Awais Aftab, MD

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.

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

” 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

 Editorial Board. He can be reached at 

Articles

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 became a founding text of the movement, which rallied around Singer’s concept as well as existing themes from disability studies.

The term neurodiversity paradigm was proposed later, in 2012, by autistic scholar Nick Walker, PhD (she/her),

 who was also a graduate student at the time. By then the ideas initially developed by Singer were increasingly being adopted by individuals with other diagnoses such as bipolar, dyspraxia, and 

 (ADHD). Walker was interested in the philosophical implications of this broader application and how it challenged theoretical assumptions and cultural and scientific practices. Walker proposed a distinction between the pathology paradigm, which she took to be dominant and to rest on a relatively restricted conception of neurological, cognitive, and developmental normality, and the emerging neurodiversity paradigm, which begins from the acknowledgement that neurological diversity is natural and beneficial for the cognitive and cultural richness of the species. On this paradigm, instead of being labeled medically normal or abnormal, those who are more enabled in a given society are considered more neurotypical, while those who diverge further from functional norms are more neurodivergent. Walker argued that developing and cultivating such a paradigm shift, to then be adopted for research, policy, and practice, would be necessary for the long-term emancipation and well-being of neurodivergent individuals. Although Singer’s chapter was relatively brief, it became highly influential within the movement, and I count it as another of the seminal texts of neurodiversity theory.

This article was formatted for print. To read the full interview, please see 

The Neurodiversity Paradigm in Psychiatry: Robert Chapman, PhD

 You have talked about neurodiversity as a sociopolitical idea, centered around social models of disability, as well as neurodiversity as a scientific concept, offering a new way of thinking about function and dysfunction. Can you elaborate on these strands of 

 (among other strands) and the shape they have taken in your own work?

 I see the cultural paradigm shift as quite similar to the change we have been seeing regarding the 

, away from pathologization and toward pride, acceptance, and inclusion. The neurodiversity movement is also part of the broader disability rights and justice movement. With neurodiversity, while there is a long way to go, we are already seeing, for instance, neurodiversity paradigm vocabularies being used in newspapers and magazines and a shift to disability rights-based practices for neurodivergent individuals in schools and workplaces.

Accompanying this, a scientific paradigm has also been emerging, albeit in a somewhat piecemeal way. More neurodivergent individuals have become involved in research, and more neurotypical researchers have begun to listen to neurodivergent perspectives. This is beginning to change how researchers formulate hypotheses and produce knowledge. Among other things, researchers increasingly recognize neurodivergent strengths alongside limitations, study cognitive problems as relational rather than as arising from individual deficits, and view neurodivergent disablement and distress based on a social model of disability rather than a medical model.

In my own work, I developed the ecological model of functioning to help clarify and formalize the theoretical basis of the emerging shift in the scientific paradigm and to challenge the default pathologization of neurodivergence. I became interested in developing a new model of mental functioning partly because neurodiversity proponents had long been (successfully) using the social model of disability, and yet many researchers were still dismissing the idea that things like autism were not pathological. I realized that this was, at least in part, because the social model of disability leaves the dominant notion of individual dysfunction or impairment relatively intact, which is important because individual dysfunction is a core part of the definition of mental disorder (or of somatic disorder for that matter). As such, even the most successful application of the social model, while vital in other ways, is insufficient for undermining the ascription of neurological or mental illness, disorder, or pathology. After all, we can and do use social model interventions for things everyone agrees are genuine pathologies, such as 

. Thus, I realized we needed an alternative model of functioning to augment alternative models of disablement and to help shift the paradigm.

Traditionally mental functions and dysfunctions have been determined through what I call “individualist comparativist” models, which compare all individuals to an aggregated norm and then rank them in levels of functioning. These models—which I date to Darwin’s half-cousin, the eugenicist Francis Galton—seek to be continuous with the kind of evolutionary biology that focuses on individual fitness or adaption, and they thus rank fitness levels from highest to lowest in members of a population. If we accept these models, then it seems like an objective fact that members of low-ranked groups such as autistics and dyspraxics are naturally dysfunctional, and hence pathological, in comparison to neurotypicals—even if the social model can be helpful for alleviating disablement. The continued use of these models reifies neurodivergent disablement as natural fact and also lends scientific authority to the normalization of neurodivergence.

By contrast, the ecological model, as the name indicates, is more influenced by how ecologists talk about functioning. Ecologists tend to be less interested in ranking individual fitness levels and more interested in how broader systems function as a whole, how functions emerge from the relations between organisms, and how the dominance of some forms of organisms can be harmful for the functioning of others. Bearing this in mind, in my article I drew on theoretical and empirical research to argue that many neurodivergent functions, or relational functions that emerge from group neurodiversity, are overlooked on the traditional models.

 To avoid these problems, I then combined the arguments of neurodiversity proponents with ecological functional models to propose a preliminary ecological model in line with Walker’s call for a paradigm shift. To the extent this proves to be useful for researchers, I hope it will help with the scientific paradigm shift by orienting researchers toward asking different questions, formulating different hypotheses, and ultimately producing knowledge that helps us move beyond the default pathologizing of neurodivergent disability, and which supports a broadly conservationist approach to neurodiversity.

 How does your ecological model of mental functions play out within psychiatry and in the context of existing philosophical debates about neuropsychiatric dysfunction?

