Awais Aftab, MD

Dr Fava has authored more than 500 scientific papers and his work has been highly influential in the field in the psychiatry. His innovations include a novel psychotherapeutic approach for increasing psychological well-being (well-being therapy), the sequential model for combining pharmacotherapy and psychotherapy, the concept of staging in psychiatry, a new method of classification of psychosomatic distress (the Diagnostic Criteria for Psychosomatic Research), the concept of oppositional tolerance with antidepressant treatment, and the clinimetric approach to psychiatric evaluation. Since 1992, he has been the Editor in Chief of 

which ranks fourth in the Science Citation Index for psychiatry journals with an impact factor of 13.74 (and precedes the 

). I particularly enjoy his editorials in Psychotherapy and Psychosomatics—a treat for any thoughtful psychiatrist—and I am a great admirer of his brilliant mind, intellectual integrity, and willingness to tackle complex clinical questions that few others are asking in the field.

I feel psychiatrists are in a very tough spot. The way they are educated and trained, they are unaware of the systematic ways in which research studies and guidelines are heavily biased and misrepresented. They have to learn to critically appraise research literature for guidance, which is a hard thing to do for clinicians without research training, especially since it often means challenging the wisdom of their colleagues, conclusions of top researchers, and “key opinion leaders,” as well as established guidelines in the field.

To make matters worse, there is very little unbiased and generalizable research. This means psychiatrists have to rely on their clinical experience when working with individual patients, which is subject to biases and distortions of its own. Despite mountains of research data, it feels like we are in an impoverished state of knowledge. Am I being too nihilistic, or do you share some of these frustrations as well?

I agree; psychiatry is going through an intellectual crisis. This crisis is shared by other areas of clinical medicine and stems from a narrow concept of science that neglects clinical practice as a source of fundamental research questions. Fewer and fewer academic psychiatrists actually assess and treat patients. Most of published research has no relevance to practice. The progress of neurosciences in the past 2 decades has often led to the belief that clinical problems in psychiatry were likely to be solved by this approach. Such hopes are understandable in terms of massive propaganda operated by biotechnology and pharmaceutical corporations.

An increasing number of psychiatrists are wondering, however, why the cures and clinical insights promised by neurosciences have not come to fruition. Biological reductionism has resulted in an idealistic approach, which is quite far from the explanatory pluralism required by clinical practice. Neurosciences have exported their conceptual framework into psychiatry much more than serving as an investigative tool.

You use the term iatrogenic comorbidity to refer to the lasting effects of previously administered treatments that negatively influence course, characteristics, and responsiveness to treatment. Can you share some examples to illustrate what you mean?

Like Moliere’s bourgeois who was surprised to speak in prose, the clinician may discover they are constantly faced with iatrogenic comorbidity. In pharmacological terms, let us just think of the case of switch into mania of a patient with allegedly unipolar depression treated with antidepressant drugs. You are faced with a modification of illness that is largely drug-induced and that is likely to affect treatment. Or, in psychotherapeutic terms, let us think of a patient who has been unsuccessfully in analysis for many years and is offered a course of cognitive behavioral therapy (CBT): their response is likely to be affected by the previous psychotherapeutic experience in terms of expectation, adherence, and motivation. The concept of iatrogenic comorbidity is simply an attempt to conceptualize the problem in a practical way.

Regrettably, psychiatrists, unlike other specialists, have been taught to consider comorbidity only in terms of diagnoses, and not as problems and treatment experiences. And they are unable to think “iatrogenic” in interpreting clinical problems, simply because they have not been exposed to the concept, which has been submitted to tight censorship by mainstream psychiatry.

Clinicians and researchers have been taught and/or have learned to ignore and misunderstand antidepressant discontinuation symptoms, such that in many instances, withdrawal symptoms are interpreted as indicators of impending relapse. In fact, the vast majority of psychopharmacological maintenance randomized controlled trials appear to conflate withdrawal reactions with illness relapse to justify superiority of maintenance treatment over discontinuation. How can psychiatrists better differentiate between withdrawal and illness relapse, and how can maintenance studies be better designed to parse out this issue?

Psychopathology, the basic neglected method of psychiatry, allows differentiation of withdrawal syndromes from relapse. Specific diagnostic criteria have been developed by Guy Chouinard, MD, and Virginie-Ann Chouinard, MD, in 2015.

 These criteria allow differentiation of withdrawal syndromes from relapse, recurrence, rebound, and persistent post-withdrawal disorders. Maintenance studies with antidepressants are likely to confound withdrawal and relapse unless specific criteria are used. We need new studies with these criteria.

 It has been interesting that the psychiatric establishment insists on using the term antidepressant discontinuation syndrome, while researchers such as yourself and critics in the general public favor antidepressant withdrawal. Does this battle of terminology have any larger significance?

The term discontinuation syndrome applied to antidepressants, versus withdrawal syndromes with benzodiazepines, was a very smart method of the pharmaceutical industry to deny the problem. It is sad that most academic psychiatrists followed these leads. The evidence, based on systematic reviews and a large body of literature, is now pretty clear and the tide is turning.

 Selective serotonin reuptake inhibitors and serotonin and norepinephrine reuptake inhibitors may cause withdrawal reactions (ie, new symptoms that were not present before) despite slow tapering; these reactions may be severe and do not necessarily subside in a few weeks. When I see a patient whose symptoms have been treated with paroxetine or venlafaxine, I am always looking for manifestations of iatrogenic comorbidity, which, unfortunately, I am very likely to find.

If you teach a psychiatric resident that symptoms that occur during tapering cannot be due to withdrawal, they are likely to interpret them as signs of relapse and to go back to treatment (exactly what “Big Pharma” likes). In the United Kingdom, the 

National Institute for Health and Care Excellence

 (NICE) guidelines are changing to reflect the potentially malignant outcome with SSRI and SNRI discontinuation. I do not see anything similar happening in the United States.

Many clinicians seem to hold the view, implicitly or explicitly, that it is better to identify and treat depression when it is mild or even subthreshold because untreated depression will progress in severity. This is coupled with the assumption that at worst, the medication may not help but it certainly won’t cause disease progression. Do such clinicians have an unfairly malignant view of the natural history of untreated depression and an unfairly benign view of psychopharmacological treatment?

These clinicians perceive a state of distress in their patients but have been taught only to think in terms of harmless medications. They are often unaware of the major advances that have been made in psychotherapy in the past decades, which are far superior to the pharmacological ones. Mild or subthreshold depression should be primarily addressed with effective and short-term psychotherapies, such as CBT. Unfortunately, the prescribing clinician is driven by an overestimated consideration of potential benefits, paying little attention to the likelihood of responsiveness and to potential vulnerabilities in relations to the adverse effects of treatment, one of the spectacular achievements of “evidence-based medicine,” which has been transformed into the marketing arm of the pharmaceutical industry. These latter components outweigh potential benefits of antidepressants in mild depression.

 You seem to interpret the results of STAR*D as indicating that the use of switching and/or augmenting strategies propels depressive illness into a phase characterized by low remission, high relapse, and high intolerance to medications.

 You tie the poor outcomes seen in STAR*D to the use of psychopharmacological strategies while conventionally the poor outcomes have been viewed as a result of patient characteristics or characteristics of disorder pathophysiology. Is there anything in the data that supports one interpretation over another?

 The findings of STAR*D were pretty clear. The aim of the trial was to apply the best pharmacological strategies for obtaining remission in major depression. Those who did not recover after a trial with citalopram were submitted to 4 sequential steps involving switching, augmentation, and combination strategies, based on available literature.

The results were rather disappointing. The cumulative rate of remission after 4 sequential steps was 67%. However, when sustained recovery (taking into account relapse rates while on treatment) was considered, the cumulative rate was 43%. This means the strenuous efforts after step 1 (open treatment with citalopram) yielded an additional 6% of sustained recovery. Remission rates decreased after each treatment step. Rates of relapse increased after each treatment step in patients who achieved remission. Further, intolerance (dropouts for any reason during the first 4 weeks, or adverse effects afterwards) increased after each treatment step.

