Awais Aftab, MD

James Barry “Jim” Gottstein is an Alaska-based lawyer and a well-known advocate for the legal rights of individuals with serious mental illness. He graduated as a lawyer from Harvard Law School in 1978. In 1982, he experienced a psychotic break due to sleep deprivation and was introduced firsthand to the mental illness system. This encounter led him to legal representation and other advocacy for individuals diagnosed with mental illness. Gottstein opened his own law office in 1985, generally focused on business matters, and is now mostly retired from the private practice of law. He cofounded the Law Project for Psychiatric Rights (PsychRights) in 2002 and currently serves as its president. Gottstein is the author of 

 is a fascinating story of how Gottstein obtained and shared confidential documents showing that Eli Lily executives had knowingly concealed data related to metabolic risks of Zyprexa including diabetes, downplayed risks in published data, and illegally promoted off-label use in children and the elderly. These documents led to a series of front-page stories by 

 and Gottstein became the target of the ire of Eli Lilly’s army of lawyers. Gottstein provides a detailed account of the events in the book.

While it is no surprise, it is still disturbing to see how pharmaceutical companies engage in blatantly unethical practices and how they employ the legal shenanigans to avoid any meaningful accountability, and how we, as a society, repeatedly allow that to happen. It takes great courage—one might even say recklessness—on the part of lawyers and activists such as Gottstein to expose such wrongdoing at great personal risk. As David Healy has 

, “… everything we know about what pharma gets up to comes from legal actions in the US and a handful of lawyers like Gottstein.”

 Half of the book is about Bill Bigley, whose psychiatric commitment and forced medication case enabled Gottstein (his lawyer) to subpoena the Zyprexa Papers and whose rights he defended vigorously, going all the way to the Alaska Supreme Court and resulting in landmark decisions. I left the book with a renewed sense of moral disgust directed at pharmaceutical corruption, a renewed sense of alarm at their pervasive influence and lack of meaningful public accountability, and a renewed appreciation for the legal rights of individuals with mental illness.

Tell us more about your background and how you got involved in psychiatric legal advocacy.

 In 1982, at age 29, after taking on too much, I got sleep deprived, became psychotic, and was hauled to the hospital in a straitjacket. Before that happened, I had no idea my mind could become unreliable. It was a complete shock. Those that believed I was a lawyer told me I would never do that again, and when I told them I had gone to Harvard Law School, that confirmed I was delusional. I was told I would have to be on psychiatric drugs for the rest of my life and the best I could hope for was to minimize my time locked up in psych wards. Luckily, my mother referred me to a wonderful psychiatrist—Robert Alberts, MD—who told me anyone who gets sleep deprived enough will become psychotic and I could learn how to prevent that from happening. In other words, I escaped having my career changed from being a lawyer to that of a mental patient. I felt lucky in so many ways and resolved to try and help others not so lucky.

There are a number of themes, as it were, in my book, 

, and one of them is to subtly bust the myth that people who get diagnosed with serious mental illness cannot recover. I do this by briefly describing a number of people who recovered after being diagnosed with serious mental illnesses and were involved in the events surrounding the release of the Zyprexa Papers.

 It is inexcusable that you and countless others have been told such things. As an early-career psychiatrist who finished training not too long ago, my perception is that there has been progress in this regard, although practice is far from optimal. I think the development of first-episode psychosis specialty programs and the recovery movement have really emphasized the diverse trajectories of psychosis in treatment approaches, and many prominent psychiatrists (such as Robin Murray, MD; Jim van Os, MD, PhD, MRCPsych; and Patrick McGorry, MD, FRCP, FRANZCP) have questioned the validity of the notion of schizophrenia and the prognostic pessimism that has historically surrounded it. We have examples of researchers with lived experience and their perspectives on recovery, such as Nev Jones, PhD, which inform our thinking. It is worth noting though that the issues that surround involuntary care are distinct from concerns pertaining to erroneously misleading narratives about recovery surrounding psychosis. The 2 are linked in your experience, but a different psychiatrist in an alternative history may very well have given you a more hopeful message during your involuntary hospitalization and may have facilitated your return to work.

: My sense is, in the main, the "Abandon All Hope Ye Who Enter Here" message has not changed much—if at all—in the trenches.

There are some encouraging developments, and I hope they will gain traction. Personally, I am spearheading the follow-up activities for MindFreedom International and Rethinking Psychiatry to the 

International Peer Respite Soteria Summit

 held virtually on the 5 Sundays of last October. We are actively working on helping people open these types of programs and provide support for ones that are currently operating. There is huge interest around the world, with over 750 people participating from 40 countries. It may be good timing because more and more people are coming to the conclusion that we need to do things differently. On the other hand, in the United States, the scapegoating of people thought to be mentally ill is the only approach everyone can agree on as a response to mass shootings in the US, and seems likely to lead to more psychiatric confinement and psychiatric drugs, often coerced.

 What have you learned over the course of your legal career about the ways in which pharmaceutical companies misrepresent, misreport, or mis-advertise findings from clinical trials? How can we, as a society, safeguard against this, and how can they be held accountable?

 The ways pharmaceutical companies misrepresent, misreport, and mis-advertise clinical trials are legion. I think the most important thing to keep in mind is, in order to gain regulatory approval and promote sales, clinical trials are designed to inflate benefits and hide the harms, rather than be a neutral evaluation. One of the ways they do this is through miscoding adverse events, such as suicide attempts being coded as lability. Another is by assuming adverse events are not related to the drug. Pharmaceutical companies can get away by not looking for unanticipated adverse events. Sometimes they deliberately conceal or minimize adverse effects, as they did in the case of Zyprexa. They also rig the benefit side. As I write in 

, in its clinical trials, in order to make Zyprexa look good in comparison, the so-called placebo group were people who had been abruptly withdrawn from Haldol, which is known to exacerbate or even cause severe psychiatric symptoms, and then the introduction of Zyprexa in the trial relieves some of those withdrawal symptoms, which manifests as clinical improvement compared to placebo. They went even further. While most people abruptly withdrawn from Haldol experience withdrawal psychiatric symptoms, some people do quite well, and they threw them out of the study. They hijacked the term “placebo washout” to describe this.

There are plenty of things that could be done about this, but the pharmaceutical juggernaut is difficult to stop, especially politically. For example, David Healy, MD, is on a mission to make the trial data available for review at the participant level, including being able to interview the participants. He makes the point it is outrageous the drug companies claim these data are trade secrets when volunteers risk harm for the benefit of society.

The most practical—and a very effective thing that could be done, in my view—is for prescribers to be appropriately skeptical of drug company claims for their latest and greatest drugs. The reality is the newer drugs are, in most instances, neither more effective nor safer than the older drugs. Often the opposite is true on both scores. It is amazing to me people prescribe the “latest and greatest” new drug, typically at much greater cost, based on the word of companies that are well-known to have lied to the professionals and the public. The true benefit of the newer drugs is monopoly prices can be charged because they are still on patent. As a general matter, the true benefits and harms of a drug are not known until it is off patent.

 published the story on the Zyprexa Papers in 2006, there have been numerous other scandals involving pharmaceutical companies. There is much greater awareness now of the criminal role played by Purdue Pharma in creating the opioid crisis in the US. The links between the FDA and pharma continue to be a source of concern, as evident recently in the controversy surrounding the approval of aducanumab despite a manifest lack of efficacy. Do you see any reason to think that we, as a society, are any safer and wiser in our dealing with pharma than we were in 2006?