It may be helpful to look at this historically. The modern debate could be dated to the 1960s, when the antipsychiatrist 

, argued that mental illness was a myth and that psychiatry was a pseudoscience. Szasz was happy to acknowledge that neurological illnesses exist. But he nonetheless held that there could be no mental illnesses, since for him, an illness must be biological (including neurological) by definition. The Szaszian position, while challenging the pathologization of emotional distress, is entirely continuous with the Galtonian project of ranking neurocognitive functions in relation to an assumed norm. This challenged the psychoanalytic psychiatry of the time, which was not based on biological research, and pushed psychiatry toward the more biocentric and cognitivist models that are still used today. While this argument still has some influence, contemporary psychiatry has largely neutralized Szasz’s critique not just by analyzing the conceptual flaws of his arguments, but also by finding ample evidence that biological processes in some form or another, though they may not take the form of discrete dysfunctions, are part of the story for many conditions listed as mental disorders. In many ways contemporary psychiatry has thus become more Szaszian, although nobody likes to admit that.

By contrast, while they have some surface overlap with Szasz in that they challenge pathologization, the neurodiversity perspective and my ecological model present a novel philosophical position that is equally at odds with mainstream psychiatry and the Szaszian tradition (including its various offshoots within critical psychiatry). At base, the ecological model rejects the assumption that humans have enough neurocognitive uniformity across the species that legitimizes the notions of normal neurological functioning. Instead, my model begins with the acknowledgement that we are a neurologically diverse species, and the insight that neurocognitive functions and dysfunctions are (at least in significant part) relationally produced and upheld, both between different minds and between mind and environment. It is not just that cognitive niche construction enables or disables different forms of functioning; it is also that a trait associated with individual disability may contribute to functioning at the group level, while a trait associated with individual ability may contribute to maladaptive group functioning. So things are a lot more complex than being normal or abnormal.

Part of the significance of adopting this model is that we recognize more neurodivergent mental functions, and that many dysfunctions are relational, often stemming in part from the neurotypical side, rather than being intrinsic to neurodivergent individuals. Simultaneously, by incorporating a social model analysis of cognitive niche construction, this also allows us to shift to viewing neurodivergent abilities as forms of marginalized functioning rather than inherent dysfunction. 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, while fully acknowledging the fact of neurodivergent disablement. Moreover, unlike the Szaszian critique of psychiatric pathologization, this model is compatible with disability justice more broadly because it applies equally to learning and cognitive disabilities and neurodevelopmental disabilities, instead of reinforcing their pathologization. More concretely, I thus hope the model will help reorient the surrounding biopolitics away from the normalizing tendencies developed by 19th-century eugenicists and toward a conservationist approach to studying and supporting human neurodiversity.

A common objection that is raised against neurodiversity is that the framework applies poorly to individuals who are severely disabled, have high support needs, and may live in specialized settings. Given that this may be on the minds of many readers as well, I think it is worth bringing up here.

 This is a very important question on a complex topic. I will restrict myself to a pair of key points. First, the form of neurodiversity that I, and I believe most proponents, endorse does not deny that there are different forms of disability, and that in some cases much more direct support is needed (even if we have critiqued the utility of terms like severe or high-functioning). In fact, the clear implication of adopting social models of disability (not to mention my ecological model of functioning) would be that individuals with more complex disabilities should get more support, not less.

A key point of contention, of course, regards whether we prefer to see complex disabilities more as mental pathologies to be treated or marginalized minorities to be supported. This brings me to my second point. Because my approach to neurodiversity is based on a disability justice perspective, it relies more on standpoint epistemology, centering the lived experience of marginalized individuals or groups. My own view, then, is that we need to do more to center the voices of those with intersecting disabilities and high support needs when talking about those who sit at the same intersections.

 At the moment, we have no data on the views of those considered severe on such topics. Interestingly, though, just looking through texts written by nonverbal autistics with intersecting disabilities and high support needs, it is quite easy to find many who hold views consistent with the neurodiversity perspective, as I have written about previously.

 Indeed, some of the most influential neurodiversity proponents, notably the late Mel Baggs, were labeled severe and had high support needs. So we cannot assume that everyone with higher support needs would reject the neurodiversity perspective. My hope is that empirical researchers will, where possible, survey the preferences of those with high support needs in a more systematic way. As a philosopher I do not have the right resources to do that kind of research, but I can say I think that should be the starting point of any conversation on this.

 What hopes do you have for the future of neurodiversity theory and practice?

 I am excited about how neurodiversity theory and neurodiversity studies have been coming on in leaps and bounds over the past few years especially. This has been led by grassroots advocates and has been strengthened more recently because of a concentrated effort of neurodivergent people to train in a variety of fields to further develop the paradigm. But there is still a lot of work to do and there are a lot of problems and barriers we are facing. One thing I often worry about is how the vocabularies of neurodiversity are being co-opted by already established neurotypical clinicians, researchers, corporations, and so forth in ways that function to uphold rather than challenge the status quo. Many of the leading pathology paradigm theorists of autism have now rebranded themselves as neurodiversity advocates without giving up on their harmful, pathology paradigm theories and commitments. My hope is that the more radical, liberatory aspects of the movement will prevail.

This brings me to a second point, which regards my hopes for institutional support. I hope educational and research institutions will make meaningful moves to support neurodivergent neurodiversity researchers. By the end of the decade, I hope to see universities establish neurodiversity research centers, neurodiversity studies degrees, and neurodiversity studies lectureships. I would also like to see neurodiversity theory modules increasingly included in clinical training, not to mention in humanities and social science degrees.