STAR*D’s message should have been clear: Do not do what we have done. Regrettably, just the opposite came out. The findings can be interpreted in light of the oppositional model of tolerance. Continued drug treatment may recruit processes that oppose the initial acute effects of a drug. This may explain loss of treatment efficacy and the fact that some side effects (such as increased appetite and weight gain) tend to ensue only after a certain time. These processes may also propel the illness to a more malignant and treatment- unresponsive course, as with a bipolar manifestations or paradoxical reactions. When drug treatment ends, oppositional processes may encounter no more resistance, resulting in appearance of new withdrawal symptoms, rebound symptomatology, persistent post-withdrawal disorders, hypomania, resistance to treatment if it is reinstituted.

In the long run, antidepressants may increase chronicity, vulnerability to depressive disorders, and comorbidity. There is now extensive literature supporting this mechanism. In practice, you may encounter patients whose symptoms have been treated with a number of psychotropic drugs, particularly in combination, and who end up as in the STAR*D. What to do is a big problem. You can blame the illness and the patient, it is easy, but you should also think iatrogenic.

 You wrote, “Current diagnostic methods in psychiatry, both DSM-5 and the forthcoming 

, refer to patients who are drug-free and do not take the issue of iatrogenic comorbidity into adequate consideration. They are suited for a patient who no longer exists.”

 How do you think the diagnostic manuals can take iatrogenic comorbidity into account?

Most of the patients we see in practice are already taking psychotropic drugs. If a primary care physician refers a patient to me, it is because the patient’s symptoms did not respond to the pharmacological treatment (generally an SSRI or SNRI) that had been started. Medications may affect clinical presentation of symptoms. In a naïve implicit formulation that runs counter to any modern insights into the plasticity of the brain, we may believe that after discontinuing an antidepressant everything goes back to the pre-treatment state. It does not, as any physician in the real world knows.

Treatment is a one-way street. We even subscribe to the hope of finding pre-treatment predictors (biomarkers), and we waste money on it. Everything changes in the course of treatment. This means we need to supplement DSM with a more comprehensive assessment that takes the issues of medication history and development of tolerance into consideration, using methods that pertain to clinimetrics, the science of clinical measurements, such as macroanalysis and staging.

It is very common for psychiatrists to encounter patients with complex presentations of multiple psychiatric comorbidities who are on multiple psychotropic medications but remain symptomatic with a mix of symptoms that does not fit into diagnostic categories and their psychopharmacological treatment history is a mess of one trial after another, consisting of medications that once worked but no more, medications that never worked, and medications poorly tolerated. Do you have any general clinical recommendations regarding how to approach evaluation and treatment in such cases?

These are exactly the patients who do not fit into any DSM category. You need to take the issue of iatrogenic comorbidity into account and spend a good deal of time for a full clinimetric assessment and use diagnoses only as temporary transfer stations that can be verified in the course of time. There is almost no research on these issues, as it happens with most of the truly important matters in psychiatry.

I can share with you what I do clinically. First, I use clinimetric assessment to capture clinically relevant information that is not included in the diagnosis. Based on the assessment, I try to taper and discontinue, very slowly, the multiple medications starting from those I judge as less important. I am also looking for counter-therapeutic elements (behavioral components) and attitudes that may affect response to treatment at the individual, family, and work levels using a framework that Karl Rickels, MD

, developed in the ’60s and that we have recently updated. I also pay a lot of attention to psychological well-being (ie, is there anything I can build on?). Then I introduce the type of psychotherapy (eg, CBT, brief dynamic psychotherapy, family therapy, well-being therapy) that may affect the targets I have identified. It is simply wishful thinking to believe that one course of treatment may entail the solution to the problems that we encounter in these complex cases. We need the sequential combination of different treatments, and this should be planned from the very beginning and subsequently modified as needed.

What percentage of patients prescribed antidepressants would you say experience clinically significant effects related to oppositional tolerance? Why is there so much variability in how individuals are impacted by these medications?

It very much depends on the type of practice. In my practice, which is very much shifted to treatment resistant, difficult, unusual cases, the percentage of cases who present with the various manifestations of tolerance (eg, loss of clinical effects, paradoxical reactions, switching, persistent post-withdrawal disorders, refractoriness) is very high and may approach 1 case out of 2. But you do not have the same crowd, the percentage may be much lower. We need studies addressing these issues in a comprehensive manner in outpatient populations.

Psychiatry is continuing its path of aggressive pharmacological treatment of “treatment resistance” in depression, and medications such as ketamine are being hailed as new miracle drugs. What is your perspective on these developments?

 These types of studies reveal the methodological frailty and the narrow perspectives of much of current psychiatry. You test a drug in a highly heterogeneous sample of patients who do not respond to a certain treatment (the reasons for which could be so different) without any discrimination in terms of tolerance and questioning whether the treatment was appropriate (you just go by the book). Because you use a controlled design, you are convinced you are performing high-level clinical science. But the results are likely to be spurious and the outcome is monitored for a very short time.

For a clinician, a short-lived response does not mean much. It can also be achieved with non-specific ingredients, such as high expectations. One course of treatment, again, is unlikely to yield solutions to the complex situations of these patients. The claim of “miracle drugs” such as ketamine are only a sign of the intellectual crisis of psychiatry. I would like to see adequate assessments and articulated courses of treatment be tested for enduring results.

Have you read or are familiar with Robert Whitaker’s book 

If so, do you have any thoughts on what the book gets right and what it gets wrong?

Yes, of course. I think it was an excellent piece of investigative journalism that was highly effective in fighting the tight censorship that mainstream psychiatry endorsed against any vulnerabilities induced by psychotropic drugs. Subsequent developments (eg, 

) had the recognized merit of addressing clinical problems, such as the withdrawal syndromes from SSRI and SNRI, that were and are still denied by professional organizations and scientific societies, as well as issues related to financial conflicts of interest.

However, the risk is forgetting that, if used properly, antidepressants, antipsychotics, and lithium are life-saving drugs, and benzodiazepines offer a rapid and safe relief for anxiety. The problem is their inappropriate application, like any other medication (eg, antibiotics).

As you have discussed, forces and incentives in the world of academic publishing converge to reward mediocrity and discourage truly innovative research.8 What would be your advice to early career psychiatrists about surviving in academia without giving up independent thinking and creative integrity?

A young psychiatrist who reads our conversation may become convinced that this is the worst of times for psychiatry. As Dickens teaches us, however, it may also be the best of times. There are entire areas of clinical research, such as those related to the iatrogenic effects of medications and psychotherapy, that are largely unexplored. Neuroscientific methods applied to specific problems (eg, what characterizes withdrawal syndromes) may offer unprecedented opportunities but should be associated with clinimetric tools (eg, specific criteria).

The recent development of medicine-based evidence

 that integrates data from clinical practice with those of randomized controlled trials opens an important line of research. Psychiatrists, who in their clinical practice use sophisticated forms of clinical judgment and master techniques of interviewing and history taking, are geared to capture the components of medicine-based evidence. Fascinating vistas for psychiatrists who are skilful in differential psychopathology and have strong curricula in clinical pharmacology and internal medicine are emerging. They should be welcome to all those who are disillusioned with the meagre practical results of decades of mainstream psychiatric research and should become the preferred channel of funding and attention. Long-term outcomes of psychiatric disorders may be unsatisfactory, not because technical interventions are missing but because our conceptual models are inadequate.

Of course, a pathway characterized by independent thinking and creative integrity may be difficult and frustrating nowadays (eg, very few journals host contributions that may hit commercial interests), and it is certainly easier to make progress in academia with meta-junk. But, in my opinion, we may be close to a change of paradigms in psychiatry. Either you persist on the current mainstream road to nowhere that leads to frustrating clinical experiences (with ensuing aversion to patient contact) or realize that there is a world of new possibilities and pathways.

 is a psychiatrist in Cleveland, Ohio, and clinical assistant professor of psychiatry at Case Western Reserve University. He is a member of the executive council of Association for the Advancement of Philosophy and Psychiatry and 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 Psychiatric Times Advisory Board. He can be reached at 

completed his medical education as well as his psychiatry residency training at the University of Padova, Italy. After working for several years in the United States, he returned to Italy in 1988, where he established an Affective Disorders Program at the University of Bologna. He is currently clinical professor of psychiatry at the State University of New York (SUNY) at Buffalo, NY. A full version of this article can be found online at 

https://www.psychiatrictimes.com/view/impoverishment-psychiatric-knowledge

Dr Aftab and Dr Fava have no relevant financial disclosures or conflicts of interest.

