Awais Aftab, MD

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.

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.

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

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.

The Neurodiversity Paradigm in Psychiatry: Robert Chapman, PhD

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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.

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 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.

Articles

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.

Psychiatry has been vulnerable to diagnostic fads. The profession has allowed itself to be exploited by pharmaceutical companies. Psychiatric theory has been vulnerable to “single-message mythologies” and zealous reductionism.

 Its leaders have neglected structural determinants of health. The state of science is what it is; we can make conditions conducive to scientific research, but discoveries and breakthroughs cannot be rushed or forced. While acknowledging the state of psychiatric science should lead to an attitude of humility, many psychiatrists in positions of power and influence have often made grandiose claims—and at times have displayed stunning arrogance.

This is not to say that psychiatry does not face unfair criticisms. There is rampant hostility, misinformation, misguided arguments, etc, exemplified well by Scientology, Szasz, and other actors. It is right to be wary of them and to push back against them, but at the same time, many psychiatrists have been too trigger-happy with allegations of “

” and have lumped all sorts of critics under the same banner.

In my opinion, psychiatry cannot wriggle its way out of this dilemma by rhetorical appeals, tone-policing of criticisms, and becoming self-assigned arbiter of what sort of critiques are allowed from inside or outside the profession. As I have mentioned, based on the social role that psychiatry currently occupies, excessive scrutiny is inevitable. The best response to this state of affairs is to actually put the house in order, push back against egregious “anti-vaxx” style misinformation, and counter inaccurate claims when such claims are made, but to otherwise remain receptive to critique from scholars, scientists, and service users/patients. (I use the term “

” in addition to patient in the spirit of inclusiveness, as it is preferred as a more neutral term by some individuals with experience of psychiatric care).

It is easy to recognize that psychiatry is working under systemic constraints that lead to many poor outcomes, but in such a situation, the psychiatric profession (represented by its leaders and organizations) has a responsibility to actively try to change the system. It has prominently fallen short in this regard. By blocking and dismissing criticisms aimed at psychiatric institutions (for instance, criticisms from the United Nations and the World Health Organization), it may very well be standing in the way of those who are actually trying to change it. With respect, psychiatry as a profession should join the effort or get out of the way.

, I mean myself and others like me who are included in it. We are not external to the profession—we are a part of it, we embody it, we represent it. We do not criticize psychiatry from some external vantage point, but as active participants within it. There has been an unfortunate tradition that many who critique dominant aspects of psychiatric theory and practice do so by framing it as a critique “of psychiatry,” giving the illusion of an external critique directed at a monolithic institution. That picture is obviously incorrect; psychiatry is a diverse discipline with many traditions, critiques 

 psychiatry are typically critiques of certain (dominant) practices within psychiatry, and these critiques often arise 

 psychiatry. It is easy to be distracted by this framing of criticisms, but it is a mistake not to engage with the criticisms because of it.

The space of psychiatric critique is populated by diverse arguments. Here is an incomplete list:

-Critiques of DSM, its limitation, and its misapplications, and the dominant role it plays in current practice

-Critiques of the links between psychiatric professionals and pharmaceutical industries

-Critiques of the medicalization of everyday distress

-Critiques that originate from a philosophical analysis of psychiatric concepts

-Critiques that originate from relevant social sciences, such as anthropology, history, and sociology

-Critiques that originate from a tradition of evidence-based medicine and question the efficacy of psychotropics such as antidepressants

-Critiques of the long-term use of medications

-Critiques that originate from human rights discourse and the use of psychiatric coercion

-Critiques from harmed patients, individuals with lived experience, and the consumer/survivor/ex-patient movement

For every sort of critique above, one can point to examples of criticism that are scholarly, academic, rigorous, and well-intentioned, even if one disagrees with them. Critiques from patients and service users are particularly important. Within our academic and clinical bubble, it is easy to develop the impression that all is well, but if we go outside the bubble, engage with individuals in the community where the clinical power differential no longer exists in the same way, and engage with individuals on 

 and the blogosphere, I can assure you that we will encounter large numbers of patients whose encounters with psychiatric care have left them dissatisfied and traumatized.