You want me to say more? If anything, I would say it is worse. For a brief period of time after the release of the Zyprexa Papers and the accompanying 

 articles, lawyers representing pharmaceutical victims were less willing to agree to keep the harms of drugs secret in order to achieve a settlement, but my sense is things have gone back to normal where the harms of drugs discovered during litigation are kept secret as a condition of settlement. The courts are supposed to look out for the public interest, but they, as well as the parties, are only interested in settlement. If keeping the harms secret is what it takes for the victims to get some (usually inadequate) compensation, the lawyers to get (usually exorbitant) legal fees, and to get the case off the court's docket—so be it.

The corruption of the medical literature has gotten to the point of absurdity, with a large percentage of medical journal articles ghost-written by the drug companies, the prominent “authors” being paid by the drug companies to put their name on the articles not even allowed access to the data.

I am somewhat heartened by the developments in psychological sciences, where many of the top journals have embraced the ideals of open science and require sharing of pertinent data. Psychology has also matured from the replication crisis. Medical journals are still behind, unfortunately, when it comes to the goals of open science, although they have taken some half-measures against ghost-writing and have improved their requirements with regards to preregistration of trials, specifying primary outcomes, and spinning of results, etc. It remains the case that many academic authors who put their names on pharma-conducted RCTs do not have direct access to data and depend on whatever analyses the pharma statisticians provide. It is disappointing that litigation leading to settlements is not serving public interest by keeping harms secret. All of this speaks to the lack of systemic safeguards—both medical and legal—and resultantly, there is a disproportionate responsibility on clinicians and patients to maintain a critical attitude.

Your advocacy through the Law Project for Psychiatric Rights (aka PsychRights) has substantially altered the legal landscape in Alaska with regards to involuntary psychiatric commitment and involuntary use of medications via a series of landmark Alaska Supreme Court rulings. Can you give us an overview of what these rulings were about?

 PsychRights has won 5 Alaska Supreme Court cases, 3 of them on constitutional grounds. For involuntary commitment, the Alaska statute allowed someone to be psychiatrically confined as gravely disabled if their previous ability to function in the community would otherwise deteriorate. In the 2007 

 case, the Alaska Supreme Court held this unconstitutional unless construed to mean the person is “unable to survive safely in freedom.” In other words, the level of disability has to be life-threatening to justify the “massive curtailment of liberty” locking someone up is.

As to court-ordered administration of psychiatric drugs, the Alaska statute said if the person is found to be incompetent to decline the drugs, the hospital is allowed to force into the person any drugs, at any doses the hospital wants. In the 2006 

case, the Alaska Supreme Court held this was unconstitutional with the hospital having to also prove by clear and convincing evidence the forced administration of medication is in the person's best interest and there is no less intrusive alternative available. This was expanded upon in the 2009 

 case, with the Alaska Supreme Court ruling the state has to provide a constitutionally required less intrusive alternative to forced medication or discharge the patient. The continued viability of this is questionable, however, as a result of a more recent involuntary commitment decision holding the less restrictive alternative to involuntary commitment has to actually exist and be available to the person.

There are nuances to all of this, but these are the basics.

 that “lawyers representing psychiatric respondents and judges hearing these cases uncritically reflect society’s beliefs and do not engage in legitimate legal processes when conducting involuntarily commitment and forced drugging proceedings. By abandoning their core principle of zealous advocacy, lawyers representing psychiatric respondents interpose little, if any, defense and are not discovering and presenting to judges the evidence of the harm to their clients.”

 Why do you think this is the case, and what do you think the lawyers representing psychiatric respondents could be doing differently?

 Fundamentally, lawyers are appointed to represent psychiatric respondents in order to check the box that the person had a lawyer. They are not expected—and, frankly, not allowed—to present vigorous defenses. They are assigned too many cases to mount a defense, especially within the extremely compressed time frame required in these cases. The lawyers go along with it because they believe if their clients were not mentally ill, they would know what the state wants to do to them is good for them. We have what is called the “adversary system” of litigation in the US, whereby having each side’s lawyers zealously presenting evidence and arguments for their clients’ position, the neutral decision-maker—a judge or jury—is supposed to arrive at the truth and the correct result. Without that, the legal proceedings are a farce.

Lawyers assigned to represent psychiatric respondents should treat involuntary commitment and forced medication, also known as forced drugging, as the high-stakes cases they are. The state is trying to lock their clients up and subject them to mind-numbing, life-shortening chemicals they do not want, after all. One of the other things I do in 

 is show how I think and go about defending these cases in the hope lawyers representing psychiatric respondents will litigate them zealously. Whether or not psychiatrists agree, they cannot accurately predict violence or self-harm—a prerequisite to commitment—and whether or not they believe the drugs are counterproductive and harmful, psychiatric respondents are entitled to have this evidence presented in court on their behalf.

The lack of effective legal representation is very harmful. People are entitled to the least 

 alternative with respect to psychiatric confinement and the least 

 alternative with respect to forced medication. By not challenging the proposed involuntary commitments and forced medication, people are not being allowed more humane alternatives. If people’s rights were being honored, more of these humane alternatives would have to be provided.

 The availability of psychiatric inpatient beds is quite limited in the US, at least compared to what it was like in earlier decades, and restrictions from insurance companies have drastically reduced length of stays, even for voluntary admissions. Reliance on psychiatric commitment is directly linked to the availability of viable alternatives in the community, and the failure of US psychiatry to provide such alternatives following deinstitutionalized has directly resulted in alarmingly high rates of homelessness and incarceration of individuals with mental illness. Given the current state of US politics and the pessimism surrounding the possibility of radical social reform, many in the psychiatric community are advocating for an expansion of psychiatric commitment. We can make the legal process of involuntary commitment much more arduous, as you advocate, but that only results in a good outcome if individuals with psychiatric disabilities receive meaningful accommodations and care in the community. In the absence of that, aren’t we just making the homelessness and the incarceration problem much worse?

 That is hardly a ringing endorsement of more involuntary commitment. I think it is silly, too. Hospitalization costs what—$2000 a day? Providing housing would be far less expensive and solve a lot of the problem. Leaving the fiscal folly of the argument aside, the dysfunction, inequality, inequity, indifference, and cruelty of our society is not a legitimate excuse to lock more people up. My biggest project right now is follow-up activities to the International 

 held on the 5 Sundays of last October. We are trying to use the summit as a springboard for creating and sustaining more Peer Respites and Soteria Houses around the world instead of hospitalizing people and administering medication into them against their will.

I do want to say I know I come across as being against the use of psychiatric drugs, especially the neuroleptics, and basically, I am—or at least I think we should try to minimize them—but it is the forced drugging I am against. I know people who find even the neuroleptics helpful, and if adults want to take them, they should have access to them.

 It is silly from a systemic and social perspective. Not only is it more expensive, but it is also more ethically problematic. I certainly agree that addressing social inequities, safeguarding social needs, and providing social support and programs such as Soteria Houses will prevent many, perhaps even the majority of (though not all) involuntary admissions, and I certainly think this ought to be a priority when it comes to psychiatric funding and policy. The problem, however, is not silly or illegitimate at all from the perspective of individual psychiatric clinicians who have no power over social dysfunction or social resources, but have been given the responsibility to deal with the psychiatric aftermaths of it. Decisions to hospitalize when confronted with the risk of homelessness, incarceration, serious physical neglect, or physical harm to self or others are complex, ethical questions. I am reminded of something the psychiatrist Paul Gosney, MD, said in a debate in the 

: “Much of modern psychiatric practice feels like we are trying to rescue people from damaged lives. If one of our tools is going to be taken away, then there needs to be a corresponding commitment from society to do better by all its members.”