Finally, within the neurodiversity movement, there are still remnants of the pathology paradigm that I think need to be overcome. For instance, some neurodiversity proponents still see neurotypes as natural kinds with timeless biological essences. I hope we can overcome this kind of biological essentialism since it is theoretically untenable and contributes to a lot of needlessly toxic discourse.

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

 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 Chapman have no relevant financial disclosures or conflicts of interest.

1. Singer J. “Why can’t you be normal for once in your life?” From a “problem with no name” to the emergence of a new category of difference. In: Corker M, French S, eds. 

2. Walker N. Throw away the master’s tools: liberating ourselves from the pathology paradigm. In: Bascombe J, ed. 

. Autistic Self Advocacy Network; 2012:225–237.

Neurodiversity and the social ecology of mental functions. 

4. Chapman R. Multiply-disabled autism and intersectional feminism. 

 September 2, 2019. Accessed September 21, 2021. 

https://www.psychologytoday.com/gb/blog/neurodiverse-age/201909/multiply-disabled-autism-and-intersectional-feminism

5. Chapman R. Are the voices of the “severely” autistic being silenced? 

 September 10, 2019. Accessed September 21, 2019. 

https://www.psychologytoday.com/gb/blog/neurodiverse-age/201909/are-the-voices-the-severely-autistic-being-silenced

“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...”

Neurodiversity and the Social Ecology of Disability

Sami Timimi, MD, is a consultant child and adolescent psychiatrist in the National Health Service of the United Kingdom (UK) and a visiting professor of child psychiatry and mental health improvement at the University of Lincoln, UK. He has authored, coauthored, and coedited several books, including his latest, 

. Dr Timimi is among the fiercest critics of psychiatric diagnoses and the medical model in psychiatry, especially child psychiatry. He is a prominent voice of British critical psychiatry, and over the years he and his colleagues have argued that psychiatric conditions in their very nature reach beyond the brain to involve sociocultural dimensions and cannot be adequately understood through the epistemology of biomedicine.

 Dr Timimi’s sweeping critique of and divergence from mainstream views is also illustrated in a 2018 debate with David Foreman, MD, in the 

 on the validity of attention-deficit/hyperactivity disorder (ADHD) as a diagnostic construct.

Your critique of current psychiatric thinking and practices touches on so many conceptual and philosophical issues, that I worry that it would be too easy to get mired in disagreements about abstract questions regarding the nature and goals of psychiatric classification or the medical model. Let’s begin with clinical practice: How would you approach the assessment and management of a child who with a pervasive and persistent pattern of inattention and hyperactivity?

First, many thanks for inviting me to be a part of your conversation series. It is so important for us to continue a discussion on the problems with, and alternatives to, dominant models. I hear the concern in your first question, but I do not think the conceptual and philosophical issues can be separated from clinical ones. How we imagine what we are dealing with, particularly if we are imbued with cultural meaning–making power, has a massive impact on what we show interest in clinically, what questions we ask, what interventions we make, and what impression our patients are given about what is happening in their lives.

This means the question you ask already sends us crashing against the shores of social construction. What do you (or this mythical family) mean by pervasive, persistent, inattention, and hyperactivity, and why have these bits of behavior been brought to the clinical foreground? If, like me, your clinical practice understands that what we do in psychiatry is essentially provide a new story about the stories our patients, or parents, might tell, then we cannot escape the interpretive nature of how we construct our story about them. After all, we have no recourse independent of subjective opinion empirical evidence.

I would be more interested in knowing their broader narrative. What has happened in that child’s and family’s life? Like the vast majority of those who end up in my clinics, many children who present like this have had more than their fair share of adversity. What are the child’s strengths and existing skills? If there were a mythical perfect treatment, what would they like to see change: school? home? relationships? Who is it—parents, teachers, child themselves—who most wants to see what sort of change? A 1-acronym formulation, such as 

, has powerful consequences. It acts as a hypnotic suggestion on those around the child and influences what they might view as important. It has the potential to obscure, or at least render as secondary, the things that might bolster the child’s esteem and the parent’s sense of empowerment.

Psychiatry and the Shores of Social Construction: Sami Timimi, MD

I may choose an alternative label such as the child is “intense.” They engage with the world with an emotional intensity that provokes powerful emotions in those around them. We could see this as a gift that needs understanding, guidance, and nurturing, rather than using a label that views their behaviors as symptoms that need suppressing. With the cultural pressure to diagnose and medicate, this is not always easy, but maybe easier than we realize.

 Yes, I do not think either conceptual or philosophical issues can be separated from clinical ones—something I strongly try to convey to my trainees as well as colleagues! My hope was that by looking at how our clinical approach is informed by these issues, we may be better able to appreciate your views. And your response is very helpful in this regard. As you mention, you are not a fan of psychiatric diagnoses and you have criticized them extensively. From my perspective, one of the things psychiatric classifications do is to serve a sort of pragmatic function, which allows researchers to conduct studies about causes and treatments and allows clinicians to link the individual in front of them with the existing body of knowledge related to causes and treatments. For instance, the ADHD construct allows clinicians to capitalize on the literature related to stimulant medications. The short-term efficacy of stimulant medications for individuals who meet criteria for ADHD is so robust—and universally endorsed by practice guidelines—that it would be considered below the standard of care not to discuss them as a treatment option for individuals who could benefit from them. However, it is hard for me to imagine how we can determine who could benefit from 

 if we were not making diagnostic distinctions, at the very least in our head—for instance, differentiating between anxiety syndrome vs inattention-hyperactivity syndrome. This does not necessitate that we are forced to consider these diagnoses as natural kinds or as neurobiological disease entities; it only means that we recognize them, at minimum, as pragmatic constructs, more or less helpful given our goals. What is your view on how clinicians and researchers can carry out their pragmatic functions of research and treatment?