The opinions expressed in the interviews are those of the participants and do not necessarily reflect the opinions of

See more Conversations in Critical Psychiatry.

1. Chouinard G, Chouinard VA. New classification of selective serotonin reuptake inhibitor withdrawal. Psychotherapy and psychosomatics. 2015;84(2):63-71.

2. Hengartner MP, Davies J, Read J. Antidepressant withdrawal-the tide is finally turning. Epidemiology and psychiatric sciences. 2019;29:e52.

3. Fava GA. Rational use of antidepressant drugs. Psychotherapy and psychosomatics. 2014;83(4):197-204.

4. Fava GA, Rafanelli C. Iatrogenic Factors in Psychopathology. Psychotherapy and psychosomatics. 2019;88(3):129-40.

5. Fava GA, Rafanelli C, Tomba E. The clinical process in psychiatry: a clinimetric approach. J Clin Psychiatry. 2012 Feb;73(2):177-84.

6. Fava GA, Guidi J, Rafanelli C, Rickels K. The clinical inadequacy of the placebo model and the development of an alternative conceptual framework. Psychotherapy and psychosomatics. 2017;86(6):332-40.

7. Chouinard G, Samaha AN, Chouinard VA, Peretti CS, Kanahara N, Takase M, Iyo M. Antipsychotic-induced dopamine supersensitivity psychosis: pharmacology, criteria, and therapy. Psychotherapy and psychosomatics. 2017;86(4):189-219.

8. Fava GA. The Decline of Pluralism in Medicine: Dissent Is Welcome. Psychotherapy and Psychosomatics. 2019;13:1-5.

9. Lobitz G, Armstrong K, Concato J, Singer BH, Horwitz RI. The biological and biographical basis of precision medicine. Psychotherapy and Psychosomatics. 2019;88(6):333-40. ❒

An earlier version of this article was posted on March 30, 2020: 

The Impoverishment of Psychiatric Knowledge

Articles

"It is simply wishful thinking to believe that one course of treatment may entail the solution to the that we encounter in complex cases," says Dr Fava. Dr Aftab explores a multitude of issues in psychiatry and science in this interview.

Psychiatry’s Intellectual Crisis: Giovanni Fava, MD

Dr Ahmed Samei Huda works as a consultant psychiatrist in the National Health Service in a deprived area to the east of Manchester in the UK. In addition to general adult psychiatric patients, much of his clinical work is devoted to the Early Intervention in Psychosis (EIP) service. Although he is from Scotland, he has lived in England for half of his life and has also spent about a year working as a psychiatrist in Australia. He is the author of 

The Medical Model in Mental Health: An Explanation and Evaluation

Dr Huda describes that he was struck by the disparity between the views of various academics and those of clinicians at the coalface regarding the medical model and its application to psychiatry (“at the coalface” is a British expression which means being directly engaged in a professional activity rather than talking about it in a managerial or theoretical way). This served as his motivation for writing 

. The book describes how he understands the medical model as it exists in clinical practice, and how this medical model is applied to mental health compared with general (internal) medicine with a focus on diagnosis and treatment. He argues that in many respects, there is a greater degree of overlap between psychiatry and general medicine than is realized by many critics with regards to the nature of diagnostic constructs and effectiveness of treatments. The volume is among the very few book-length examinations of the subject, especially from the perspective of a clinician.

Can you briefly describe your conceptualization of the medical model in psychiatry? What do you think are some common misconceptions about psychiatry’s relationship with the medical model?

The medical model is about identifying the relevant information that will help the patient in their presenting predicament in order to help them make informed choices to achieve their desired therapeutic goals (which may be cure or relieving distress or preventing some undesired outcome and so on). The first common misconception is that it is a 

. Doctors take a history to find out what happened to the patient as the best source of relevant information supplemented by examination and investigations. This results in a clinical picture which is matched to the diagnostic construct which fits closest. A diagnosis is not a certain fact—it is an opinion as to the information most relevant to helping the patient and is always provisional.

This diagnostic construct carries probabilistic information such as likely outcomes, treatments and chances of success, important complications to beware of and other conditions that are likely to be present. Values are important in deciding what types of problems are suitable for medical help, but these values are more likely to be shared for general medical conditions than psychiatric conditions. In psychiatry these values are often more disputed.

Another common misconception is that general medical diagnosis is completely different from psychiatric diagnosis whereas there is substantial overlap in reliability of agreement over diagnosis, the nature of the condition being classified (clear-cut syndromes, spectrums with health, spectrums of conditions, etc), lack of knowledge of causes and pathological mechanisms, usefulness in clinical practice, high rates of co-occurrence of conditions and the impact of social factors.

Some people also have the notion that that medications in general medicine aim to cure, their mechanisms of action are always fully understood, and they are highly effective in contrast to psychiatric medication. The reality is that medical as well as psychiatric interventions have a variety of aims aside from cure, such as relieving distress, prevention (such as vaccination), inducing a compensating state or preventing deterioration. We don’t always know much about how some general medical treatments work not just psychiatric treatments. There is also an overlap in effectiveness between general medical treatments, psychiatric medications and psychotherapy. Most of my colleagues whom I surveyed prescribe psychiatric medications on the basis of empirical evidence of effectiveness with the acceptance that how the benefit is achieved is often not known.

When it comes to conceptual frameworks, we can distinguish between the descriptive and normative aspects of the discussion, ie, what the medical model looks like in practice, and what the medical model should be like. Are there any aspects of the medical model as it currently exists that you think should be different? Are there deficiencies we can improve upon?

 “Many a slip twixt cup and lip” applies here. Whereas we are supposed to be collaborative and patient-centered this often doesn’t happen—more obviously in compulsorily detained patients but also in voluntary patients. For millennia doctors” main therapeutic benefit was the placebo effect so maintaining an air of authority and omnipotence could be argued to be beneficial but society has moved on and working together with patients as equals should be our goal such as using their favored treatment goals not our own. Related to this we need to work harder at incorporating patients’ views when we revise our diagnostic classifications and into what research we do, its aims and methodologies.

We need to be more observant. I worked with a nursing assistant who said that when the patients moved from an asylum-style ward with filthy carpets and furniture to a former geriatric ward that was cleaner, there was a dramatic improvement in patients' behavior in many respects yet this type of information is often missing in our textbooks even though it should be obvious—treat people as too unimportant for clean surroundings and they will behave inappropriately.

We also need to be more responsive to iatrogenic harm. I grew up in an asylum where my mum worked as a doctor and could see first-hand the negative effects of institutionalization on blunting drastically the potential of people and the harmful consequences of long-term excessive doses of medication. Another problem with the medical model is that we have a tendency to dominate or assume we should be in charge but we need to be more open to care models where we are either not involved or only see people if there is a need for our expertise. One final point—we must not reduce illness (of any type mental or physical) to only disease. Our aim is to help people not merely their bodies.

You show that psychiatric diagnoses and treatments fare similarly to diagnoses and treatments in a lot of other areas of medicine. I think you make the case for that persuasively. But not all criticisms of psychiatry make this distinction between psychiatry and rest of the medicine. Many critics may well accept your description of the medical model but may dispute the fact that psychological suffering 

 viewed through the medical model. What are your thoughts on that line of criticism?

 In my book I say “there are multiple models of viewing people’s problems, and multiple ways of helping people with these problems. The medical model is not necessarily the best way to view or help a problem.” Doctors are used to working in multidisciplinary teams with different professionals and their particular models of conceptualizing and methods of helping patients. So, for some patients the medical model will not be helpful or even harmful. Often patients require the help from several different models and professionals to help them with often complex predicaments.