 Honestly, I am highly sympathetic to efforts to reduce involuntary hospitalization and for there to be robust legal safeguards, as you advocate, but I am skeptical that this on its own will result in good outcomes unless there is a corresponding commitment from society to do better by individuals with psychiatric disabilities. The need for this sort of commitment is perhaps something upon which we can both strongly agree?

 I certainly agree on the need for that sort of commitment to noncoercive, nonharmful approaches. One of the ways to achieve that is for people to have effective legal representation because no more than 10% of people involuntarily committed actually meet commitment criteria, and nonemergency involuntary medication can never meet the legal standard of being proven by clear and convincing evidence that it is in the person’s best interest and there are no less intrusive alternatives. If the system was not allowed to psychiatrically confine the 90% of people who do not meet commitment criteria and force psychiatric drugs into people against their will, society would have to find other ways to deal with people who are disturbing and thought to be mentally ill. I think of involuntary commitment and involuntary medication as the path of least resistance for the hospital, and it should be far more difficult.

I will give you an example. After the 30-day involuntary medication order I got reversed on appeal on constitutional grounds, the 

 case was a 4-month all-out legal battle, the likes of which the hospital had never seen before—and did not like. Shortly after that, I received a call from someone who had been court ordered for a psychiatric evaluation and the hospital had to file a commitment petition against him the next morning or let him go. I contacted the CEO of the hospital and told him I did not think the person met commitment criteria and would represent him if they filed a petition to commit him. Well, they tried really hard to find something else and I never got to meet my potential client because literally as I was driving up to the hospital that evening to meet with him, he was being driven away to something less restrictive and they never filed a commitment petition.

 case, Loren Mosher, MD, the former chief of schizophrenia research at the National Institute of Mental Health and the principal investigator in the Soteria-House study, 

 under oath that involuntary treatment should be “difficult to implement and used only in the direst of circumstances,” and

[I]n the field of psychiatry, it is the therapeutic relationship which is the single most important thing… Now, if because of some altered state of consciousness, somebody is about to do themselves grievous harm or someone else grievous harm, well then, I would stop them in whatever way I needed to… In my career, I have never committed anyone… I make it my business to form the kind of relationship [through which the mentally ill person and I] can establish an ongoing treatment plan that is acceptable to both of us.

This is the needed approach, and patients are entitled to it.

 You say that the use of “nonemergency involuntary medication can never meet the legal standard of being proven by clear and convincing evidence that it is in the person's best interest and there are no less intrusive alternatives.” 

That is a pretty strong claim. Can you elaborate?

This will be a lawyer nerd answer. First, it is important distinguish the “police power” justification for forced medication versus the “

” justification. The police power justification is to stop an immediate threat of great harm. In Alaska, it is called an emergency and has very strict requirements. It is for situations like when the tiger attacking Roy Siegfried was put down with a shot of Haldol. In contrast, the 

 justification is based on a judicial determination the person is incompetent to make a decision about the medication, and therefore, the government must step in in the nature of a parent and make the decision for the person in their best interest.

The legal standard for that is to prove by clear and convincing evidence it is in the person’s best interest and there are no less intrusive alternatives. I do not believe either can be proven by the clear and convincing standard which has various definitions depending on the state, but basically means “highly probable.” As an aside, in the United States Supreme Court case of 

, the psychiatric patient argued since the state was seeking to lock him up like a criminal, they should have to prove the right to do so beyond a reasonable doubt. The Supreme Court held psychiatrists could never prove their case beyond a reasonable doubt and since the confinement was not for a punitive purpose, they had to prove it by clear and convincing evidence instead, which is a higher bar than the more likely than not standard in other types of civil cases. This was for involuntary commitment, but it has been held the same standard applies to involuntary medication. This does vary by state, but I think it is the correct constitutional standard.

In my view, based on the evidence, the state can never prove it is highly probable that forcing psychiatric drugs into an unwilling patient is in their best interest in light of the abysmal outcomes and physical harm they cause, including early death. I also do not think it can legitimately be proven by clear and convincing evidence there is no less intrusive alternative that could be provided. I know people may disagree with me and, in fact, I tended to lose at the trial court level. I think that was because of the practical problem there was no actual less intrusive alternative to which my client could be sent. I write in 

 about my last case representing Bill Bigley, where I had presented the evidence and the judge ordered Bill be drugged against his will anyway, ruling, “Even if the medication shortens Bigley’s lifespan, the court would authorize the administration of the medication because Bigley is not well now and he is getting worse.” So, I know many people disagree with me, including probably most of the people who will read this, but it is my view no legitimate determination can be made that it is highly probable forcing psychotropic medication into someone is in their best interest and there is no less intrusive alternative. It is hard for me to accept that shortening Bill Bigley’s life was in his best interest.

 I want to say for the record that, as a clinician, I am not persuaded by your stance on the involuntary use of medications, and based on my experience of working with the courts, neither are they, but I appreciate your engagement, and I am sure your arguments will give many readers much to think about. Thank you!

is a psychiatrist in Cleveland, Ohio, and clinical assistant professor of psychiatry at Case Western Reserve University. He leads the interview series “

. He has been actively involved in initiatives to educate psychiatrists and trainees on the intersection of philosophy and psychiatry. He is also a member of the

 Editorial Board. He can be reached at 

Dr Aftab and Mr Gottstein has no relevant financial disclosures or conflicts of interest.

1. Berenson A. Eli Lilly said to play down risk of top pill. 

. December 17, 2006. Accessed July 20, 2022. 

https://www.nytimes.com/2006/12/17/business/17drug.html

2. Healy D. The Zyprexa Papers: this book had to be written. Samizdat Health. March 21, 2020. Accessed July 20, 2022. 

https://samizdathealth.org/zyprexa-papers/

Involuntary commitment and forced psychiatric drugging in the trial courts: rights violations as a matter of course. 

The UK Government should withdraw from the Convention on the Rights of Persons with Disabilities.

Faith Myers v. Alaska Psychiatric Hospital. 

http://psychrights.org/states/alaska/caseone/30-day/3-5and10-03transcript.htm

Articles

A lawyer weighs in on pharmaceutical corruption and involuntary psychiatric care. 

The Fight for Pharma Accountability and Psychiatric Rights: Jim Gottstein, Esq

Niall (“Jock”) McLaren is an Australian psychiatrist. He is Honorary Research Fellow in the Department of Philosophy at University of Queensland. He recently retired after nearly half a century of practice, including 25 years in the far north of Australia. He has extensive experience in remote and military psychiatry and posttraumatic states. He has published extensively on the application of the philosophy of science to psychiatry, most recently with a formal integrative theory for psychiatry, the biocognitive model. He was previously interviewed as part of this series in 

 Since your participation in this series in 2019, you have written and published your new book 

Natural Dualism and Mental Disorder: The Biocognitive Model for Psychiatry

 I am excited to have you back in the series to discuss the details of your model. Our earlier exchange gives the readers a fair idea of your discontents with contemporary psychiatry. Let’s begin with the notion of “natural dualism.” What do you mean by that, and how does it differ from the more commonplace notion of “dualism” that many mental health professionals are familiar with?