 These are great questions, but we need more than this interview to properly unpack them; nevertheless, I will have a go. First, there is an important difference between psychiatric diagnosis and a psychiatric classification. There are many different classification systems, with diagnosis being a particular system based on classification by cause (at least proximal cause). This is why your statement that diagnosis “allows clinicians to link the person in front of them with the existing body of knowledge related to causes and treatments” works when it is shedding light on cause and therefore the development of treatment technologies that address cause, but it does not work when the system of classification is unable to identify, or get close to identifying, proximal causes. Worse, calling it diagnosis leads to (an understandable) assumption that cause and therefore evidence-based useful treatments are known/knowable. Because what we call psychiatric diagnosis is not diagnosis, in that technical sense. Thinking that it is has led to practice that is skewed and patient expectations that are unrealistic.

What about making pragmatic decisions? I do not agree that the construct of 

 allows clinicians to capitalize on the literature for stimulants, for example. It makes them imagine they can, which is far more dangerous. Thus, we end up with vested interests shaping guidelines, which then influence public perception and media reports, and distort doctors’ practice. The result has been catastrophic mass prescribing of stimulants to children and equally catastrophic convincing of children and their caregivers that they have a hardwired condition that makes them incapable of doing certain things and requires that they ingest the same substance that we warn adults about its profound dangers.

 has been known for a long time and is no different if you get the label of ADHD or not. Decades ago, studies found that if you take them, regardless of diagnosis, it improves your ability, in the short term at least, to maintain task concentration. So that is the danger of imagining these are pragmatic groupings: It embeds and reifies ideas, turning an imagined entity into an assumed concrete reality, which when done without realizing that this is what you are doing, has the potential for unhealthy consequences to individuals, the profession, and our culture more broadly.

You have talked about the “McDonaldization” of child development, where the difficulties of growing up are categorized neatly and then addressed with quick fixes. You have also talked about psychiatric diagnoses functioning as “brands” that are sold to consumers and generate lucrative markets around them. Can you tell us more about what you mean by this?

Trauma and the Politics of Diagnosis: Janice Haaken, PhD

 refers to the way the challenges and uncertainties connected with growing up are placed into neat categories of things wrong with individual children, which can then be fixed with simple, one-size-fits-all interventions. A market economy and culture preys on our desire for the here-and-now satisfaction of our cravings, provided in a fast manner that requires little engagement with the product beyond its consumption. Get your products and messaging right, and you can entice your consumers when they are still young and then have them as potential customers for life. McDonaldization is just a more culturally familiar reference to the process of commodification—in other words, the process of turning something into an object of economic value. Commodification’s overriding value is making money. In this arena, you need to convince a population that all manner of experiences may lead to unpleasant and dangerous consequences if not identified and remedied with your products (a diagnosis, a book, a medication, a therapy, a course, a supplement, etc).

You have argued that the current system of mental health care alienates individuals from the meaning inherent in their own emotional difficulties, undermines their capacities for everyday 

, and by doing so, perpetuates those very difficulties. Can you elaborate on how you think this process of alienation unfolds?

The labeling of our experiences with medicalized language (diagnosis, symptoms, disorder, dysfunction, dysregulation, etc) has spread far and wide. My kids and their friends talk about feeling “depressed,” a medical word. It entrenches a fear of, and alienation from, an appreciation of the ordinariness and understandability of a panoply of human emotional experiences. When we place our emotional experiences in a problematizing framework, we extract the everyday meanings these have and become worried that there is something wrong in us beyond our capacity to comprehend. 

 campaigns have made this dynamic worse. Far from normalizing the diversity of our emotional experiences and helping create an awareness of the variety of reactions to all the things that happen in our life being ordinary and/or understandable, even in those more extreme states, we have instead made more individuals suspicious that their experiences are a signal that there is something deeply wrong in them.

These medicalized frames also undermine our natural resilience, sensitize us to an idea of our vulnerability, and encourage us to transfer our agency to practitioners who are assumed to have some special knowledge about our experiences that we cannot possess.

Medical colonialism—of language and the concepts that flow from this—means that we do not have any other strong culturally available model for emotions beyond banal mechanical ones. As a result, we fear, and are fascinated by, displays of emotions, and we easily slide into an idea that individuals need help to learn how to control and manage how they feel. To me, one of the worst phrases to emerge in modernist mental health practice is the oxymoronic “emotionally dysregulated.” The aspired to neoliberal entrepreneurial individual has to learn how to nourish their ego and use their thoughts to control their emotions. There are too few resources in medicalized Western cultures for learning how to sit with, experience, withstand, and understand emotions as important forces for action and connection. We have imbued our emotional life with a destructive power more than a liberatory one.