Some people do not wish the use of the medical model to be so prevalent in mental health services. Leaving aside the historical contingencies there are good practical reasons why this is so. Tyrer

 in the UK found that consultant psychiatrists had 5 to 10 times as many patients as other mental health professionals. This is because the medical model with brief appointments and using diagnosis and other heuristic methods as well as use of medication instead of spending 50 minutes weekly providing therapy allows doctors to see many patients and work in emergencies including overnight.

You write that teaching of medicine focuses on practices and facts, and not on their conceptual foundations, that doctors are typically reflective about their actions and feelings, and not on underlying concepts. "Thus, they may have stereotyped and limits views of what a diagnosis is, or the fact that illness and disease are always objective entities clearly demarcated from health." An implication of this is that the doctors in their communications with patients and the public can be unwitting proponents of biomedical reductionism and disease essentialism. I am advocate of “

 and have been involved in teaching philosophy of psychiatry to trainees, and my experience has been that many trainees and psychiatrists have a very essentialistic understanding of disease concepts. Do you think medical educators should try to remedy such thinking?

 I teach classification to the psychiatry trainees of the North West of England and as part of that I do try to talk about the varied nature of medical conditions. As I have said earlier, we use categories as they fit with human psychology well but many health problems are dimensional—often on a continuum with health with no clear demarcation between health and sickness as well as being on multiple dimensions of attributes of medical interest.

I think nosology should be taught at medical school so that all doctors can be aware of the nature of medical conditions for example they are not all diseases or illnesses. Pregnancy is not an illness, but doctors see pregnant women because they or their fetuses may develop medical illnesses or problems for instance. Doctors in other specialties often encounter problems that we are already familiar with in psychiatry—such as what is the best way to draw thresholds to define conditions (for example defining renal failure) and how to take into account co-occurrence of conditions (such as talking about hypertension, hypercholesterolemia and type 2 diabetes as if they were completely separate conditions).

I grew up in an asylum where my mum worked as a doctor and could see first-hand the negative effects of institutionalization on blunting drastically the potential of people and the harmful consequences of long-term excessive doses of medication. 

Other important lessons from philosophy such as how to recognize valid and invalid arguments would also be valuable—denying the antecedent or affirming the consequent is frequently found in medical and mental health literature. Most medical schools include some sociology but medical students should also be taught to recognize cultural biases in their thinking.

One of the more commented upon passages from your book states: “It was doctors’ professional authority (ie, their ability to be held to account by relevant authorities, their ethical codes of behavior, and their ability to be administrators) rather than sapiental authority (ie, knowledge of mental health problems and effective treatments) that led to them being put in charge of asylums in the 19th century. If psychologists or social workers existed as highly developed professions with professional authority during the Victorian era, then perhaps they would have become asylum superintendents instead of doctors.” This was an intriguing thought for me. This alternative history would’ve unfolded in very interesting ways. Do you think there are any current aspects of psychiatric practice that would be better served if they were primarily managed by psychologists?

This alternative history would certainly be different with its own gains and losses. Mental health services would probably have had a greater focus on listening and identifying and helping with traumatic events. Less use of medication would mean less adverse effects and problems with withdrawals. There would probably be a greater focus on community work and less use of detention as it would be harder to justify detention as psychosocial interventions require some willingness to participate. Given the current under-representation of ethnic minorities in clinical psychology, I doubt there would have been any reduction in institutional racism in mental health services. There would have been a greater focus on research on psychosocial causes and mechanisms but I’m skeptical if there would have been more research on adverse effects of psychotherapy which is a highly neglected field currently. Non-diagnostic classifications would likely have been more prevalent.

For those conditions which respond better to psychosocial approaches, such as anxiety and mild to moderate depressive disorders, a psychology led service can be beneficial, with more efficient access to psychotherapy instead of long waiting lists like we currently have. But this would also require there to a lot more psychotherapists (and perhaps more group therapy). Antidepressants can be used as second line if therapy is ineffective. For those meeting criteria for personality disorders, a psychological approach can help avoid stigmatizing labels and offer a focus on dealing with trauma and its psychological consequences. A mix of individual and group approaches promptly delivered rather than multiple contacts with psychiatric services of a “firefighting” nature focusing on risk and brief appointments spaced weeks/months apart can be much more helpful.

On Twitter, you are known as a prominent defender of current psychiatric practices against critics, yet I believe your book reveals a far more critical mind. I suspect if you weren’t spending most of your energies defending psychiatry, you might actually have been a critic yourself of the reductionistic and unreflective tendencies within our profession. What do you think?

I will mention a few problems. We have not paid due attention to the adverse effects of psychiatric medications. Even accurate information on frequency of some severe adverse effects is lacking. A patient first described to me antidepressant withdrawal in the mid-90s yet we still have no accurate estimate of the prevalence of severe withdrawals (or an uncontested definition) for each antidepressant drug so we can inform our patients of the risk. Apart from lack of good data, there is a lack of clinics and other services to support victims of severe withdrawals. Our studies on the effectiveness of antidepressants vs placebo for preventing relapse of depression have probably overestimated the benefit because some of the relapses in the placebo group may actually be due to withdrawals; the actual benefit is still likely to be clinically significant but less than that for effective psychotherapy. We also have little idea of the frequency of persistent and/or severe cognitive impairment after electroconvulsive therapy which is a serious gap in knowledge.

Another issue is to reduce measuring treatment effectiveness to reducing symptoms or preventing exacerbations of symptoms. It relies on the assumption that for all patients reducing what we describe as symptoms is their priority and that reducing them will produce other benefits such as improving quality of life, functioning and preventing other outcomes such as suicide. Of course, we need some standardization of outcomes in studies but as in all of medicine we need to increase patient participation in study design to study outcomes that patients themselves value not what we think they should value. We also need to further clarify what we mean by apparently straight forward terms as “quality of life” and “functioning” as they involve a lot of implicit values. There is also suspicion of the concept of “recovery” as many patients feel it has been used to discharge distressed and vulnerable people from services.

You write that you prefer the term “condition” over terms such as “disorder” and “disease,” because the term carries less philosophical baggage. By condition you mean that this is a state in a person that “may come to the attention of health services but does not mean that this state is definitely an illness or disease, or even a state that should be regarded as a primarily a health problem (instead of, for example, a social problem).” By calling psychiatric disorders as conditions, are you acknowledging that there is sufficient room for debate regarding whether these conditions are diseases or disorders with underlying dysfunctions, or even that they are best understood as medical conditions? If so, that’s a prominent departure from psychiatric practices which label most diagnoses as disorders and often encourage the rhetoric of calling psychiatric illnesses as “brain diseases.”

 A problematic reductionism in our field is the tendency to “disease” talk—using language such as treating mental disease, depression is a disease, schizophrenia is a serious mental disease. Maybe the intent is to equalize the status of mental illness with general medical illness but to me it is inaccurate terminology and we should as professionals try to be accurate. For me, a diagnostic construct is a disease when people meeting criteria for the diagnostic construct have shared differences in structure and/ or processes compared to people who don’t meet the criteria for the diagnostic construct. Given the heterogenous nature of the depression construct there is not this commonality of differences in structure and/ or process. For schizophrenia there is more evidence of such changes such as increased presynaptic dopamine activity,

 but this is not found in everyone meeting these diagnostic criteria, and it is also found in some people meeting manic psychosis.

 So to call diagnostic constructs such as depression or schizophrenia a “disease” is to give a misleading picture of what we know about these conditions.

Many others and Wakefield view disorder and diseases as a dysfunction (a purportedly value neutral term which can include biological or psychological dysfunctions) that is negatively valued. Both disorder and disease carry negative connotations. If you tell someone their personality is disordered, well, that’s fighting talk where you are armed with medical terminology and they are defenseless—there’s nothing more personal than personality (leaving aside that these are arguably not disorders of personality per se rather than psychological reactions to trauma in the context of other vulnerability factors). Both disorder and disease carry the assumption of something “wrong” or “dysfunctional” located within the individual.