 Thank you, and that is an important question to start with. Talking philosophy to a psychiatric audience is never easy, as too many psychiatrists seem to think that they are biological scientists, so it does not apply to their activities—but it does. 

 is simply the process of confronting and trying to answer complex questions, and what is more complex than the nature of mind and its disorders? Dualism is one attempt at answering the question of the nature of mind, but it gets a bad press these days, mainly due to misunderstanding. Dualism means 2-fold—that mind and body are not obviously the same. Richard Watson said, “The crux of dualism is an apparently unbridgeable gap between 2 incommensurable orders of being that must be reconciled if we (wish to justify)  our assumption that there is a comprehensible universe…”

 That is neat, because it also tells us there are 2 forms of causation.

Historically, dualism relates to the French polymath, Rene Descartes (1596-1650), who said mind and body are composed of 2 different substances: the physical stuff of bodies and brains, and the mental stuff of the mind, each requiring nothing other than itself to exist. That leads to the problem of how those substances can possibly interact—the classic 

, of which he was perfectly well aware. It also leads people these days to deride his work. For example, philosopher Daniel Dennett of Tufts University in Boston dismisses with contempt any idea of dualism as pure magical thinking. Instead, they try to eliminate 1 side of the question by building a nondualist or monist philosophy of mind, such as “Mind and brain are a unity” or “Mind reduces to the brain.” That does not work, and never will work.

Natural dualism says “Yes, mind and body are profoundly different, with no properties in common, but mind arises from the brain by natural, law-like processes (laws of supervenience),” which we can probably understand. The idea is closely associated with philosopher David Chalmers, but very explicitly, there is no magic involved. My work takes it further and offers a biological mechanism by which a nonphysical mind supervenes upon or emerges from the physical brain. I have suggested what those laws are, but crucially, it uses processes that we have known about for a long time.

 You present a computational model of the mind as an informational space. What do you see as the boundaries of your notion of the “mind” here? When it comes to psychological processes such as memory and perception, which possess an essential neurobiological dimension, where does 

This can be confusing because we are sentient beings; our entire perception of ourselves is based in this point. We are first and foremost information detectors, collectors, processors, storers, and transmitters. In the book, I derive a formal definition of information, but essentially, it is what we know and experience—what we can act on and communicate. That is the result of the brain doing its job as a very high-speed, multichannel information processor of ineffable complexity. The main boundary of the mind is that it is utterly private. My brain generates my mind, and you cannot share it unless I use speech or action to convey a small part of it. The next boundary is that the sense of mind or consciousness the brain generates is completely dependent on the healthy brain. Even slight variations in physiology, such as a fever, can interfere with the natural process of generating the mind. We call that confusion or delirium. Physicians have to be very aware of it.

Descartes said that if you want to know the mind, the only place to start was in the dissecting room, and I totally agree. It is not possible to understand the concept of a mind emerging from the brain without a detailed knowledge of the brain and neurophysiological processes. This means, of course, that if the biocognitive model gets any traction, then the field of a nonmedical psychology will shrink dramatically. But it also means that the concept of a reductionist biological psychiatry is headed for the history books, replaced by a well-grounded mentalist psychiatry.

 within this framework? How does your view of personality differ from how personality is conceptualized in psychodynamic terms, or how it is conceptualized by the 5-factor model proponents?

I spend quite a lot of time deriving a formal definition of personality, which doubles as a description. Because this is a computational model, not hydraulic as the Freudian model was or static as in DSM terms, personality devolves to the particular set of rules which determines each of us as a unique human being. Remember that this set of rules is vast, and we often do not know what they are, but I explain all of this. Personality must be seen as a very dynamic process, not a fixed thing. What we call a normal personality results from a set of rules which are both internally consistent and consistent with the rules of the larger society, producing a cheerful (euthymic) person who meshes with the surroundings. However, if my rules are internally contradictory, producing distress or confusion, or clash with the larger society’s rules, producing conflict (or both), then we have personality disorder. Of course, my rules can change, for better or for worse. That means personalities can change; they are not genetically fixed. This may be abrupt as in posttraumatic cases, or gradual as in education and life experience. But the biocognitive model allots a much greater role to personality in mental disorder than biological psychiatry does. Biological psychiatry wants to see everything as “chemical imbalances.” No, it is not.

 How are “mental disorders” defined in the biocognitive model? How does your notion of mental disorder differ from, say, how the DSM understands mental disorders (a syndrome that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning that leads to significant distress or 

First point to mention: Mental disorder is real. It is as real as hunger or the pain of appendicitis, so the so-called “

” approach—that mental disorder is a myth—is completely wrong. Second: DSM is avowedly atheoretical. It is a nosology, not a model of mental disorder, although it implicitly supports the reductionist approach. It is descriptive, not explanatory, so, except in the case of posttraumatic disorders, it does not assign causes. DSM-5 gives only 3 pages to discussing “psychological factors affecting medical conditions” in the vaguest terms possible.

In a few words, the biocognitive model says that mental disorder is a state of self-sustaining mental distress and dysfunction. Mental disorder is not like ordinary grief, which resolves itself, or a bit of a fear that people can work on, or being angry over your team losing, because we get over that sort of thing. That is our nature. The mere presence of distress or poor performance does not 

 constitute a mental illness—it only becomes mental disorder when it is self-sustaining and the person cannot recover.

The model assigns a major role to personality, to current stressors and to cultural factors, but more importantly, it offers a formal mechanism of integrating psychological (including personality) and sociocultural factors into the clinical picture. DSM does not do that; it does not offer a model of mind or any integrative mechanisms. For all those people who have wanted a genuinely integrative “biopsychosocial model,” here it is.

 In your model, how does the process become self-sustaining? Are there analogous ways in which information processing in a computer can be self-sustaining? Another prominent approach in psychiatry that emphasizes the self-sustaining nature of mental disorders is the network theory,

 which conceptualizes mental disorders as symptom networks where symptoms are causally related to each other (instead of being caused by a latent variable or a central disease process), and “If these causal relations are sufficiently strong, symptoms can generate a level of feedback that renders them self-sustaining.”

 It seems like there are different ways in which it is possible for us to theorize how psychiatric syndromes become self-sustaining.

 The process of mental disturbance becomes self-sustaining by a simple feedback loop more or less consistent with what Norbert Wiener described in 1948, the difference here being that part of the loop is cognitive—a matter of what the subject knows and believes. The arrow of causation loops between mental and physical. I have given a number of examples of how seeing or hearing something can generate an unpleasant mental state whose symptoms then cause the person to become more distressed. It is a simple matter; we see it myriad times a day in anticipatory anxiety, but it also applies to normal life.

For example, “Mr Smith” has to give a talk in front of his bosses. He is worried about how he will perform, and his heart starts to beat a bit faster. But he believes a fast pulse means an impending heart attack, so, as soon as he becomes aware of it, he becomes more agitated, which makes it beat faster. Before long, he is so agitated he has to cancel his presentation. That is an easy one—extremely common, for which beta blockers are rapidly effective, and cheap. But the crucial factor is the cognitive element—that the patient must be scared of his own symptoms. I have also emphasised the Challenge Hypothesis and its role in dominance hierarchies, and how the drive to dominance produces its own instability. This is important, not just in psychiatry, but in social and political life.