 Given that mental health is a multidisciplinary area, a professional space shared by psychiatrists, primary care physicians/general practitioners, psychologists, and social workers, among others, what are your thoughts on the relationship between these disciplines? How would you like this professional space to be reorganized? In what areas should psychiatry be at the forefront and in what areas should it take a backseat and let other professions take the lead?

 It is sad that psychiatrists have been pushed into being primarily viewed as the prescribers in mental health services. Our representative institutions and academics have been complicit in this. The flimsy appeal that our models and practices are biopsychosocial—apart from not really knowing what this looks like in practice—is a smokescreen to what much of practice as a psychiatrist has become.

I consider myself a traditional child psychiatrist. My first placement in child psychiatry in the early 1990s was in a children’s hospital in London. The lead consultant worked in collaboration with the other professionals and the team used primarily systemic models. We had access to 2 beds for in-patients and, as well as outpatient work, we carried out consultation on cases requested by the pediatricians. In those 9 months, I prescribed medication to only 1 individual, and beyond broad formulations, the idea of a diagnosis was nowhere. It all made sense to me and persuaded me that this was the career for me. I felt that child psychiatry’s gift to medicine was understanding that there was a context to individuals’ suffering—they existed in systems of support and meaning—and to the idea of development—that life is dynamic and changes.

As I undertook the 4-year training to become a consultant, I saw, with concern, the tide of 

 sweep across the Atlantic from the United States. It gradually colonized our curriculums.

Potentially, psychiatrists are the only mental health practitioners who can do it all, from prescribing to therapy. We also ought to be
able to identify organic conditions that may cause psychological problems as well as the organic complications that arise from psychological challenges, such as eating issues. If we live up to our promise, we should be leaders in mental health services, helping bring other professions along, as well as not being afraid of becoming embroiled in the politics and politicization of services. If we do not seriously reform and reconnect with our wider roots as a profession (most psychotherapies were originally developed by doctors), which, for example, had historically strong relationships with disciplines such as anthropology, then there are plenty who would come and rightfully take our place. This would be a great loss to the task of humanizing medicine.

The opinions expressed are those of the participants and do not necessarily reflect the opinions of Psychiatric Times™.

is a psychiatrist in Ohio, and clinical assistant professor of psychiatry at Case Western Reserve University. He is a member of the executive council of the 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 

1. Bracken P, Thomas P, Timimi S, et al. 

2. Foreman DM, Timimi S. Attention-deficit hyperactivity disorder (ADHD): progress and controversy in diagnosis and treatment. 

3. Timimi S. Rebuttal to Foreman’s article ‘Attention-deficit hyperactivity disorder (ADHD): progress and controversy in diagnosis and treatment.’ 

Insane Medicine: How the Mental Health Industry Creates Damaging Treatment Traps and How You Can Escape Them.

Sami Timimi, MD, shares his thoughts on alienation and ADHD, and what role current systems of mental health play.

Upon the Shores of Social Construction

Wouter Kusters, PhD, is a Dutch linguist and philosopher. He is the author of 

; Lemniscaat; 2014). An English translation of 

 was published in 2020 by MIT Press with the title 

A Philosophy of Madness: The Experience of Psychotic Thinking

 (translated by Nancy Forest-Flier). Kusters works as an independent researcher, writer, teacher, and consultant in Gouda, Netherlands. For details, readers can explore his website at: 

 was based on Kusters’ own experience of a psychotic episode in 1987. It won a pair of important prizes in the Netherlands: the Van Helsdingen Award (2004) for the best work on the intersection of philosophy and psychiatry, and the Socrates Award (2005) for the best and most inspiring Dutch philosophy book of the year. After the publication of this book, Kusters made a professional switch, turning from academic linguistics to a career as an independent writer and researcher. He started studying again as an undergraduate philosophy student, during which time he published his second book on psychosis, 

 (Lemniscaat; 2007). Shortly afterward, in the summer of 2007, he experienced his second episode of psychosis, which led to a psychiatric hospitalization, and this provided further impetus for him to continue his work on philosophy and madness. He finished his master’s thesis in philosophy in 2010, which formed the basis of an updated version of 

; Lemniscaat; 2014. His books were a success in the Netherlands and met with widespread acclaim. The publication of the English translation of 

; MIT Press; 2020) has brought his work to the attention of the English-speaking world, and it has prompted a renewed debate on philosophical and phenomenological perspectives on psychosis as well as the relationship between philosophy and psychosis.

 I think it would be prudent for us to begin with at least a few words regarding the nature of inquiry you are undertaking in A Philosophy of Madness, and how that relates to your own experiences of psychosis.

 My book is a philosophical treatise in the tradition of Montaigne’s 

; in the vein of Nietzsche’s and Kierkegaard’s approaches to thought, writing, and life; and with affinities to the early works of the French existentialists, Sartre and Camus. What brings these works together is the focus on philosophical problems of good and evil, life and death, I and the other, without getting lost in academic reasoning for the sake of reasoning itself. It does not present a psychopathological theory, but it does focus on madness as a lived experience, as a concept in philosophy, and as a phenomenon called 

 in psychiatric practice and theory. By stressing the experiential character of psychosis, which I have access to via my own memory, as well as via all kinds of reports and first-person narratives, the direction of my exploration is toward comparable experiences and their expressions. This brings us to all kinds of philosophical thoughts, bordering on reflections around 

, but also to important themes of language, fiction, and nonfiction. For any psychiatrist educated a little beyond the mainstream medical illness, cure, and therapy narratives, it must be clear that my exercise brought me into the small but highly professional and well-informed tradition of phenomenological psychiatry.

