I would like to offer a response that challenges some of the underlying premises of your project—particularly the insistence that psychiatry must ground itself in a scientifically validated methodology to reclaim its epistemic legitimacy. While your call for rigor and your critique of reductive evidence-based medicine are well taken, I worry that the POP model may still be operating within the very paradigm it seeks to refine: one that assumes that mental suffering can—or must—be contained, explained, and resolved within the logic of scientific reasoning.
This assumption raises several concerns.
First, the attempt to codify clinical reasoning into a systematized methodology risks reproducing the same reductive tendencies that have long plagued the field. Psychiatry’s preoccupation with being seen as a “science” has often come at the expense of other vital forms of understanding—narrative, relational, historical, spiritual, communal. As Thomas Insel himself conceded in reflecting on the National Institute of Mental Health’s heavy investment in biological psychiatry: scientific progress did not translate into healing. A model that seeks to refine psychiatry’s clinical judgment may be necessary, but one that seeks to rescue it through scientific legitimacy alone may miss the deeper shift that patients, practitioners, and communities are increasingly demanding.
Namely: a redefinition of what knowledge is, and what kinds of knowing matter.
Rather than continuing psychiatry’s long-standing effort to secure its place as a “real science,” perhaps we should embrace the fact that psychiatry is, at its best, an integrative and interpretive practice—one that necessarily draws from disciplines outside traditional science: the arts, the humanities, the spiritual and the communal, the ecological and the historical. This isn’t a rejection of science, but a refusal to allow science—particularly narrowly conceived biomedical science—to be the only arbiter of what is valid.
Your POP model gestures toward individualization, collaboration, and the centrality of patient goals, which is deeply commendable. But even in its commitment to pragmatism and prediction, it still frames mental life through a lens of modeling and intervention, assuming that the clinician’s task is to generate testable hypotheses about the patient’s condition. What if, instead, the clinician’s task is not just to “model” but to witness, to accompany, to inquire alongside the patient without needing to resolve or contain their experience in a way that can be objectively mapped?
Mental suffering is often shaped by structural violence, intergenerational trauma, colonization, land displacement, and spiritual alienation—none of which are easily modeled, and none of which are easily addressed through interventions within the clinical frame. To truly engage these complexities, psychiatry must move beyond the clinic and see itself as one node in a network of healing traditions, rather than the apex of expertise.
This would mean not just acknowledging the value of alternative knowledge systems—community-based, Indigenous, faith-based, relational—but actually reconfiguring psychiatry’s own epistemology to make space for them. Not just science plus culture or spirituality, but a new orientation altogether: one in which science becomes humble, and psychiatry rejoins the world as a participant, not its analyst.
In that light, the future of psychiatric training may lie not only in better models but in better conversations—across disciplines, communities, and traditions of meaning. Psychiatry might then not just improve its predictions, but deepen its capacity for presence, humility, and transformation—qualities often found less in maps than in stories, rituals, and relationships.
Thank you again for this essential contribution. I hope it opens the door to even broader and more radical conversations about what psychiatry can become.
In reading your comment, I think we agree on many things. Psychiatry should be an integrative and interpretive practice drawing on a wide range of disciplines. And indeed, what patients rightly want of us is to witness, to accompany, and to inquire alongside them. Yet they want more than this. They consult us because we offer, and they believe we possess, some specialized expertise that is relevant to their distress. They want us to help them formulate a course of action to improve their lives.
We are creatures with purposes, desires, values, and projects that have meaning. Hence, as the philosopher John Dewey emphasized, human experience always entails an apprehension and interpretation of our situation from the point of view of those ends. Hence experience always includes some notion of how to alter our selves and/or our environments to further those ends, in short a plan of action. To propose an action for ourselves or someone else is to generate a hypothesis and make a prediction that the proposed action will further our ends in a particular way. Hypothesis generation and test is intrinsic to human experience in living. Our only choice is whether this process is tacitly unexamined or whether we articulate the methods we employ.
Current, more naturalistic theories in the philosophy of science argue that science is not some unique methodology divorced from normal human deliberation, whether that be the old hypothetico-deductive view of the logical positivist or some other theories demarcating stressing science. Science simply is employing the cognitive and deliberative techniques characteristic of our species in an especially rigorous and self-critical manner. To say that psychiatry should be scientific, from this framework, is simply to say that we owe our patients rigorous and transparent reasoning that can be shared with them to give our conclusions credibility. This is true clinical humility as we are not asking patients to simply trust our expertise. Like a student taking a test, it is not enough that we give an answer. We need to show our work. The patient then can judge how much faith they want to place in what we are saying. The content of our models do not need to be limited to cold, objective third-person data. The insights derived from narrative and interpretive understanding should be fully employed. In my book, especially in the early parts of chapter 10, I discuss the compatibility between POP models and narrative and hermeneutic strategies. The clinical examples in the book, I think, demonstrate this.
The goal is not to have to choose between science and more humanistic approaches with our patients. Rather the goal is to broaden and humanize our conception of science to embrace the full range of human experience in our thinking, and yet to demand a rigor and clarity to our thinking such that it can stand up to critical appraisal.
It is one thing to assert there is some concrete physically, spatiotemporally isolatable entity, and it is another to assert there is something other than this in any constituent or part or combination or whole. If you are going to assert either, without a will to kill yourself if you're factually wrong, then you cannot be trusted in either case, because by definition, you have no skin in the game. That is, if you're wrong, and you don't kill yourself as result of being wrong, then you're worse than Satan.