Many situations or state of affairs regarded as suitable for the attention of helping professionals do not meet the criteria for disease or disorder. Pregnancy is an obvious example. If one has high blood pressure or blood sugar due to a mixture of diet, lack of exercise, genetic and other factors is that really dysfunction or an expected outcome of a complex set of interactions (though of course high blood pressure or sugar may cause problems as a result including pathological changes or other dysfunctions)? Moving to mental health problems, many of them have no proven dysfunctions. They are states of affairs though that are regarded as appropriate to seek help from helping professionals of various kinds—usually because of associated distress, reduced functioning and/or risks of adverse outcomes. Is it possible to have any dysfunction in uncomplicated grief? Some people will argue that there are no dysfunctions in many mental health problems whilst others are convinced that they are present.

You endorse a version of “promiscuous realism,” indicating that the medical model is simply one way of conceptualizing a condition, and it is not necessarily the best way to view or help a problem. I suppose one problem with our current practice of medicine is that when a condition is medicalized, the narrative becomes completely dominated by the medical perspective. For instance, in certain circles it would be completely taboo to say that the medical model is not necessarily the best way of viewing depression. The system wants us to accept that depression 

 a medical disorder in some real, fundamental way, not simply that it 

 viewed as a medical disorder. The system is willing to support services such as psychotherapy or social interventions as long as appropriate lip service is paid to the disorder language. Imagine a grant funding application that begins by saying that depression is not necessarily a medical disorder… it would never get funded! What are your thoughts on this state of affairs?

Social factors are the biggest determinant of all health including physical health. Conceptualizing the consequences of social factors, a health problem is a bigger motivator to change things—hence the big investments in clean drinking water and reducing substandard housing to improve health. This is because reducing illness and improving health is a more common shared value than seeking social justice. NHS England already has a target to eliminate child abuse but as far as I can see there is no implemented strategy to do this. Public health is a great example in this regard with a focus of interventions on social factors to improve mental and physical health. To quote the great 

, “Medicine is a social science and politics is nothing else but medicine on a large scale. Medicine as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution; the politician, the practical anthropologist, must find the means for their actual solution.”

As a pragmatist I recognize that sadly many people are not motivated to reduce social inequality or injustice. I work with the grain of people. Recent electoral history has shown that rational calculation and social justice are on the losing end. We can continue as Virchow would say to inform people and politicians of the consequences of their decisions but they are more likely to change them if they are framed as health consequences. People with mental health problems are more likely to get access to benefits if they are regarded as health problems. I am aware I may be accused of guild self-interest but if mental health problems are framed only as say social problems then it is likely that the services to help people with these problems will be even more underfunded and inadequate.

In terms of research and clinical practice it’s important that “medical” is not the same as “biological” and the psychiatry curriculum and practice in the UK has been “biopsychosocial” for decades. Saying something is a “medical” problem doesn’t mean only doctors should see and treat them, other models of helping may be superior. Given the complexity of the brain it is likely that only a prolonged and highly expensive research program has a chance of delivering benefits to patients. It makes economic let alone intellectual sense to broaden out the research budget to examine psychological and social factors properly which are likely to provide benefits to patients at lower cost. You can’t eliminate psychology from mental health and social factors are the biggest determinants of all health. Greater representation of psychologists and sociologist/ social workers on mental health research funding bodies along with more patients as it is their interests that should be paramount.

 Your view that framing issues fundamentally as social problems (vs medical problems) will lead to these issues being underfunded and inadequately addressed reflects a certain pessimism about our societal priorities, which is likely justified. However, I am also rather pessimistic about the notion that framing issues as health problems necessarily (or even in most cases) leads to social issues being addressed in a more satisfactory manner. My pessimism is based on what has happened with psychiatric disorders over the last 3 decades. We have seen billions of dollars invested in the development of pharmaceutical compounds and additional billions on neuroscience, but there has been very little investment in public health approaches. To borrow words from Allan Horwitz

, we have left untouched social structures that do not provide meaningful jobs, a decent living, or equitable social arrangements. I don't think biopsychosocial thinking has done much to rectify this situation just because the model is too eclectic to offer any meaningful guidance. I'd say we have a tremendous ethical imperative to ensure that medicalization is not hijacked by those who seek to profit from it. Yet, as far as I can tell, we have failed miserably in this regard.

 says we should make people aware of the important social factors that need addressed—not just politicians but the wider public. This is what public health does for many health problems. Psychiatrists such as Professor Rob Poole have written books on the importance of social factors on mental health. In my book I have a chapter on social factors and health. The Royal College of Psychiatrists does mention the importance of social issues in its commissioning advice. We could all do more though to raise awareness of the social dimensions of all health in the population generally. We can take the lead in this as psychiatrists as along with public health we are the medical specialty with greatest awareness of the importance of social factors. Now the US is a strange place where drug companies advertise directly to patients to turn them into consumers, which shouldn’t be allowed, and the US health system can almost be described as being criminal. Thirdly, we need to do more research on social factors and publicize the results. It must be said that even if we had this just society, more houses and so on, some people would still have mental illness and would benefit from treatment including medication.

We have had some personal correspondence regarding the use of the word “critical,” especially when it functions as a form of self-identification. I think there is much to learn from critical perspectives, and I have great respect for many critical psychiatrists and psychologists, such as 

, both of whom are past interviewees in my series. However, one of my goals through this series has also been to demonstrate the wide variety and the broad sources of critical perspectives within the profession, including from individuals who may not self-identify as being “critical.” What are your thoughts on the use of the term “critical” and what do you think of such efforts to adopt a broader understanding of what critical implies?

 The adoption of the term “critical” by a subset of opinions is problematic. I think it’s a “glamorous” term in academia especially the social sciences indicating a sort of rebellion with a self-image of protecting the vulnerable from an oppressive mainstream with Foucault as their idol (who was pretty ropey when it came to historical accuracy). As a viewpoint this school of thought is often highly skeptical of the role of “natural science techniques” in mental health but they haven’t come up with a better alternative method for discovering causes or evaluating effectiveness of treatments.

There are other views of what “critical” is. In medicine, critical appraisal is the means by which we examine how solid the evidence is for assertions such as the effectiveness of a treatment. We rarely have certainty, more often we have degrees of confidence. The techniques in critical appraisal are meant to be used in this way but are sometimes misemployed by some to bash treatments they don’t like (such as by setting unrealistically high thresholds and excluding evidence instead of saying the evidence is of a certain quality or lacks certain important features) whilst adopting the opposite attitude to approaches they favor. Another view of “critical” is the idea that one must be prepared to change beliefs if more accurate evidence or superior concepts are available, a critical attitude that is rarely enacted.

I think it’s important for everyone to be critical—of their own assertions and concepts as well as those of others. We can always do things better, listen better, think better. Our knowledge is uncertain, our concepts vague, our potential for pointless or even harmful interventions is great, awareness of implicit values guiding decisions is crucial and awareness of whether our involvement in people’s lives is warranted is needed on a case by case basis. There are plenty of legitimate and accurate critiques of psychiatry to be made without resorting to badly applied “critical” theories and hyper-skepticism about natural sciences.

Some critics, including some well-known psychopharmacologists, bring up the possibility that due to the development of oppositional tolerance there is a

 of patients with schizophrenia in whom the long-term use of antipsychotic medications can result in a chronification of illness and worse functioning? What do you think of this hypothesis?

 Firstly, it’s important to note that chronicity and frequent recurrence in psychosis has been noted in the pre-antipsychotic era. Secondly, there are two points here—one is the pathophysiological pathway you suggest and the other is a “black box” empirical observation. Dopamine super-sensitivity leading to relapse is a credible explanation for a biological mechanism for why people eventually relapse despite continued use of antipsychotics.

 I don’t think it’s a credible reason for inducing chronification in many as the dynamic response causing increased sensitivity to dopamine could also go in the opposite direction and we already know frequent recurrence occurred prior to the use of antipsychotics, too.