You have argued that a philosophical investigation of psychosis provides a better and less prejudicial approach than many mainstream psychological and psychiatric accounts. What sort of prejudices do you have in mind?

 The main prejudice concerns the usual way of approaching psychosis as a negative or a lack and leaving it there. That is, seeing it purely as a deficit, a disorder, a nonfunctioning of some aspect of the mind/brain/body that is supposed to be well-functioning in the individual who is not psychotic. Take for example the idea, found in various kinds of mainstream accounts, that psychosis is some kind of 

. Such a judgement implies that there is good, proper thought, and that psychotic thought can be sufficiently defined as a disturbance, a disordering of this normal, natural way of thinking. It may be said that the disorder is one of jumping too fast to conclusions, or a dysregulation of perceiving salience properly, or an inability to synthesize information coherently, or it is just being plainly illogical. All such approaches share the assumption (the prejudice) that psychosis can be sufficiently defined by what it is not.

The implication of such accounts is that the psychosis is just a disruption that should be suppressed and taken away in order to let the normal flow of experience run again uninterruptedly. It is assumed that there is a healthy, sane part, and an insane, psychotic part, both manifesting themselves in various contexts and intensities. Therapy then consists in identifying and annulling the psychotic part (eg, by medication, by cognitive behavioral therapy, or by so-called 

, and stimulating the healthy part). The patient then eventually learns to associate him- or herself with the healthy part, dissociate from the disordered part, and to consider the psychosis as the illness, not belonging to who he or she really is, but as something that was intruding from the outside. They learn to say: “the psychosis disturbed the real me.” Instead of: “the psychosis showed a different aspect of me.” It thereby dissociates them from their own experiences, memories, and past.

The assumption in much theory, and the accompanying practices, is that the life-world of the individual is affected by a natural disorder, which eventually impairs the individual in their freedom, in their meaningful interaction with others, and in their sense of being a conscious individual. What most of these accounts simply miss is that the psychotic experience itself is meaningful. Psychotic individuals often experience more freedom, instead of less, and they feel their consciousness is not troubled, but they report all kinds of experiences that are phrased with positive light metaphors. By defining 

 as a certain lack, psychiatry and psychology imply that meaning, freedom, and truth are only found in the nonpsychotic way.

Critique of Pure Madness: Wouter Kusters, PhD

What philosophy has to offer here is an examination of both sides, an inquiry into those notions that are so often assumed to be absent in psychosis. Philosophy investigates the power and implications of the negative: for instance, in what world does the psychotic live, when it is claimed that s/he does not live in a real world? How is this supposed unreality experienced? Why does it often feel more real than so-called ordinary reality? And so on. Only by letting go of our own prejudices about reality and thought, about how language and meaning operate, may we gain a deeper understanding of other (psychotic) kinds of organizations, other kinds of being-in-the-world than that of the nonpsychotic individual.

I do not have any principled criticism of the use of medication or cognitive behavioral therapy in itself. But the pretension that often accompanies the provision of effective treatment, that the clinicians understand what psychosis is better than the persons themselves—that can have a negative impact on people’s lives. If psychosis were really just like 

 or a broken leg, a temporary natural disturbance of the mind, why would so many remain so puzzled afterwards? What is this mysterious, seductive quality of psychosis? Psychosis is not only a disorder. It is also the basis for thinking toward a different order.

 I have been wondering about the relationship between psychosis and philosophy. In my mind, one way to approach it would be to treat psychosis as a method of inquiry into the nature of reality such that, at the end of it, something is revealed about the nature of the world and our existence. Another approach might be more negative. In this approach, psychosis by itself does not tell us what reality is, but it throws our everyday epistemic complacency into disarray. We can no longer trust our sensory inputs, our perception of space and time, our social instincts, etc, and this provokes a state akin to Cartesian doubt, where we can no longer take our ordinary understanding of the world for granted. With some poetic license and oversimplification, perhaps I can refer to these positions as the 

, respectively. Certainly, there can be all sorts of interesting combinations and variants of these approaches. Would you consider this to be a useful framing? If so, do you lean toward a particular position?

 That is a very illuminating framing indeed, and relates to the power of the negative. Let me comment on both positions and their relation to madness. In the original version of the Cartesian thought experiment, the one described by Descartes himself, a subject throws himself into full doubt, distrusts his senses, and searches within his own thought for a firm ground for existence, an undeniable truth, beyond all doubt. Descartes describes how in this process of radical doubt, everything is rejected because of its principled uncertainty, mutability, and transiency. The only thing that cannot be doubted, is that there is me, enveloped in a doubting process. And then from this elementary given, the famous rationalist adage follows: 

 (“I think, therefore I am”). In the dark nights of the mad soul, the individual with psychosis may have an analogous thought process, and they may end up in a kind of intellectual and existential despair, driven by radical self-doubt. But this despair may also take the form of an experience of perplexity about the undeniability and givenness of one’s own existence. The argumentative structure in Descartes’ texts shows similarities with the existential doubts the madman is in.