Morehead says that “the time has come for all psychiatrists to consistently speak out on behalf of our patients.” Indeed, it has, and I would add that we can only do so genuinely and meaningfully if we also speak out on behalf of our patients who have been harmed by psychiatric care. Not only that, but we should go a step further and facilitate the process of empowering our patients to speak for themselves—as is the goal of the service user and lived-experience communities, as well as movements such as 

It is important to note that the examples of criticisms with which Morehead opens his article do not correspond to the “common criticisms” that he subsequently addresses, giving a misleading impression. For example, Morehead cites Anne Harrington’s 

 The book is a history of psychiatry’s efforts to understand the biological basis of mental illness, especially in the context of grandiose ambitions and reductionistic claims of biological psychiatry during the 1980s, 1990s, and 2000s.

 Harrington’s book is a scholarly work by a reputable historian that every psychiatrist should read. In fact, Anne Harrington, DPhil was recently invited to speak by the Royal College of Psychiatrists

 and had an excellent online dialogue with the British psychiatrist Matthew Broome, MD, PhD, which illustrates well how we can benefit from historical critique and engage productively in response.

Morehead references the 2012 paper by Phillips et al on conceptual and definitional issues in psychiatric diagnosis.

 This article highlights some of the most prominent names in philosophy of psychiatry and reveals the philosophical difficulties that surround the notion of mental illness and the elusiveness of a satisfactory definition. This has been a topic of interest to me for many years, and my own philosophical work in this area reflects the conceptual inadequacies of our notion of mental illness.

 If Morehead believes that there is no need for such philosophical analysis and we already have an adequate definition at our disposal, he is welcome to disagree with me and engage with the philosophy of psychiatry literature, but it is unclear to me why this should be seen as an example of problematic and irresponsible critique of psychiatry.

These are what Morehead calls the 3 most common criticisms:

Criticism 1: Psychiatric illnesses are not real illnesses in the conventional sense because they are not physically and biologically real.

Criticism 2: Psychiatric medications make things worse. They are dangerous substances pushed by drug companies and greedy psychiatrists.

Criticism 3: Psychiatrists are biological reductionists and pill pushers who diagnose and prescribe everyone they see regardless of their condition.

These criticisms as stated are frequent enough in layperson, Szaszian, and Scientology critiques of psychiatry, and they are worth rebutting in their own right. However, these criticisms have very little to do with the sophisticated critiques offered by respected scholars and psychiatrists such as Dr Harrington, Dr Frances, Dr Steingard, Dr Waterman, Dr Fava, Dr Cosgrove, and Dr Kleinman, all of whom are included in the list at the beginning of the article. If these authors have not made these criticisms—and they have not—then why use them as prefatory examples? By doing so, Morehead risks conveying an inaccurate portrayal of the nature of their criticisms.

Furthermore, for each of the common critiques Morehead brings up, there are related critiques that are indeed worth taking seriously. For instance, it is indeed the case that research studies have reported a wide variety of associations between psychiatric disorders and various biological factors, but these tend to be at the group level, often of small magnitude, and they tend to be neither sensitive nor specific, neither necessary nor sufficient. They are better understood as biological 

. At the same time, research has also reported a wide variety of associations of psychiatric disorders with psychological and social risk factors, and these associations are of a magnitude equal to, if not greater than, the associations with biological factors. Even for conditions with high heritability such as 

, identified genetic associations, captured in aggregate by polygenic risk score, account for a woefully small percentage of risk, while risk factors such as trauma are far more potent and far more neglected.