Network theory, on the other hand, seems to be deficient in that it does not involve this crucial cognitive factor. The concept uses the recursive properties of networks, but inserts symptoms as the nodes, not giving credit to the notion that symptoms do not exist in isolation—that they exist separate from the mind. They are part of a much larger mental state of which the subject’s knowledge state is an integral part. Because network theory is not part of a larger theory of mind, it treats the human as an automaton, not a sentient being. I am not much convinced by these highly abstract theories in cognitive sciences. It always seems to me the theory comes first, then they look for somewhere to apply it.

 Does your definition of mental disorder exclude any conditions presently classified as mental disorders? For example, would “prolonged grief” count as a mental disorder under your framework?

I do not believe in “psychiatry unlimited.” The biocognitive model excludes a lot of what has become “disease” over the past 40 years since DSM-III burst on the scene. Just as 

 is the normal reaction to the perception of a threat, grief is the normal reaction to the perception of a loss—any significant loss. It is the converse of attachment—the downside to our capacity to form relationships—that defines us as humans. For a grief reaction to resolve, the sufferer must be able to build a new and satisfying lifestyle. All that takes time, a supportive environment, opportunities, and so on. Grief only becomes a disorder when it cannot get better or is life-endangering. If it does not get better, it is the psychiatrist’s job to work out why, and to help the sufferer work through the loss to build a different future—not to throw suppressive drugs around. Same goes for childhood disorders such as “attention-deficit/hyperactivity disorder.” The biocognitive model says, “Every child is different, so the learning environment must be tailored to the child, not vice versa.”

At present, psychiatry locates the disorder in the individual. That is what biology and genomics looks for, but that is an ideological stance. It has no argued basis in science. I will give a reference for that: In the interactive model, some disorders are inherent in the individual, some are wholly reactions to social events, but the great majority are a complex mix of biological, psychological, and social factors. Sorting that out brings back the art of psychiatry.

 Psychiatric conditions often entail prominent bodily manifestations, such as psychomotor retardation, appetite changes, sleep changes, blunting of affect… how do you conceptualize these physical manifestations of psychiatric disorders in informational terms?

Everything we do is mediated by informational flows. I move my index finger: Instructions have been sent as information in neurons via pyramidal tracts to AHC to motor end plate; prior to that, the decision to move it was affected by information processing in the cerebrum, but our technology is not quite up to that task yet. I explain all of this in general terms showing how the mind-body problem can be resolved quite easily using available technology. I give an explanation for blunting of affect in depression and put a lot of emphasis on the role of anxiety in mediating many of the changes we see in mental disorder.

I think anxiety is very important—in fact, I wrote a 

 about it—but that is swimming against the DSM tide, because DSM wants to see discrete categories of mental disorder, whereas I am arguing that it is all dimensional. The biocognitive model is much more complicated than the DSM “tick a box” approach. And quite often that complexity requires judgement and discretion; psychiatrists actually have to work hard to understand what is going on. But anyway, I give precisely defined examples of how somatic changes are enacted. This is not rocket science, but it does require a different mindset. I have to say this: The worst effect of the modern “biological” push in psychiatry is that it made psychiatry boring.

 If mental disorders are purely a matter of informational malfunction, how does your model account for the presence of neurobiological risk factors (such as genetics, HPA axis, inflammation, neurotrophic factors) that influence the probability of experiencing various mental disorders? Similarly, if the mind is purely informational, how do 

 and biological interventions successfully change the informational content?

 Mental disorder is the overt or experienced manifestation of some disturbance in the brain-mind complex. Remember that when something goes wrong in an informational model, there are 2 aspects to consider: (1) the physical, meaning the brain, and (2) the informational or mental. The initial physical state of the brain is determined by the genome; the most extensive studies so far have failed to find any significant genetic contribution to any single mental disorder. At best, there is a generic tendency to mental disorder which, as I argued in the 

 is probably a genetic tendency to overreact to perceived threats. But we know from the Challenge Hypothesis that people who feel threatened will perceive more threats, which has direct effects on activating a wide range of defensive systems in the body. Using the Challenge Hypothesis, I put a lot of emphasis on the role of testosterone as an inherent destabilizing factor, but people do not like it—they see it as threatening. They want to see themselves as coolly rational, but they feel threatened if you want to talk about their response to threats.

the chemicals are under direct mental control. The mental perception is the first event in a long causal chain. That is directly opposite to what reductionist biological psychiatry says and, I say, explains why they cannot find any primary physical causes to mental disorder. There really are not any. But until now, psychiatry has not had a model of mind tailored to its needs, so they tried to write the mind out of the equation.

 You have said that the biocognitive model offers “a genuinely bio-psycho-social model.” Can you elaborate on that? What makes this model bio-psycho-social?

 It is biological in that it says you cannot even begin to work out why the human mind is as it is without taking into account the “wetware” of the entire CNS. And the rest of the body, of course. It is psychological, as it says the mind runs the brain, not the other way around, and it shows just how the mind-body problem is to be approached so that a resolution falls into place. With a formal mentalist theory of mind, firmly grounded in the physical structure and function of the brain, we can integrate social factors into the calculation instead of paying lip service as DSM does. What you believe becomes instrumental in determining how you behave and how you feel, which solves the determinism question: Yes, we most definitely do have free will, but, as 

 and so many others indicated, it is biased.

 We are not half as rational as we think we are.

The problem is what has been called “The Great Twentieth Century Prejudice” of insisting that mentalist constructs are necessarily supernatural. This has led to so many dead-ends, biological reductionism, behaviorism, functionalism, the list goes on. We humans have mental capabilities. The problem for science is to give account to them, not write them out of the equation.

 “Primary physical causes” aside, I want to clarify something here. You emphasize the direction of causality from mind to the brain (eg, “mind runs the brain”). You also mention the importance of biology, which suggests a bidirectional causal relationship. Do you think that the mind-to-brain casual interactions are more important in the case of mental disorders than brain-to-mind interactions?

 Yes. That is the whole thrust of the model: to outline mechanisms by which the individual’s knowledge state triggers the emotional reactions, which are seen as “mental illness.” Anxiety, as I argued in my little monograph, is the model of a pure psychological disorder—there is no brain disease at all. The cognitive model relies on the feedback loops which I mentioned before. Remember the loop goes from mind to body and back to mind again, where the reinforcement occurs. In grief, it is the knowledge that something precious has been lost that triggers the emotional reaction, of misery, despair, hopelessness, etc. 

 starts with the awareness, even less-than-conscious, that life is hopeless and will never get better; the emotions flow from that, not the other way around. The most common cause of a recurrent or chronic depressive condition is an unrecognized anxiety state. But psychiatrists do not take anxiety seriously.

The principle here is important: Psychiatry has to acknowledge that mental states have mental causes. There is in principle no way a mental state can be reduced to a physical state of the brain—that confuses the product with the mechanism. Yes, I know that people like Eric Kandel and Richard Carrier and so many others are sure it can be—all that is lacking is a model. I would like to see one, but they have never produced it.

 Does the biocognitive model have any implications regarding how psychiatric disorders should be classified?

