't be more on-the-nose when it comes to underlying sexism). As a lay person, maybe I'm just seeing the lay side of things, but it seems to me like diagnostic expansion is overwhelmingly pushed by people who want access to diagnosis for themselves or their children, not by psychiatrists.
Psychiatrists do literally set the terms of discussion at certain junctures, but we also see that patient groups are perfectly willing to invent terms or seize upon ideas that don't have broad acceptance within psychiatry and bring those into the mainstream of how the culture thinks about mental health conditions. Ideas with more power behind them will proliferate more on average, but entities that aren't psychiatrists such as pharmaceutical and insurance companies probably have much more of that power than actual psychiatrists, and have power over the psychiatrists to boot.
Actually, I'd argue that AA is a lot more prevalent or at least universally familiar than medical treatments for addiction, and that's because it has, for generations, had the force of law behind it, with many people being required to attend a 12-step group in lieu of some other criminal punishment. And many of the criticisms of AA's effectiveness and the ways it can harm members are based in exactly those things that made it appealing to the legal system. As for non-medical groups without that advantage, it is obviously difficult for unfunded, disabled people to self-organize alternative institutions of care in a society where even finding a free space to meet is increasingly difficult, and I don't think that should be seen as evidence that these organizations couldn't do a better job of addressing human suffering than the existing mental healthcare system (hopefully in conjunction with it rather than one having to wipe the other out) if they had enough resources.
More than one of the outspoken critics of psychiatry I've encountered have been people who, at some point in their post-secondary educations, got an ADHD diagnosis and stimulants to continue in an educational environment that was, as you've described, a trait-demand mismatch (and some educational environments would be a trait-demand mismatch for almost everyone without stimulants). So they go on stimulants for years, and over time realize they would have been better off questioning the values that led them to take a drug with significant side-effects than staying on their educational/career path at all costs.
But the thing is, no psychiatrist made them get that ADHD diagnosis or take those stimulants. I was also diagnosed with ADHD as an adult, and that process is a very active choice usually *motivated* by a desire to get stimulants to help with your career (or even just to make your job tolerable). Sure, you might truly (and even accurately) believe that you had all the symptoms of ADHD as a child and have been unnecessarily suffering without a diagnosis, but that narrative is formed in front of a computer screen "doing your own research" on ADHD, or maybe in conversations with friends, or perhaps even with a therapist who refers you to a psychiatrist, all before you ever see the psychiatrist. People who are not psychiatrists valorize this framework, and psychiatrists don't need to put any effort into promoting it--the demands of the school and work environment creating a problem that stimulants might be able to solve is sufficient.
The criticism therefore is not of psychiatrists per se, or even the institution of psychiatry, but of the society that creates the trait-demand mismatch and so much pressure to be successful in a certain way, and that callously devalues the subjective experience of the person who may feel worse-off on stimulants while performing better. And it's also a criticism of the critic's own younger self who wholeheartedly believed in medically molding themself for a specific career. It's easier to project shame over your early self and their vulnerabilities on someone else, in this case the figure of the psychiatrist, than to accept that you once had very different values than you have now.
I think there is some valid seed of pain around the idea that maybe the right mental health practitioner could have dissuaded them from taking stimulants to continue down a career path that was a sure route to burnout, but it's obvious that such an attempt would likely have been unsuccessful, and is just as likely to provoke anger at psychiatrists from people who (rightly or wrongly) perceive themselves as truly needing the diagnosis and medications.
Aftab is right to ground clinical authority in pragmatism, but if legitimacy is “negotiated,” we need to ask: who is doing the negotiating? Contra to the “madness-as-dysfunction” model, I side with Justin Garson’s "madness-as-strategy" model and Sanneke de Haan’s view of disorder as an agentic shift in existential sense-making. For de Haan, this isn’t just cognitivist or "rationalist", it’s rooted in sensorimotor (physical) processes to which only the subject has immediate agential access. If the physician steps in only when their resources are exhausted, they will likely fail to grasp the strategic logic of that sense-making that Garson is trying to explain to us from an agent-causation paradigm.
See: Garson, J. (2024). Madness. OUP.
On the issue of negotiation, I’ve previously written: “Disorder judgments, therefore, require a formal or informal process of negotiation among stakeholders. People with the condition are the most important stakeholders, but there are others as well, such as their families, clinicians, funders who will pay for healthcare and research, the legal system, etc. Just to make it clear: the process is, under ideal circumstances, constrained by the relevant considerations. It is not whimsical; it is not anything-goes relativism, where anything can be a disorder just because we want it to be.” (https://www.psychiatrymargins.com/p/the-politics-of-psychiatric-classification )
I’m partial to de Haan’s account!
I like Garson madness as dysfunction vs design distinction, but I don’t think most mental disorders are instances of madness-as-design.
Evolutionary Psychopathology by Del Giudice, 2018. It's far more sophisticated than Nesse. Give it a look some day. Although, it is missing the dissociative disorders...
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.
Thanks, Awais, for another thoughtful column. I agree with the "core" of your argument, having reached a similar conclusion in an essay published in Philosophy Now. The gist of which was:
"All this leads us to an inescapable conclusion: that unless we have a universally recognized ‘taxon’ – a set whose membership is defined by necessary and sufficient criteria – there is no test to determine what does or does not lie within the bounds of the category ‘disease’ (i.e., as a medical problem). Therefore, arguments about psychiatry’s medicalizing normality cannot be settled through scientific methods. Rather, such debates are essentially political-rhetorical exercises, not arguments about empirically verifiable claims. Of course, this doesn’t mean that the debate is unimportant, or without practical implications for our classification of psychiatric diseases.
Paradoxically, those who argue that psychiatry medicalizes normality but who simultaneously assert that there is no clear demarcation between normality and abnormality effectively refute their own argument. For if there are no absolute, categorical boundaries separating ‘normal’ from ‘abnormal’, then the claim ‘psychiatry is medicalizing normality’ cannot logically be sustained. That is to say, if ‘normality’ has no precise boundary in the medical realm – including psychiatric medicine – then there can be no verifiable medicalization of normality."
Best regards,
Ron
P.S. A William James approach to the scope of medical authority: Next time you are experiencing substernal chest pain, carefully consider the merits of seeking out a philosopher. (Mutatis mutandis: auditory hallucinations, etc.)
It's a curious matter as to who has the problem with psychiatry's authority - and responsibility - to minister/treat/help people who come our way. Much as I have some handle on the critical- or anti-psychiatry people's problems with it, it's still the case that if a person comes in to see us, they're not thinking much about anything other than feeling better. All the details of diagnosis/disorder/condition/whatever can wait. It is, at its core perhaps, pragmatic. Maybe it's different outside the USA, but pragmatism has been a more uniquely American value for a long time, and there's wisdom in that. It's not a blank check, and all psychiatrist-patient matters are negotiations, but within the context of an atheoretical or a-philosophical stance by most patients who are feeling bad. Conflicts come up, and they are often related to values or power; unless we step over some line, society cedes us this authority (and responsibility), just as you say, as it is with law or education.
Nobody can fill the vacuum that'd be left if we weren't given that by society, so there's an implicit buy-in. I think some wish we should have some kind of a vote on the matter. We have to work to maintain society's trust, but the buy-in is already there (if we don't screw it up).