Of course, in some individuals it may well cause a chronic recurrent pattern that was never going to happen otherwise but the percentage of people in which this happens is unknown and based on my clinical experience it is probably a small percentage of people. In EIP I see people with low prolactin who are not in relapse as well as people with high prolactin who are in relapse (both the opposite of what would be predicted if dopamine super-sensitivity was the major reason for relapse). The counter of this is that dopamine super-sensitivity may be more of a problem for patients who have been treated for many years not the 3 years they are under EIP but usually I find many people have either an established relapsing pattern before the end of their 3 years with EIP or we have stopped antipsychotics and they seem ok but may relapse years later whilst off medication.

The “black box” empirical observation is that trying to stop antipsychotics after the first episode of psychosis has resolved and remained well for 6 months does seem to improve long term functioning in the Wunderink study.

 Leaving aside methodological issues (such as the stopping antipsychotics group seemed to have less people with schizophrenia which is associated with worse prognosis and it seems that the outcome assessments were not blinded to treatment group) the other point is that there weren’t major differences between the stopping medication group and continuing medication group in terms of average dose of antipsychotics and percentages of people who had managed to stop medication entirely by the end of the study. So it seems that stopping antipsychotics after the first episode is the best policy but I think stopping after 12 months is better than 6 months may be too soon and increase relapse risk. Sadly most people relapse and need to go back on antipsychotics but the lowest effective dose should be used to minimize negative effects on functioning. 

 suggests many people improve between 5 to 10 years so a trial of stopping medication—again at that point is a reasonable strategy. An American study in the 1960s randomized patients who had been on long term antipsychotics to another antipsychotic, placebo or barbiturate and noted that several patients in the placebo group did not relapse.

 The major issue is to use the minimum effective dose and to consider stopping medication gradually if there has been a sufficient relapse free period except if severe risks associated with relapse.

You write: “I disagree with location of dysfunction within the individual as the dysfunction may be located within their environment, including social network, or the actions of others causing an appropriate response, but individual factors may modify this response.” Can you elaborate on your thinking here?

Causation of medical problems in general can often be multifactorial and complex and mental health conditions tend to be exemplars of this. As for dysfunction specifically, well I’m not sold on there always being individual dysfunction being present. Let’s use the analogy of metabolic syndrome conditions—the blood pressure and blood sugar may be the expected response to the situation of the individual—their diet, level of activity, psychosocial situation and genetics—it is not a 

function but the expected function but accepted the consequences frequently associated may be harmful (atheroma, damaged eyes/kidneys, etc). Similarly, the emotional/ cognitive responses to stressors like bullying, sexual abuse and trauma may be expected and even adaptive in ways but some of the consequences may be harmful—high levels of distress suicide risk, substance use, and so on.

The assumption that the problem is always located within the individual may not always hold—if someone is experiencing bullying or other adverse stressors due to the actions of others and is distressed as a result is the dysfunction located within them or the people who are causing them the distress? To put it simply, the assumptions contained within the terms disorder or disease are not regarded as being true by many professionals for lots of the problems that are regarded as suitable for the attention of helping professionals (not just mental health problems) so I prefer the term condition which still sounds a bit “medical” but seems the least worse term as I take it to mean a state that is thought suitable for the attention of helping professionals.

The opinions expressed in the interviews are those of the participants and do not necessarily reflect the opinions of 

Dr Aftab is a psychiatrist in Cleveland, Ohio, and clinical assistant professor of psychiatry at Case Western Reserve University. He is a member of the executive council of Association for the Advancement of Philosophy and Psychiatry and 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 

Dr Aftab and Dr Huda have no relevant financial disclosures or conflicts of interest.

1. Tyrer P., Al Muderis O., & Gulbrandsen G. Distribution of case-load in community mental health teams. 

2. Aftab A, Waterman GS. Conceptual Competence in Psychiatry: Recommendations for Education and Training. Academic Psychiatry. 2020 [Epub ahead of print]. 

3. Howes OD, Kambeitz J, Kim E, et al. The nature of dopamine dysfunction in schizophrenia and what this means for treatment: Meta-analysis of imaging studies. 

4. Jauhar S, Nour MM, Veronese M, et al. A test of the transdiagnostic dopamine hypothesis of psychosis using positron emission tomographic imaging in bipolar affective disorder and schizophrenia. 

5. Friedlander E. Rudolf Virchow on pathology education. Accessed September 4, 2020. 

6. Horwitz AV. Transforming normality into pathology: the DSM and the outcomes of stressful social arrangements. 

7. Chouinard G, Jones BD. Neuroleptic-induced supersensitivity psychosis: Clinical and pharmacologic characteristics. 

8. Wunderink L, Nieboer RM, Wiersma D, et al. Recovery in remitted first-episode psychosis at 7 years of follow-up of an early dose reduction/discontinuation or maintenance treatment strategy: Long-term follow-up of a 2-year randomized clinical trial. 

9. Morgan C, Lappin J, Heslin M, et al. Reappraising the long-term course and outcome of psychotic disorders: The AESOP-10 study. 

10. Casey JF, Bennett IF, Lindley CJ, et al. Drug therapy in schizophrenia: Aa controlled study of the relative effectiveness of chlorpromazine, promazine, phenobarbital, and placebo. 

In this interview with Dr Aftab, Dr Huda discusses his views on the medical model in psychiatry, the misconceptions surrounding it, its strengths and limitations, and its relationship with other frameworks.

The Medical Model in Theory and Practice: Ahmed Samei Huda, MBChb, MSC

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.

Dr Lucy Johnstone is a consultant clinical psychologist in the UK. She is the former director of the Bristol Clinical Psychology Doctorate and was the lead author of “

Good Practice Guidelines on the Use of Psychological Formulation

” (Division of Clinical Psychology, 2011.) She has worked in adult mental health settings for many years, most recently in a service in South Wales. She is the author of 

A Straight-Talking Guide to Psychiatric Diagnosis

Formulation in Psychology and Psychotherapy: Making Sense of People's Problems

 (, 2nd edition, Routledge; 2013), along with a number of other chapters and articles taking a critical perspective on mental health theory and practice. She was lead author, along with Professor Mary Boyle, for the “

” (PTMF), a Division of Clinical Psychology-funded project to outline a conceptual alternative to psychiatric diagnosis. Dr Johnstone currently works as an independent trainer. Her particular interest and expertise is in the use of psychological formulation, in both its individual and team versions, and in promoting trauma-informed practice.

Dr Johnstone’s views on psychiatric diagnosis have attracted a great deal of attention and controversy over recent years, especially online on platforms such as Twitter. Such forums are not always ideal for debates that can arouse strong feelings, so I appreciate Dr Johnstone’s willingness to participate in this interview series, where we have a better opportunity for productive dissent, to chart the extent of disagreements, and to explore potential for common ground. For an interview series that is devoted to critical and philosophical perspectives, it would be an egregious omission if I did not engage with Dr Johnstone, given the emerging prominence of hers and similar views, particularly in the UK, and the support she and her colleagues have received from the Division of Clinical Psychology of the British Psychological Society. While the series has not shied away from engaging with controversy, featuring criticisms which might provoke substantial antipathy among some psychiatric readers is not without its challenges. As the interview makes clear, I am not a neutral participant here, and I come to the discussion with my own disagreements.

Formulation has a long history in psychiatry and psychology. It is an integral part of psychiatric training, both in the UK and the United States. It is intriguing to me that you envision formulation as an alternative to diagnosis, as a way of replacing it. I think most folks in psychiatry and psychology don’t see diagnosis and formulation as mutually exclusive, but rather as complementary and synergistic. In fact, many would argue good diagnostic practice requires diagnosis to be made in the context of a formulation. Why should we see diagnosis and formulation as competitors rather than allies?

 I have spent much of my career practicing, writing about and offering training in formulation. In the UK, formulation is the central plank of clinical psychologists’ training and subsequent work, whatever our specialty or general perspective. This is much less true of other professions in the UK, although it seems to be changing, as formulation is added to the core competencies of other professions as well.