 It certainly does. It immediately says that the current categorical approach to mental disorder, in the form of the DSM system, will not work. That is not new; even Thomas Insel said it. The biocognitive model requires a dimensional approach, which was entertained for personality disorder in 

, but they had to abandon it. They realized that if they started using it on 1 part of mental disorder, the entire categorical approach would fall apart, and they were not prepared for that. So instead of this relentless growth of mental disorder, classifying everything that moves as “illness,” the biocognitive model offers a more restrained psychiatry that looks carefully at all aspects of the person’s life and tries to understand them in an etiological sense: “What has happened to get this person into this position in life today?” That takes a lot more art than simply ticking a few boxes in a noisy emergency department. We must resurrect the art of psychiatry and stop this pretentious nonsense of talking about “clinical neurosciences.” And it says that Insel’s project to develop a classification based in “brain circuits” will go nowhere—it is in fact an irrefutable claim, so his project is nonscientific.

 Since you do accept that taking into account the “wetware” of the CNS is essential, what sort of neuroscientific research do you think it makes more sense for psychiatric researchers to pursue?

 The first thing for any psychiatric researcher is to work out what psychiatrists should be studying, meaning they have to write their model of mental disorder. There cannot be a research program without a model of the field; that is not science. We do not need to be doing any “neuroscientific research”—we need a consensus on the nature of mental disorder and the best way of approaching it. For example, look at the vast sums of money spent on genomic research with, even its most ardent supporters would agree, skimpy results that have never influenced treatment in any way. But who proved that mental disorder has a genetic basis? Nobody—it was just assumed as an article of faith. You might not remember the “biogenic amines in the hypothalamus” story, or taraxein or minimal brain damage; the research preceded the elementary process of working out whether these things were possible. It was only when the research failed that people wondered if it ever had a chance, but by then they had moved on to the next fad.

That is what the biocognitive model is about: Here is an articulated model that starts with first principles and builds a structure that can be tested. It says, “The great bulk of ordinary mental disorder is wholly psychological with no underlying brain disorder.” It does not actually need much basic research; we can comfortably ride on other researchers’ work. But regardless, the model has to come before any research program is written, the model dictates the research program, and psychiatry has never done that.

 Critical psychologists in the United Kingdom (eg, proponents of the Power Threat Meaning Framework and DropTheDisorder movement) vehemently reject the notions of “disorder” and “dysfunction” entirely and prefer to see psychiatric conditions as “normal understandable reactions to life circumstances.” What would you say to such critics in defense of your continued use of the term “disorder”?

I have never heard of those movements, but it sounds like they are the latest version of Szasz's theme. 

, just did not get human distress. I will reference my critique of his approach. There is a clear difference between “normal understandable reactions to life circumstances,” which will get better with time and support and adjusting one’s ambitions and so on, and mental disorder which does not get better because the person has become trapped in a self-sustaining state of distress. This notion is critical. I put a lot of emphasis on this concept in the book, using different examples but mostly cases of anxiety because it is so obvious and so important.

Anxiety is the only recursive human emotion; it can act back on itself to reinforce and intensify itself. Anxiety is serious—do not believe anybody who says otherwise. It becomes the exemplar of the serious mental disorder that arises in the setting of a perfectly healthy brain. Is this possible? Of course, because there are 2 realms in the biocognitive model: the physical or brain level and the psychological or informational level. Errors can occur in either of them. In an information processor, can glitches in data input or the processing algorithms cause the machine to seize up or shake itself to bits? That is a no-brainer.

 In cognitive sciences, we have seen a shift toward what are called the 4E approaches according to which mental processes are Embodied, Embedded, Enacted, and Extended.

 4E approaches are skeptical that cognition can be described fully in terms of abstract processes such as computations and representations and argue that we must refer to bodily mechanisms and active interactions between the organism and the environment when talking about cognition. Do you see any incompatibility between your computational view of the mind and the 4E approaches?

 Oh boy. I was restricted to 70,000 words, so there are lots of topics I did not mention, and bringing in too many esoteric subjects is a great way of losing your readership. I have not read that particular book, and while there are lots of books I have not read, my impression is that my work is entirely consistent with their approach. I have always said that if a model of mind does not generate a model of mental disorder, it is not worth the paper it is printed on. The available models of mind, and I do not want to sound as though I am picking on him, but Dennett’s functionalism is a good example: It does not lead to a model of mental disorder. We can discard all those models. But the Embodied Cognition model—yes, I am 110% on the same side as they are. What did you say? “We must refer to bodily mechanisms and active interactions between the organism and the environment when talking about cognition.” Yes. Totally agree. I have just written a book about that. That means for the first time in its history, psychiatry is right up with the latest trend in philosophy.

And there is another book illustrating this point due out at the end of this year. Last year, I was feeling a bit tired of psychiatry, so I decided to apply the biocognitive model to a different field—one that interests me: politics. Specifically, I looked at the question of ultra-right-wing extremism, aka fascism. The biocognitive model gives a novel view of this crucial topic, but it is not “psychiatry unlimited” because it concludes, “These people are not mentally ill.” It is a growing field, and it all goes back to dualism. Descartes was on the right track after all. Thanks for your questions; it is an interesting field.

 I found your account of natural dualism and its application to psychiatry quite interesting, despite some reservations. I am curious to see how it will be received by philosophers of mind and philosophers of neuroscience, as these are highly contested and actively debated issues with many deep disagreements among philosophers. Aside from the intriguing discussion of natural dualism based on information processing, the notion of mental disorder and biopsychosocial integration that you end up with in the book seem to me to be fairly similar to various existing philosophical and nonreductionistic approaches. It is pretty standard to conceptualize mental disorder in terms of distress and dysfunction (the philosophical challenge that many have taken up in recent years has been to develop conceptualizations of mental disorder that do not rely on notions of dysfunction). The emphasis on self-sustaining has also become prominent in the last decade thanks to network theory but has existed in various forms previously. The dimensional nature of mental disorders also has a long history, represented these days prominently by the Hierarchical Taxonomy of Psychopathology (HiTOP) system. Biopsychosocial integrative approaches to psychopathology have also been around, eg, McHugh and Slavney’s 

 approach in the 1980s building on Meyerian and Jasperian foundations, or more recently, we have seen integrative and philosophical accounts offered by Bolton and Gillet (

The Biopsychosocial Model of Health and Disease: New Philosophical and Scientific Developments

, 2020). Bolton and Gillet also see biopsychosocial causal interactions in terms of information processing, and de Haan works with the framework of mind as embodied, embedded, and enactive. The novel thing about your book is that you arrive at your conclusions by developing a dualistic account of mind in informational terms, and the strength is that you link your model of mental disorder to a model of mind, but from my point of view, that is also a weakness. Given the lack of philosophical consensus around fundamental questions in philosophy of mind, I do not think that we have to take any particular stance on the viability of your account of dualism to successfully conceptualize psychopathology in dimensional, integrative, and nonreductionistic terms. In other words, to the extent that your vision of psychiatric practice is dimensional, integrative, and nonreductionistic, it is in alignment with existing dimensional, integrative, and nonreductionistic philosophical approaches, and the question for readers such as myself is whether your informational account of the mind is persuasive enough that we want to bet the viability of biopsychosocial integration on it. Your thoughts on this?