What is often forgotten in popular considerations of Cartesianism is that in building on 

, Descartes goes on to prove the existence of God as well as reality, using arguments that are today seldom accepted as self-evident truths. Descartes draws the conclusion that from being able to think an utterly perfect being (God), we must conclude that this utterly perfect being exists, otherwise it would not be utterly perfect. Now, the madman may in myriad ways follow, mirror, and deviate from such ways of thinking, and may get fully lost in all kinds of imaginations that are very difficult for an outsider to understand. However, when we are aware of these philosophical problems and this basic scheme of Cartesian reasoning, we might come a little closer to some understanding.

Of course, there are also many differences between the Cartesian and the mad thought experiments. An important difference is that for Descartes this was simply a thought experiment, an epistemological exercise, but for the madman the radical doubt is a serious matter; he is drowning existentially, losing all firm ground, and desperately searching for an anchor. We might say indeed that Descartes performs an epistemological experiment, while, following the ideas of the Dutch psychiatrist and philosopher Antoine Mooij, the psychotic is involved in an ontological experiment.

Let’s look at mysticism in comparison. In the early days of Christianity, mysticism was an intellectual and theological way to argue, to contemplate, to pray, to envision, and eventually to experience awe at the greatness and the power of the Almighty God. Then there was no essential difference between mysticism, theology, and philosophy. It was only much later that mysticism became associated with visions in the West, in an epochal historical change in which visual 

 also became ascribed as a dominant characteristic of psychosis. Just as I stress the partially passive, experiential character of the active Cartesian doubt experiment, I view mysticism as a more active and intellectual undertaking than it is usually considered to be. The usual distinction made between active thought and passive perception (and their counterparts in psychopathology, delusions vs hallucinations) is too rigid, and it is in mad philosophy and philosophical madness that we see a continuing doubting of both, and a crossing of the separation between them, by way of the viability and flexibility of language signs and experience.

 How do you approach the experience of delusions, which on the surface represent the antithesis of philosophical thinking? Instead of an ongoing grappling with a confusing reality, in the case of delusions we see a closing down of inquiry, resulting in what has traditionally been described as a fixed, false belief, unshakeable in the face of reasoning or contrary evidence. Would you say that perhaps it is only after the delusional force of the beliefs has dissipated that we can begin to philosophically understand the meaning of that experience?

 I think that delusions in the way you describe them here are only one side of the delusional story. Unlike many superficial cognitive accounts of delusion, I think that so-called delusions are better analyzed as reactions to an underlying, and temporally preceding, delusional mood, which is in fact also the position of most phenomenologists as well as psychoanalysts. A famous adage of the latter is that delusions are not the problem, but they are instead the first attempts to express and deal with another problem, of a quite different order. Nevertheless, I fully agree that a philosophical understanding, in the common understanding of this phrase, can only happen 

. A self-understanding and a philosophical elaboration that is intelligible to others, communicable in common language, must handle and circumnavigate the seduction to remain trapped by the awe for the ineffable, both in its ecstatic as well as despairing forms. The paradox of any such understanding, including mine, is that with this understanding, the thing itself, the psychosis, is in danger of retreating beyond the horizon. And this same striving toward understanding may attract and provoke psychosis to rise up again from the invisible. I know that some readers of my book put it down, but then had to resist being drawn back toward that enigma.

, you say at one point: “Philosophy never promised you a 

, [and] neither do I. Furthermore, it could well be argued that there is some kind of antihuman tendency in extreme philosophical and psychotic thought. Both philosophy and madness may have intense ‘superhuman’ or ‘a-human’ powers that burn anything substantial, anything meaningful, away into a hole of nothingness. But, well, the interests of life are not necessarily those of philosophy.” Can you comment more on this misalignment between the interests of life and the interests of philosophy/psychosis?

 Most modern philosophy starts from and leads back to common-sense assumptions. Many are rooted in the Age of Enlightenment and have the overt values of modern society as their implicit background. They assume that what is argued by human thought, including the findings and results of philosophizing, are and should be beneficent for [human] life. We find that assumption under all kinds of moral and political philosophies, but also under so-called philosophy of psychiatry. However, it is not so obvious that philosophical thought should lead to beneficial effects on society or the individual.

There are a range of extreme critical philosophical views, such as views of ultraconservative, nationalist, racist, antihumanist, transhumanist, and even antinatalist nature. While some of these views are considered dangerous to society, they still remain sustained within a broadly defined space of reasons, although this may be contested by others. Some philosophical ideas go even further and have the paradoxical capacity to be self-undermining for the thinker who thinks them. They may be detrimental to what we usually consider the space of reason; they are contra [human] life. That is, they argue in quite sophisticated ways that not being is to be preferred over being. They use notions of emptiness, the void, and nothingness, not to draw positively flavored, so-called spiritual conclusions, but only to affirm annihilation, death, 

, destruction, and [auto-]extinction. Such philosophies can be seen as a variety of nihilism—although this term refers to a much larger range of philosophies—with important names such as Friedrich Nietzsche, of course, but also Emil Cioran and especially Ray Brassier, with his devastating book 

. Just being against life does not mean that these ideas are untrue or can be excluded from the realm of philosophical thought. When we take philosophical thought seriously, we cannot reject conclusions just because they do not fit our restricted human-centric point of view. That is what I mean by saying the interests of life are not necessarily those of philosophy.