There is a lively debate in the UK about whether formulation is an addition, or an alternative, to psychiatric diagnosis. (This debate does not apply in fields such as health psychology where clearly a medical diagnosis must form the basis of the formulation.) A significant number of clinical psychologists take the latter position. The Division of Clinical Psychology (DCP)’s “Good practice guidelines on the use of psychological formulation”

state that a best practice formulation “. . . is not premised on a functional psychiatric diagnosis (eg, schizophrenia, personality disorder),” whereas the Royal College of Psychiatrists

trainees to “. . . demonstrate the ability to construct formulations of patients’ problems that include appropriate differential diagnoses.” Individual members of each profession may take a different view, but we can see that there is a crucial difference between what the DCP Guidelines define as “‘psychiatric formulation’ as opposed to ‘psychological formulation.’” The first might look something like “schizophrenia triggered by life stresses and bereavement,” whereas the second might be summarized as “hearing hostile voices as a result of childhood sexual abuse.”

The argument for psychological formulation—or formulation as an alternative to diagnosis—is simple. A formulation is a hypothesis, drawing on the best evidence, and tailored for the particular client. If you have a reasonably complete hypothesis, based on someone’s life experiences and the sense they have made of them, about why they are having mood swings or feeling suicidal or self-injuring, then you don’t need another, competing hypothesis that says, “And it is also because you have bipolar disorder/clinical depression/borderline personality disorder.” Even if we think these are valid categories, the diagnosis is now redundant. In science, you test 1 hypothesis at a time, not a combination of 2. Moreover, these hypotheses are based on contradictory core messages: “You are experiencing an understandable reaction to your life circumstances” and “Your problems are the symptoms of a medical illness.” This is not just theoretically confused—in practice, it gives mixed messages to the client about causality, responsibility, and so on. As a psychologist working for many years with people in various extreme forms of distress, I have never drawn on diagnostic assumptions, and I have also been privileged to see how diagnostic language fades away when teams are offered alternative, formulation-based perspectives. The diagnostic way of thinking simply becomes irrelevant.

I don’t agree with you that a diagnosis is a causal hypothesis over and above a formulation, but I think this issue is indirectly related to some of the other questions I have to ask you. So, let’s carry on. A common refrain among critics seems to be that what we call mental disorders are understandable and normal responses to adverse psychosocial experiences. From your perspective, when it comes to the realm of the mind and behavior, is there such a thing as a “disordered” response to adversity at all? Is everything—no matter how bizarre, distressing, impairing, or irrational—“normal”?

A better word than “normal”—which has various different meanings—is “understandable.” For example, it is not statistically “normal” to believe that men in red cars are planning to kill you, and this belief may lead to levels of distress that are not “normal” as compared to most people’s, and to many difficulties in leading what we might call a “normal” life. However, a formulation-based approach starts from the belief that, as clinical psychologist Gillian Butler puts it, “. . . at some level it all makes sense.”

 The so-called paranoid belief about men in red cars stands for something, and it is meaningful in terms of the person’s past and present circumstances and the sense they have made of them. It is our primary task as mental health professionals to join service users in “a process of ongoing collaborative sense-making”

 which can usefully be summarized in a formulation. So yes, I agree that assuming we have excluded the rare organic causes of “bizarre, distressing, impairing, or irrational” responses, then the guiding principle of “At some level it all makes sense” applies. In fact, I can’t immediately think of anyone I’ve worked with for whom it did not, in the end, turn out to be true.

 I have 2 concerns with this. One is that “disorder” and “understandable” are not necessarily contradictory notions. For instance, what we call “PTSD” is certainly an “understandable” reaction to trauma, yet to say that 

is not a disorder because it is understandable would be to talk past the intended meaning of disorder. My second concern is related to falsifiability. Let’s say a person presents to you with obsessions and compulsions. You approach the person with the assumption that the obsessions and compulsions are meaningful in terms of the person’s past and present circumstances. How would you know if you are wrong? I think humans are very good at creative story-telling. We can come up with narratives where none may exist. So, what makes this process of sense-making 

Firstly, I would reject the “disorder” part of the label of PTSD. As we know, post-traumatic stress reactions are included in one of the two chapters of DSM

 now explicitly devoted to responses to psychosocial events and circumstances; indeed, biological causes are exclusion criteria. They do not, then, describe “disorders” in a medical sense, but natural responses to overwhelming circumstances. Echoing earlier editions of DSM, I would prefer the term “reaction” as in “post-traumatic stress reaction,” if we are to use this label at all.

The answer to your second question is, in principle, simple. As you say, a psychologist would work with such a person over a period of weeks or months to develop a shared formulation, or hypothesis, about the function and meaning of their intrusive thoughts or ritualising. Together you would plan an intervention based on that hypothesis. In other words, you would test the ideas out in practice, and amend them as necessary. That is what a hypothesis is for, and that is the heart of scientific practice. For example, if we both make a guess that the compulsion to check electrical plugs arose in the context of wanting to feel safe because an abusive ex-partner threatened to burn down the house (I am thinking of an actual client here), then we would hope that making those links, working through some of the traumatic memories, and finding other ways to feel safe, might reduce the need for checking, as well as addressing the core problem for which the checking was an attempted solution. If it didn’t, then we would need to revisit and revise our formulation.

I would add that therapeutic work is art as much as science. Such a formulation would be drawn from intuition, clinical experience, and empathy with the client’s story, as well as more formal evidence, and part of testing it out would be the client’s feeling that it “fits” at a gut level, and makes sense to them. But the process is also entirely defensible as scientific practice. Indeed, the reason we need formulation in mental health work is because diagnosis—which serves pretty well as the hypothesis in general medicine—does not do so in psychiatry. Thus, teams are essentially left floundering, switching from one non valid label to another, and trying out every drug in every combination available. This can continue for a lifetime.

 Do you advocate for a complete and total abolition of psychiatric diagnoses? Do you think formulation can perform all the pragmatic functions of diagnosis in clinical practice, in research, and for demonstrating efficacy of medications for purposes of regulatory approval?

Firstly, I’m not sure “abolition” is the right word. I believe we should use concepts that are evidence-based and jettison those that are not. I would hope this is not a controversial point. I follow your distinguished fellow countrymen such as Dr Allen Frances

 in agreeing that “there is no reason to believe that DSM-5 is safe or scientifically sound” and Dr Thomas Insel,

 who wrote that the weakness of the DSM is its lack of validity, and that patients deserve better.

Frances and Insel are optimists who think we will come up with a new, valid diagnostic system in the next decade or so, but meanwhile no responsible clinician should be uncritically using, or imposing, constructs that are known to have the same scientific status as “dropsy” or “railway spine” or “wandering womb” and that can have such devastating effects on people’s lives and identities. This is, I believe, a scandal. It is why I wrote, “A straight talking introduction to psychiatric diagnosis”

 so that people can make an informed choice about whether they wish to take on these labels and identities.

Secondly—formulation is obviously not suitable for all the purposes currently served by diagnosis, but nor is diagnosis. Again, this follows logically from the admitted fact that psychiatric diagnoses are not valid scientific categories—which is why, for example, the National Institute of Mental Health (NIMH) 

it would be “re-orienting its research away from DSM categories”

 and using what they call transdiagnostic constructs instead. That is 1 alternative. Simple descriptive terms, such as hearing voices or experiencing panic/low mood, can often serve clinical and administrative purposes. There are many other possible ways forward that do not rely on diagnostic categories, some of which we have discussed in Chapter 8 of the 

I think it serves a rhetorical purpose to compare the scientific status of contemporary psychiatric diagnoses to "wandering womb" but bears little resemblance to reality. An analogy would be if I said that psychological explanations have the same scientific status as the notion of "schizophrenogenic mother." Neither examples are very charitable. You bring up Dr Insel, but perhaps you don't appreciate that the notion of validity that Insel is referring to is such that nothing in the “psy” professions has achieved that. The sort of validity that he talks about, psychological formulations are likely to be even worse than psychiatric diagnoses in capturing that. Allen Frances has had concerns about DSM-5 which he has articulated very well, but he is certainly not a skeptic about diagnoses. He sees them as immensely useful constructs. And by Dr Frances’ standards, even British Psychological Society (BPS) has not fared well, as he has 

BPS's approach to psychosis as, “All very pie-in-the sky stuff with no real-world foundation.”

 has discussed it very well in his work—and most clinicians, including psychologists, intuitively understand that clinical work and scientific work differ in important ways. I think its disingenuous to argue that psychiatric diagnoses are not valid with respect to a certain scientific standard but then not apply that same standard to psychological formulations. Are you aware of any scientific evidence that demonstrates that psychological formulations have greater validity based on the scientific standards by which we judge psychiatric diagnoses?