 I agree—there is nothing new under the sun. The difference here is that this model offers a mechanism of mind-body integration. Look at Wittgenstein: no model of mind. Chomsky: no formal model of mind. Dennett: a model of sorts, but no integrative mechanism and no suggestion of mental disorder. Sellars: no model or mechanism. Richard Carrier: avowedly reductionist, but no explanation—no model of mind. Thomas Nagel: interesting, but right at the end of 

Why the Materialist Neo-Darwinian Conception of Nature is Almost Certainly False

, he says, “However, I am certain that my own attempt to explore alternatives is far too unimaginative.”

 I am not arguing. Bolton and Gillett openly stated: “It is not straightforward to find the right metaphor for the relation between the biological, the psychological and the social” (p33).

 Why did they want a metaphor when they are supposed to be talking about a model? Because they do not have a model. They missed the central point: that merely describing biological, psychological, and sociological factors does not integrate them. I am forever telling people that description is not explanation.

I am not offering a metaphor. The biocognitive model offers a formal computational mechanism to integrate these facets of life which, after all, are just common sense. Of course, some mental disorder arises in brain disease—we have all seen that—but it does not tell us why the same syndromes can arise in the absence of brain disease. Most disorder is a mixture of psychological and social factors in a perfectly healthy brain because, just like a computer, “software” glitches can ruin everything. But the thing is, psychiatrists have got to stop kidding themselves they have a reductionist biomedical or a biopsychosocial or whatever model when, as a matter of demonstrated fact, they do not.

Does a computational approach to the mind pave the way for practicing a biopsychosocial psychiatry? 

The Biocognitive Model for Biopsychosocial Psychiatry: Niall McLaren, MBBS, FRANZCP

Association for the Advancement of Philosophy and Psychiatry

 (AAPP) took place on May 21-22, 2022, New Orleans, LA in Hilton New Orleans Riverside (alongside the American Psychiatric Association (APA) annual meeting as one of their affiliates). For the past 3 decades, the AAPP annual meeting has been celebrated by psychiatrists, psychologists, and philosophers interested in the intersection of philosophy and psychiatry, and the enthusiasm was even more palpable this year.

This year’s meeting had an open theme, and it showcased a diverse range of topics. The influence of standpoint epistemology, epistemic justice, and related themes such as epistemic privilege, epistemic vigilance, and hermeneutic ignorance were noticeably prominent in the meeting, evident in the multiple sessions of the conference on both days, the keynote lecture, and the 2022 Jaspers Award winning paper. Other notable themes touched on by multiple talks included philosophical critiques of CBT, agency and moral responsibility in psychiatric disorders, psychiatric classification, and the nature of psychiatric disorders.

The 2020 AAPP annual meeting had been cancelled due to the pandemic, and 2021 meeting had been held online, so this was the first in person meeting since the pandemic. There was a renewed excitement not only at the prospect of attending live talks, but also at reconnecting with old friends and engaging in meandering philosophical conversations during breaks, meals, and while walking the streets of the French Quarter of New Orleans.

In what follows, I present very brief summaries of talks from the meeting. Readers are referred to the meeting program and the abstracts of the talks for details, which can be accessed 

Sarah Arnaud, PhD, and Anne-Marie Gagné-Julien, PhD, kicked off the meeting by talking about the new activism in psychiatry and the scientific turn evident in fields such as neurodiversity and mad studies. Utilizing Harding’s notion of “strong objectivity,” they argued that psychiatric activism can be understood as a legitimate form of scientific criticism, and that neurodiversity movement and Mad Pride are beginning to pursue scientific goals that may ultimately transform psychiatric science or establish scientific alternatives to psychiatry. (Arnaud and Gagné-Julien also host a popular 

philosophy of psychiatry webinar lecture series

Eleanor Harris discussed how individuals with delusions are particularly vulnerable to epistemic injustice and presented an account of epistemic over-vigilance as the mechanism behind epistemic injustice in the case of delusions. Riana Betzler, building on Olivia Bailey’s work on humane understanding (“the direct apprehension of the intelligibility of others’ emotions”), argued that medicalization and pathologization in psychiatry have the potential to violate humane understanding in the context of systemic and structural injustice.

Using the example of craniosacral therapy, G. Scott Waterman, MD, examined the links between a treatment’s purported mechanism of action, the status of the treatment as a placebo intervention, and the ethics of placebo administration, making a case for humility, and transparency in clinical practice.

In a creative and innovative presentation, Richard DeSantis showed how Hegel’s critique of stoicism can be interpreted as a critique of CBT, while also achieving the remarkable feat of making Hegelian thought accessible to a multidisciplinary audience. J.P. Grodniewicz, PhD, analyzed belief revision during the course of CBT in light of unificationist and fragmentationist models of belief-organization, arguing for the validity of the latter.

In the Edwin R. Wallace Memorial Lecture, one of the key highlights of the meeting, Serife Tekin, PhD, explored epistemic, scientific, and ethical problems with the use of psychotherapy chatbots in clinical settings, particularly how such practices are embedded within assumptions prevalent within WEIRD (Western, Educated, Industrialized, Rich, and Democratic) societies that do not carry over to other sociocultural settings. Tekin elaborated on this by pointing to the perils and pitfalls of using Arabic-speaking psychotherapy chatbots as way of addressing the mental health of Syrian refugees.

Brent Kious, MD, PhD, considered the ethical challenges posed by medical aid in dying (MAID) for psychiatric indications, focusing on instances where MAID is requested by patients who have declined reasonably safe and effective treatments, such as ECT for depression. Kious argued that MAID should not be offered if there are treatments available that remain unutilized by the individual that could substantially ameliorate the symptoms and if the illness-specific quality of life after treatment cannot reasonably be viewed as worse than death.

Jared Smith tackled the application of traditional accounts of reason-responsiveness and semi-compatibilism to individuals with OCD and the notion that individuals with OCD are insufficiently reactive and lack the control required for agency and responsibility. Smith argued that once a proper understanding of OCD is taken into account, it becomes obvious that individuals with OCD are 

 to reasons, not insufficiently receptive, and this presents a challenge to existing accounts of compulsions and responsibility.

Christina Weinbaum scrutinized brain disease and moral models of addiction, as well as Hanna Pickard’s notion of responsibility without blame, to argue for viewing addiction through Gideon Yaffe’s burden-based excuse approach, and advocated understanding moral responsibility as a spectrum rather than as a dichotomy.

Natalia Washington, PhD, undertook a philosophical investigation into the nature of diagnostic kinds and the goals of psychiatric nosology, arguing for diagnostic kinds as socially constructed extended kinds (building on the work of Ron Mallon), and advocated for the need to adopt a stance of prudential pluralism about diagnostic kinds in psychiatry as well as medicine.

Rosa Runhardt, PhD, analyzed the notion of reactivity in psychiatric classification and measurement (ie, diagnosis can influence attitudes and behavior of individuals such that subsequent measurement of symptoms is affected). Runhardt outlined instances where such reactivity can be considered legitimate and the implications for prediction and intervention in the case of mental disorders.

Katherine Rickus, MBChB, PhD, presented a paper examining epistemic privilege in psychiatry and inquired whether there could be a philosophical justification for a psychiatrist or a therapist to reasonably question a client’s first-person description of their own emotional states.

Kathryn Petrozzo’s talk was also focused on philosophical issues of responsibility and agency. She discussed how reduced responsibility in cases of psychiatric disorders is often discussed in terms of reduced agency, which has problematic consequences in the form of stigmatization and unfair treatment in the legal system, making a case for reconceptualizing agency in psychiatric disorders and punishment reform.

