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Are critics of psychiatry stranded in a ‘Jurassic world?’ — Mad in the UK

In a recent Psychiatric Times interview with Lucy Johnstone,1 the interviewer took the very unusual step of seeking ‘clarification’ from two psychiatrists that she mentioned in the interview. These ‘clarifications’ were then published at the end of the interview. One of these psychiatrists, the eminent professor Sir Robin Murray, concluded with the following statement:

‘Sadly, a few psychologists appear to have been stranded in a Jurassic world where they spend their energies railing against a type of psychiatry which became extinct years ago.’

This is a bold statement. It is also an increasingly common example of psychiatry’s critics being dismissed out of hand for allegedly being ‘out of touch’ with the theory and practice of modern psychiatry.

In times past, the standard rebuttal to those who highlighted the lack of evidence for biomedically caused ‘mental disorders’ was some version of ‘yes, but we will obviously find evidence of this causation eventually’ which affirmed the approach but denied that there was a problem. It is increasingly common in current times, however, for critics to be dismissed on the grounds that psychiatry is not, as it apparently turns out, committed to biomedical causation/explanation after all. This is often accompanied by suggestions that such critics have not understood what psychiatry — and indeed medicine at large — actually does, and/or that psychiatric theory has evolved philosophically from its biomedical days and the conceptual naivety of the past has matured. Sir Robin Murray seems to be alluding to this kind of position.

If true, this would obviously pose a problem for those critics of psychiatry. So, it would seem proper to examine the arguments behind these sorts of statements in order to see whether the critics are now in fact the naïve ones, or whether the charges brought against psychiatry remain valid. I will look at 3 core arguments below.

1. The Critical arguments about psychiatry argue against a ‘straw man’; we are ‘all biopsychosocial now.’

The first and the most common argument suggests that few psychiatrists (if any, according to some) actually practise the biomedical model of psychiatry. Rather, it will be said, psychiatrists (in the UK, at least) have been using the ‘biopsychosocial model’ for the past 40 years or so — since Engel’s seminal 1977 paper that birthed the term.2 Far from an exclusive focus on biological causes and treatments, the modern, practical application of Engel’s descriptive position purports to integrate the biological, psychological and social levels of experience in its psychiatric explanations and treatments. If this is indeed the norm, then it can be claimed that the ‘critical position’ is arguing against a straw man.

Leaving aside the fact that the vast majority of psychiatric research to this very day concerns biomedical causes/explanations/treatments and that billions of dollars have been spent on such failed science over the last few decades; that claims such as ‘mental disorders are medical conditions just like heart disease or diabetes’, ‘mental disorders are brain disorders’, or ‘mental disorders are related to problems with chemistry in your brain’ are ubiquitous (found, for example, on the American Psychiatric Association website)3; and that psychiatrists — despite allegedly thinking in this complex and integrative way for 40 years or so — are still rarely anything other than in the business of 15-minute ‘med reviews’, which cover status examinations, symptom/side effect descriptions, and/or changing from one drug to another — it’s important to understand what is actually being conveyed by the term, especially with regards to the ‘social’ aspect.

The chief intended purpose of the term ‘biopsychosocial’ is to assert that unlike in the biomedical era ‘social causes’ are now permitted a place in the causal chains that psychiatry sees as leading to its ‘mental disorders.’ And it is true, psychiatry has indeed conceded such a causal role for some time now. To be fair, there is also an increasing emphasis on discussing social factors. But when one understands what the ‘social’ means in this context, the continuing allegiance to biomedical explanation becomes clear.

For a model that purports to integrate social experiences, it is very strange that their lived, meaningful dimensions and idiosyncratic character are absent from the causal explanations. The ‘social’ in biopsychosocial in fact only features in terms of external ‘triggers’ or’ stressors.’ So, when it is claimed that the model accounts for the social world of the person, what is meant is that it acknowledges external pressures that contribute to otherwise biologically determined processes. The actual personal, meaning-pervaded social experiences we are all immersed in are, as such, irrelevant to the model, or at least without any causal efficacy. A ‘social cause’ within this model is simply a quantity of external force on the biological system, which is then where the disorder is located and expressed.

While admitting a causal role to social factors is of course an improvement on the purely biomedical model, if that role is limited to a position in a causal chain that leads inexorably to biological processes, then we have not moved past the biomedical model in any meaningful way. We have just stretched it out a bit. While the biopsychosocial model is not pure biological reductionism or determinism, we are nevertheless talking about experiences that are only relevant in their effect on biological processes which then determine the ‘disorder.’ It is these processes that remain the focus — the main treatments (e.g. drugs, ECT) have remained the same — evidencing the supposed incorporation of the social world is nothing of the sort. The actual meaningful dimensions of our social experience remain absent from the explanations and, as result, from the primary interventions.