We might have to disagree about my analogies. Whether or not they are “charitable” (and by the way I don’t accept the construct of “schizophrenogenic mothers” either), they are accurate. We have talked about the scientific method. In science, it is understood that constructs routinely have to be revised and abandoned in favor of more accurate ones. As one of the UK’s most senior psychiatrists, Robin Murray

, puts it, “I expect to see the end of the concept of schizophrenia soon . . . The term schizophrenia will be confined to history, like ‘dropsy.’” In Biblical times, people believed that madness was caused by evil spirits. No one could actually see them, but everyone was sure they were there. Diagnoses like “wandering womb” or more currently “schizophrenia” are based on exactly the same logic. There are no bodily signs to confirm or disconfirm their presence, but we are convinced we’ll find them someday. This is purely a matter of faith, and it flies in the face of the mountain of evidence for psychosocial causal factors in all forms of mental distress.

As I said above, I am aware that Allen Frances is not a skeptic about diagnoses in general. His position seems to be: The ones we have are entirely wrong, but they are better than nothing, and new, valid systems will be along in a decade or so. In the meantime, we have an entire branch of medicine based on the unproven theory that what are called “functional psychiatric disorders” are best understood as medical illnesses. I don’t think that is a defensible position, especially when these labels are presented to patients as facts. Nor do I agree with Dr Frances’ determination to dismiss the BPS document “Understanding Psychosis,” to which I contributed, as “psychosocial reductionism.” It isn’t, and nor has he been able to produce an example of anyone who takes such a position; the document contains a very careful, inclusive consideration of the biological aspects of what we might call “psychosis.” Far from being “pie in the sky,” it is solidly based in the best clinical practice of leading UK clinicians, supported by recovered service users themselves. I’ve had these debates with him.

 “Understanding psychosis” was welcomed by the 2 most senior UK psychiatrists, one of whom said he wished his own profession had written it. There seems to be a real trans-Atlantic difference here. I can’t quite account for it, but it is an interesting topic in its own right.

I am familiar with these criticisms of psychological formulation. As I said above, a psychological formulation is a hypothesis. The statement that “psychological formulations are not valid” makes no sense. It is like saying “Hypotheses about the origins and meanings of people’s distress are not valid.” Hypotheses cannot be declared globally “not valid.” A particular formulation, or hypothesis, might turn out to be mistaken, of course, and that is why we test it out in practice and modify it accordingly, as I described above. Having said that, psychological formulation is not in a head-to-head competition with diagnosis for scientific status. It is based on a completely different paradigm—one that is meaning and narrative-based, as opposed to a natural science one. This was our starting point for the Power Threat Meaning Framework.

 Your understanding of psychiatric diagnosis seems to be restricted to a rather specific biomedical understanding of diagnosis, in which the diagnosis is incompatible with meaning and agency and ignores personal and social context. That is certainly one way of understanding psychiatric diagnosis, but not the only way. Many in the psychiatric field have criticized such understanding of psychiatric diagnosis and have articulated versions of psychiatric diagnosis which are compatible with meaning and agency, and with psychosocial context. You can find such philosophical accounts in the works of Paul McHugh, John Sadler, and Derek Bolton, to name a few. I can see why you are against the stereotypical biomedical understanding of diagnosis, but have you had any engagement with some of the more philosophically sophisticated accounts?

I think much of this writing misses the point. We may be able to come up with all kinds of cleverly nuanced perspectives on how we, as professionals and philosophers, understand psychiatric diagnosis, but the fact remains that people are being told they have mental illnesses and disorders, with all the usual connotations of those terms in Western societies. Moreover, they are heavily encouraged to take on the particular narrow understanding that you refer to—we are all bombarded with messages about “mental illness” being “as real as a broken arm”, and needing to be managed by drugs “just like diabetes.” Even the dubious compromise that is the “biopsychosocial” model—a way of acknowledging some role for psychosocial factors while at the same time instantly relegating them to “triggers” of a disease process—is not much in evidence on the ground. And furthermore, the biomedical message is reinforced by the fact that these labels are applied by doctors and nurses, working in hospitals and clinics, who use not just the labels themselves but the whole medicalized discourse of symptom, patient, prognosis, treatment, relapse, and so. The “stereotypical biomedical understanding of diagnosis” as you put it, is absolutely everywhere. In the PTMF, we argue that this leads to epistemic injustice

—in other words, people are systematically denied the knowledge that they need in order to create their own meanings about their experiences.

I do get a bit impatient with these abstract debates. I have yet to hear any real life service user say, “Although the doctor told me I have schizophrenia I’m not too worried, because ‘illness’ is really being used as a metaphor for suffering in this case and it doesn’t exclude personal meaning.” I am sure readers are aware that the consequences of being diagnosed—such as being sectioned, forcibly injected, and so on—are not just metaphorical. Some of these learned articles strike me as a form of defense against admitting to the fundamental inadequacy and devastating damage of the current diagnostic system. Essentially, we need to acknowledge that we are not dealing with patients with illnesses, but people with problems. We cannot make the necessary shift to a more appropriate and humane system unless we are prepared to drop the whole biomedical discourse altogether.

 I don’t think these are abstract debates. Clearly there is a lot wrong with the popular perception of what a diagnosis entails, and I believe we need tremendous effort to counter that. Yet, if all you’ve criticized is a widespread stereotype, then you have been engaging in a certain sense with a strawman. Sure, your arguments work well if you are trying to convince the public or convince professionals who don’t have a nuanced understanding of these things, but if your goal is to engage with thoughtful psychiatrists and psychologists, then this is not sufficient by any means. I’ve already mentioned Allen Frances. Kenneth Kendler, who is the vice chair of the American Psychiatric Association DSM Steering Committee, has done excellent work over the past 2 decades in outlining what our best understanding of psychiatric diagnoses should be. You don’t seem to consider the possibility that popular understanding of psychiatric diagnoses may simply be caricatures—caricatures that you may be inadvertently reinforcing yourself by presenting them as the “real thing.”

My primary goal—and that of other colleagues and allies, both professional and service user—is to work towards a non-medical understanding of emotional suffering, which is actually what we mean by “mental illness.” We do this on the basis that there is not, and never has been, any hard evidence that the experiences we call “mental illness/disorder” are best understood in this way, while there is an overwhelming amount of evidence that they arise within, and can be understood as a response to, psychosocial adversities of all kinds. The dominance of the diagnostic viewpoint blinds us to the extent to which non-medical alternatives are already flourishing. We have described some of them in the Appendices of the PTMF Overview. For example, we have Open Dialogue, the Hearing Voices Network, and many courageous survivor campaigners—including Jacqui Dillon and Eleanor Longden, co-authors of the PTMF—who recovered only by leaving psychiatry behind.

I realize this places me in the second of the 2 camps, under the so-called heading of “antipsychiatry,” as described by Ronald Pies in your 

In this interview, Dr Aftab and Dr Johnstone discuss her criticisms of psychiatric diagnosis and her approach to psychological formulation as a conceptual alternative to diagnosis. 

Author | Awais Aftab, MD

Articles

Psychiatry’s Intellectual Crisis: Giovanni Fava, MD

The Medical Model in Theory and Practice: Ahmed Samei Huda, MBChb, MSC

Moving Beyond Psychiatric Diagnosis: Lucy Johnstone, PsyD

Psychoanalysis and the Re-Enchantment of Psychiatry: Jonathan Shedler, PhD

The Many Histories of Biological Psychiatry: Anne Harrington, DPhil

Reflections in Times of Crisis

The Battle for the Soul of Psychiatry: Ronald W. Pies, MD

Weaving Conceptual and Empirical Work in Psychiatry: Kenneth S. Kendler, MD

Psychiatric Disorders as an Imperfect Community: Peter Zachar, PhD

Psychiatry and the Human Condition: Joanna Moncrieff, MD