Bahar Orang, MD, (in a paper cowritten with Suze Berkhout, MD, PhD) discussed the intersection of policing, psychiatry, and the mental health crisis response in the context of activism around defunding the police. The notion of mental health crisis itself was interrogated and they used Sylvia Wynter’s “Man-as-Human” framework and Bruce La Marr Jurelle’s work on carceral and colonial modernism to critique coercive practices in psychiatry.

Bennett Knox presented their paper, recipient of the 2022 Karl Jaspers Award (forthcoming in the journal 

) on the standpoint of the psychopathologized and hermeneutical ignorance in psychiatry. Knox argued for “social objectivity” as a desideratum for psychiatry and the DSM, made a case for meaningful inclusion of the psychopathologized in the DSM revision process, and discussed how a failure to do so threatens DSM’s social objectivity and constitute epistemic injustice.

Alexander Pereira was also scheduled to present his paper “Specific Phobia is an Ideal Psychiatric Kind,” which had won the 2020 Karl Jaspers award but had to cancel due to a last-minute emergency.

Justin Garson, PhD’s fascinating talk tied historical and philosophical elements by examining how debates around defining madness in the Late Modern period were framed as a problem of distinguishing madness from 

. Drawing on Locke, Kant, Wigan, and Heinroth, Garson showed that madness was theorized not as an 

 of reason but rather as carrying reason within it, although in a 

 form. He outlined the implications this has for contemporary philosophical discussions of mental illness. (Garson’s book 

 has recently been published by Oxford University Press to widespread critical acclaim.)

In one of my favorite talks of the meeting, Jonathan Fuller, MD, PhD, challenged the syndromic view of psychiatric disorders and made a case for understanding mental disorders as dispositions, similar to chronic medical disorders: “Chronic diseases are typically dispositions towards physiological manifestations; for instance, diabetes mellitus is a disposition towards hyperglycemia, while asthma is a disposition towards airflow limitation in the small airways. In contrast, mental disorders are dispositions towards the symptoms and behaviors that comprise their diagnostic criteria; for instance, major depressive disorder (MDD) is a disposition towards the symptoms/behaviors that comprise a major depressive episode, while substance use disorder is a disposition towards certain addiction behaviors.” Fuller argued that understanding mental disorders as dispositions allows us to account for the “stickiness” of mental disorders and their longitudinal course and management by pointing to a property underlying the syndrome.

Jack W. Kent Jr. followed up Fuller’s talk by offering a commentary on a 2018 paper by Fuller on chronic diseases. Kent Jr. argued that common characteristics of chronic disease also apply to mental illnesses, and that these may be better described as “chronic conditions” rather than as “chronic diseases” to better capture the interplay of voluntary and involuntary contributors to their progression.

The junior scholars were well-represented at this meeting, and it was widely commented that the quality of their talks was among the best things about the event. Another unique strength of the AAPP annual meeting (and of AAPP as an organization and of PPP as its official journal) is the balance of psychiatric clinicians and philosophers. The AAPP annual meeting is one of the few meetings worldwide with robust participation from both clinicians and philosophers where both can feel at home and take part in a transformative interdisciplinary dialogue.

Strong representation from University of Utah. From left to right: Brent Kious, MD, PhD; Kathryn Petrozzo; Bennett Knox; Natalia Washington, PhD. Photo courtesy of Kathryn Petrozzo.

 afterwards about her positive experience of the meeting: “@aapp_PhilPsych conference was completely and utterly fantastic. I met the most incredible people who are doing really important and meaningful work and having the opportunity to be a part of this family is something I'm so honored about. Thank you all for everything!”

Christian Perring, PhD, the president of AAPP, said in a statement to 

™: “Philosophy of psychiatry, like philosophy of medicine and medical ethics, continues to generate a good deal of interest among academics and clinicians. AAPP plays an important role in both stimulating interest and also enabling dialog between people in different fields. We were very pleased to see how much enthusiasm there was at our 2022 conference, especially among early-career scholars. It is a promising sign for the future of the field.”

The 2023 annual AAPP meeting will be held on May 20 and May 21, 2023 in San Francisco, CA, along with the 2023 annual meeting of APA. The call for abstracts for the 2023 meeting will be issued in the coming weeks on the AAPP website. Announcements are also made via the official AAPP twitter account @aapp_PhilPsych.

” for Psychiatric Times. He has been actively involved in initiatives to educate psychiatrists and trainees on the intersection of philosophy and psychiatry. He is also a member of the

The 2022 annual meeting of the Association for the Advancement of Philosophy and Psychiatry was full of transformative, interdisciplinary dialogues. Here are some highlights. 

The Rise of Philosophy of Psychiatry: A Portrait of the 2022 AAPP Annual Meeting

Conversations in Critical Psychiatry is an interview series that explores critical and philosophical perspectives in psychiatry and engages with prominent commentators within and outside the profession who have made meaningful criticisms of the status quo.

Robert Chapman, PhD (they/them or he/him), is a philosopher in the United Kingdom. They are senior lecturer in education at Sheffield Hallam University, focusing on the philosophy of neurodiversity. They have published widely on issues in philosophy of disability, the ethics of autism, and critical neurodiversity studies, and are currently writing their first book on the philosophy of neurodiversity. Their Shirley Foundation-funded doctoral research was carried out at the University of Essex between 2013 and 2018 and focused on the ethics of autism. They have taught at the University of Essex, King’s College London, and the University of Bristol. They are proudly neurodivergent and disabled. They also blog for

Psychology Today and at Critical Neurodiversity.

Let’s start by an introduction to the neurodiversity movement and the neurodiversity paradigm. What is neurodiversity and where does it clash with mainstream medical thinking?

 The neurodiversity movement is a social justice movement pushing for a shift away from the default pathologizing of mental, developmental, and cognitive disability and toward what I have called a social ecological approach to understanding disablement. It all started when autistic individuals began meeting and raising consciousness online in the 1990s. Many realized they were tired of being represented as tragic deviations from supposedly normal functioning, and they were also often traumatized by ensuing attempts to “treat” or “cure” their 

. Eventually, as a new way to challenge how we think about normality, they began to talk about whether the principle that increased biodiversity is necessary for a robust ecosystem also applied to neurocognitive diversity within species. Just as we value, see beauty in, and try to conserve biodiversity, why not think about neurocognitive diversity in the same way? Based on this, Judy Singer, PhD, a member of these communities and, at the time, a sociology student, coined the term neurodiversity and called for a “politics of neurological diversity” in her 1998 thesis. Singer circulated her thesis, which was grounded in the theories of disability studies, among other autistic activists before publishing a revised version as a book chapter in 1999.

“This model challenges the idea that many neurodivergent individuals necessarily have neurological or cognitive pathologies, as well as the idea that neurotypicals are necessarily superior...”

Awais Aftab, MD

Articles

The Fight for Pharma Accountability and Psychiatric Rights: Jim Gottstein, Esq

The Biocognitive Model for Biopsychosocial Psychiatry: Niall McLaren, MBBS, FRANZCP

The Rise of Philosophy of Psychiatry: A Portrait of the 2022 AAPP Annual Meeting

Neurodiversity and the Social Ecology of Disability

Upon the Shores of Social Construction

What Can Philosophy Learn From Madness?