The problem exists, as such, unchanged. The critical argument updated to reflect this change would assert that, without justification for doing so, (biopsychosocial) psychiatry still explains distressing emotional experiences biologically, by reducing non-biological events to quantities that only have ultimate relevance in terms of the biology of the person.

2. It is not necessary for mental disorders to have biomarkers as there are other general medical disorders that do not.

The perennial failure to find ‘biomarkers’ (measurable indicators of a biological state or condition used to identify disorders/diseases in medicine) for the vast majority of ‘mental disorders’ has led critics over the decades to conclude that the experiences in question are not legitimate medical disorders/diseases. The argument put in defence is as follows: as there are some uncontested diseases/disorders in general medicine that do not have established biomarkers, then biomarkers are not necessary for something to be considered a disease/disorder. Therefore, it will be suggested, the presence of biomarkers is not relevant to establishing whether these experiences are medical disorders or not.

So, has a flaw been found in the critical position? No.

The fact is that the vast majority of uncontested physical diseases/disorders do have known biomarkers and the vast majority (arguably all) of purported ‘mental disorders’ do not. When it is the case that, say, 95% of entities in one category fit a definition and 95% in another do not, does it really make sense to argue that they are, in fact, a single category because there is a minuscule overlap? Clearly not. The employment of biological tests/physical examinations that identify anatomical and biomedical markers is obviously vital to almost every instance of medicine. Indeed, it is this above all else that is arguably responsible for medicine emerging from the so-called dark ages.

The argument, as such, is deceptive. Biomarkers are at the very heart of what modern medicine is and how it functions. In the case of psychiatry, however, they are entirely absent for the vast majority of ‘mental disorders,’ despite monumental efforts to discover them. While their absence does not technically disqualify psychiatry’s ‘disorders’ from the rest of medicine, it nevertheless puts it at categorically odds with it. Because modern medicine would cease to be modern medicine if biomarkers are considered dispensable elements of disease/disorder, the problem for psychiatry remains.

The argument, in fact, is not even about disorder/diseases, psychiatry or medicine. There are always exceptions to the rule in almost any definition, because discerning ‘necessary and sufficient conditions’ for something is extremely rare. It is, as such, a highly pedantic argument that forgoes common sense to make a logical point, and in doing so alienates itself from the actual practice of medicine, which is of course what we are all concerned with. There is nothing unique at all about the definition of disease/disorder in this regard, so we might also consider it disingenuous to invoke a general philosophical problem about knowledge as if it were specific to this situation. The application of this philosophical problem, ironically, is what occupies the third argument.

This argument and others like it serve to occlude the categorical difference between the experiences that come to be diagnosed as mental disorders and the disorders of general medicine (known in psychiatry as functional/psychiatric vs. organic/somatic disorders). Any number of pedantic distinctions can be put forward to try and conflate or collapse this difference, but the fact remains that the phenomena under psychiatry fundamentally pertain to meaningful, purposeful experience in the world, inextricably bound up with the world. The disorders of general medicine, by contrast, are almost exclusively focused on the functioning of the body, with only incidental or secondary allusion to the person’s relationship with the world, if there is any allusion at all.

This is a crucial difference. In being fundamental in this way, the world (and the others we relate to in it) are implicated in distressful emotional/psychological experiences in the same primary sense as brains/bodies are in somatic or organic disorders. It follows from this that pathologising the individual in terms of their brain/body is wholly inappropriate in the case of emotional/psychological distress. It is no surprise, therefore, that biomarkers are not forthcoming if the search for them rests on this category error. It is this — not some form of caricatured ‘mind-body dualism’ — that is at the root of the critical stance, something which is largely ignored in favor of addressing straw-man arguments not in fact held by such critics.

3. Disorder/disease is a ‘practical kind’ not a ‘natural kind.’

Given the paucity of evidence for biological disease processes and given psychiatry’s non-negotiable commitment to distressing psychological/emotional experiences being the remit of medicine, some psychiatrists have turned to the distinctions of philosophy in order to attempt a new theoretical case for psychiatry. The ‘solution’ has not been to think again about whether distressing psychological/emotional states are best thought of as medical diseases/disorders — which would seem to be the obvious option given the problem — but to (re)define the concept of ‘disease/disorder’ it