I would like to offer a response that challenges some of the underlying premises of your project—particularly the insistence that psychiatry must ground itself in a scientifically validated methodology to reclaim its epistemic legitimacy. While your call for rigor and your critique of reductive evidence-based medicine are well taken, I worry that the POP model may still be operating within the very paradigm it seeks to refine: one that assumes that mental suffering can—or must—be contained, explained, and resolved within the logic of scientific reasoning.
This assumption raises several concerns.
First, the attempt to codify clinical reasoning into a systematized methodology risks reproducing the same reductive tendencies that have long plagued the field. Psychiatry’s preoccupation with being seen as a “science” has often come at the expense of other vital forms of understanding—narrative, relational, historical, spiritual, communal. As Thomas Insel himself conceded in reflecting on the National Institute of Mental Health’s heavy investment in biological psychiatry: scientific progress did not translate into healing. A model that seeks to refine psychiatry’s clinical judgment may be necessary, but one that seeks to rescue it through scientific legitimacy alone may miss the deeper shift that patients, practitioners, and communities are increasingly demanding.
Namely: a redefinition of what knowledge is, and what kinds of knowing matter.
Rather than continuing psychiatry’s long-standing effort to secure its place as a “real science,” perhaps we should embrace the fact that psychiatry is, at its best, an integrative and interpretive practice—one that necessarily draws from disciplines outside traditional science: the arts, the humanities, the spiritual and the communal, the ecological and the historical. This isn’t a rejection of science, but a refusal to allow science—particularly narrowly conceived biomedical science—to be the only arbiter of what is valid.
Your POP model gestures toward individualization, collaboration, and the centrality of patient goals, which is deeply commendable. But even in its commitment to pragmatism and prediction, it still frames mental life through a lens of modeling and intervention, assuming that the clinician’s task is to generate testable hypotheses about the patient’s condition. What if, instead, the clinician’s task is not just to “model” but to witness, to accompany, to inquire alongside the patient without needing to resolve or contain their experience in a way that can be objectively mapped?
Mental suffering is often shaped by structural violence, intergenerational trauma, colonization, land displacement, and spiritual alienation—none of which are easily modeled, and none of which are easily addressed through interventions within the clinical frame. To truly engage these complexities, psychiatry must move beyond the clinic and see itself as one node in a network of healing traditions, rather than the apex of expertise.
This would mean not just acknowledging the value of alternative knowledge systems—community-based, Indigenous, faith-based, relational—but actually reconfiguring psychiatry’s own epistemology to make space for them. Not just science plus culture or spirituality, but a new orientation altogether: one in which science becomes humble, and psychiatry rejoins the world as a participant, not its analyst.
In that light, the future of psychiatric training may lie not only in better models but in better conversations—across disciplines, communities, and traditions of meaning. Psychiatry might then not just improve its predictions, but deepen its capacity for presence, humility, and transformation—qualities often found less in maps than in stories, rituals, and relationships.
Thank you again for this essential contribution. I hope it opens the door to even broader and more radical conversations about what psychiatry can become.
In reading your comment, I think we agree on many things. Psychiatry should be an integrative and interpretive practice drawing on a wide range of disciplines. And indeed, what patients rightly want of us is to witness, to accompany, and to inquire alongside them. Yet they want more than this. They consult us because we offer, and they believe we possess, some specialized expertise that is relevant to their distress. They want us to help them formulate a course of action to improve their lives.
We are creatures with purposes, desires, values, and projects that have meaning. Hence, as the philosopher John Dewey emphasized, human experience always entails an apprehension and interpretation of our situation from the point of view of those ends. Hence experience always includes some notion of how to alter our selves and/or our environments to further those ends, in short a plan of action. To propose an action for ourselves or someone else is to generate a hypothesis and make a prediction that the proposed action will further our ends in a particular way. Hypothesis generation and test is intrinsic to human experience in living. Our only choice is whether this process is tacitly unexamined or whether we articulate the methods we employ.
Current, more naturalistic theories in the philosophy of science argue that science is not some unique methodology divorced from normal human deliberation, whether that be the old hypothetico-deductive view of the logical positivist or some other theories demarcating stressing science. Science simply is employing the cognitive and deliberative techniques characteristic of our species in an especially rigorous and self-critical manner. To say that psychiatry should be scientific, from this framework, is simply to say that we owe our patients rigorous and transparent reasoning that can be shared with them to give our conclusions credibility. This is true clinical humility as we are not asking patients to simply trust our expertise. Like a student taking a test, it is not enough that we give an answer. We need to show our work. The patient then can judge how much faith they want to place in what we are saying. The content of our models do not need to be limited to cold, objective third-person data. The insights derived from narrative and interpretive understanding should be fully employed. In my book, especially in the early parts of chapter 10, I discuss the compatibility between POP models and narrative and hermeneutic strategies. The clinical examples in the book, I think, demonstrate this.
The goal is not to have to choose between science and more humanistic approaches with our patients. Rather the goal is to broaden and humanize our conception of science to embrace the full range of human experience in our thinking, and yet to demand a rigor and clarity to our thinking such that it can stand up to critical appraisal.
Great explanation, Doug!
It is one thing to assert there is some concrete physically, spatiotemporally isolatable entity, and it is another to assert there is something other than this in any constituent or part or combination or whole. If you are going to assert either, without a will to kill yourself if you're factually wrong, then you cannot be trusted in either case, because by definition, you have no skin in the game. That is, if you're wrong, and you don't kill yourself as result of being wrong, then you're worse than Satan.