In the context of the relation between psychosis and philosophy, this is important to consider, and this also sweeps away all romantic humanist notions of both philosophy and psychosis. Consider the case of someone like Anders Breivik, the Norwegian terrorist and right-wing extremist. Some philosophies or world views, as well as some particular forms of madness, are thoroughly destructive and devoid of good intentions. They are closer to the darker variety of the mystical aspect of madness. American philosopher William James described it as 

In such cases, the philosophical aspect of the psychosis would not only consist of the strange ineffable character of an experience filled with awe and puzzlement, but also of an intra- and interpersonal struggle between life-affirming forces and life-denying, a-human or antihuman forces. The implicated question is whether we must eradicate such poisonous ideas, or must we taste and experience them ourselves, to examine the enemy, and immunize ourselves against them, with all kinds of risk of contamination? The implicated practical problem for psychiatrists is to make responsible decisions in matters that comprise philosophical and theological as well as political complexities. What is demanded of the psychiatrist here has hardly anything to do with scientific knowledge; it is also difficult to be captured in 

, and it can only be referred to with notions like prudence.

 You have warned against romanticization of psychosis. From what I can tell, while you seem to be in favor of controlled explorations of psychosis by means of philosophy or mysticism, you do not seem to wish the clinical, raw experience of psychosis upon anyone. While you have derived insights from your 

, I imagine that you are also glad to have come out of psychosis. How do you think we can reconcile the tension, to the extent that it exists, between the clinical and philosophical attitudes toward psychosis? Individuals with psychosis are often tremendously distressed and impaired, and they typically require some form of clinical care to help navigate this distress and impairment. How do we reconcile this with the romantic image of the madman as a misunderstood mystic or an unrecognized philosopher or with the more prosaic image of a deviant whose deviance has been pathologized?

 I think that the clinical attitude should incorporate the philosophical attitude, and clinicians should be educated in this. In fact [he laughed],I would recommend that they should all read my book, or perhaps follow the course I teach about my book! In my book, they would indeed meet these images of the misunderstood mystic, the unrecognized philosopher, and the pathologized deviant. However, my book does not want them to accept these images as the essence of psychosis, but as starting points from which a dance, dialectic, or conversation may begin between philosophy and madness, the rational and the irrational, without being condemned to one position or the other.

is a psychiatrist in Cleveland, Ohio, and a clinical assistant professor of psychiatry at Case Western Reserve University. He is a member of the executive council of the 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 has no relevant financial disclosures or conflicts of interest. Dr Kusters receives royalties from the sales of his book and generates income from the online course he offers on his website.

The Varieties of Religious Experience: A Study in Human Nature.

Wouter Kusters, PhD, uses his experiences with psychosis to better inform his philosophy. What can we learn from him? 

What Can Philosophy Learn From Madness?

“Any discipline that would dare to address, in the aggregate, the politically oppressed, the socially marginal, the sexually deviant, the worried well, the intimately abused, the morally dubious, the unpredictably irrational, and the emotionally labile 

 be controversial. Psychiatry, by the nature of its subject matter, is destined to be esteemed and loathed, scrutinized and dismissed, overlooked and debated. Psychiatry accepts many of the messy truths that almost everyone else would like to ignore or deny.”

It’s Time for Us to Stop Waffling About Psychiatry

 by Daniel Morehead, MD, with great interest, particularly since it makes frequent references to some of my work in 

 series. Dr Morehead and I agree about a lot of things: the fundamental legitimacy of psychiatry as a branch of medicine; the essential role psychiatry has to play in the treatment of mental health problems; that a defense of psychiatry is warranted against egregious and misplaced criticisms; and that the value of psychiatry must be conveyed to legislators, insurers, and the general public. Psychiatry is a profession with a rich intellectual history that exemplifies some of the best of what medicine has to offer. The tools it has at its disposal are limited, but when used appropriately, offer tremendous relief to individuals with psychiatric distress and impairment. I am proud to be a psychiatrist, consider myself privileged to do the work that I do, and would not trade it with any other medical specialty.

Despite these core agreements on the status of psychiatry, I am not entirely in agreement with Morehead’s characterization of 

 as destructive and harmful. My own view is different, shaped by my longstanding engagement with these critiques. Critiques of psychiatry are necessary and important, and will continue to be so, and psychiatry can only dismiss them at its own peril. It is my opinion that we need to reconceptualize psychiatry’s relationship with critique in a more productive manner.

There are understandable reasons psychiatry is scrutinized way more than other medical specialties. It, for instance, exercises social control over the lives of individuals under its care to a degree exercised by no other specialty; it is subject to more value disagreements; it has to work across multiple disciplines and perspectives that are difficult to integrate; it has a tumultuous historical legacy; the state of scientific development is still comparatively rudimentary; and it deals with conditions that are 

To see Dr Morehead's original article, check out 

Then read Dr Morehead's response to this article, 

It’s Time for Us to Realize We Are All on the Same Side. 

These and other factors ensure that psychiatry will be under the spotlight (just as we can expect that the police force will almost always be more scrutinized than the postal service). This additional scrutiny intersects with disorder within psychiatry’s own house, giving critics plenty of flammable material to work with. Even problems that are pervasive across all of medicine—such as industry influence and corruption of evidence-based medicine—become more noticeable in the context of psychiatry thanks to the additional scrutiny.

 There are also too many “unhappy customers” when it comes to psychiatry, so to speak: recipients of psychiatric care who have been left traumatized, disenchanted, even devastated by their experiences. There has been tendency within the profession to not take such individuals seriously, at least not without being forced to do so.

Does psychiatry need criticism in order to improve? 