 This raises the question: Why should biological risk factors be privileged over psychosocial risk factors when it comes to understanding psychiatric disorders? This privileging of biological over psychosocial is, in a sense, what we do when we characterize psychiatric disorders as 

Consider Morehead’s second criticism. Psychiatric medications do indeed have legitimate clinical uses. Even critics such as 

, who otherwise adopts a Szaszian view of mental illness, accept that antipsychotic medications have therapeutic utility in acute psychosis. Acknowledging this does not mean we can look away from the evidence that the efficacy of these medications has been systematically exaggerated and their harms downplayed through problems with the design, conduct, and reporting of clinical trials.

 To bring up 1 example of neglected risks, it took years of protests by harmed patients and concerned clinicians for the profession to even begin to acknowledge the severity and burden of antidepressant withdrawal syndrome.

 With regards to antidepressant efficacy, the Cipriani et al meta-analysis

 cited by Morehead indeed shows that antidepressants outperform placebo by a statistically significant margin, but the magnitude of average difference between antidepressants and placebo is so small at face value that its clinical relevance is unclear.

 The situation is even worse for children and adolescents. A 2021 Cochrane review and meta-analysis

 concluded that antidepressants “reduce depression symptoms in a small and unimportant way compared with placebo.” While this does not by itself prove that antidepressants have no clinical utility—we have decades of clinical experience to rely on, and there are analyses that suggest that selective serotonin reuptake inhibitors may have more specific actions on depression mood rather than aggregate rating scale scores

—this does however indicate deeper problems with our reliance on standard “evidence-based” strategies of randomized controlled trials, systemic reviews, and meta-analyses. This is something we can only begin to tackle if we take the critiques seriously. It also highlights that the efficacy of antidepressants is not robust enough to justify the astonishingly high levels of prescribing we currently see—13.2% of US adults had used antidepressant medications in the past 30 days during 2015 to 2018, according to the Centers for Disease Control and Prevention.

Morehead states that mental illness speeds up the aging process and reduces the lifespan by an average of 10 years, without seemingly stopping to ask whether this accelerated aging and shortened lifespan could be facilitated in part by the use of psychiatric medications. Psychiatric medications, such as antipsychotic medications, confer high risk of 

, diabetes, and hyperlipidemia, all of which are well-recognized factors associated with increased aging and mortality. A recent editorial in 

 has hypothesized that long-term exposure to antipsychotics increases the risk of premature dementia in individuals with psychosis.

 In my view, complacency in the face of such evidence is alarming. It is easy for psychiatric professionals to focus on the harms of under-diagnosis and under-treatment, but these gestures ring hollow and insincere if the profession also does not adequately address the harms of over-diagnosis and over-treatment.

Psychiatry is at a crossroads. The medical model has been dominant in mental health, and while it has an essential place, its dominance is being challenged by many forces and is no longer guaranteed in the future. Clinical psychology is maturing as a discipline, tackling the “theory crisis,” developing its own classification systems such as HiTOP, rediscovering psychoanalysis, and developing innovative treatments for serious mental illness.

 There is also a new energy in social work, and service user movements grow stronger every day. Institutions such as the United Nations and the World Health Organization have challenged psychiatry to improve its record in terms of human rights.

 The world is changing, and along with it, psychiatry’s place in the order of things. Navigating this changing landscape requires a vulnerability and humility that does not come easily. It requires appreciating and defending our foundations within medicine, but it also requires appreciating the pluralistic nature of mental healthcare, to learn from our critics, and to take ownership of the problems that confront us.

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 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

 Editorial Board. He can be reached at 

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Ethische Aspekte der Forschung in Psychiatrie und Psychotherapie

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https://www.madintheuk.com/2020/02/calling-someone-antipsychiatry-is-not-an-argument-feels-abusive/

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Does psychiatry need criticism in order to improve? 

It’s Time for Us to Stop Being So Defensive About Criticisms of Psychiatry

Dan J. Stein, MBChB UCT, FRCPC, PhD, DPhil, is professor and chair of the Department of Psychiatry at the University of Cape Town (UCT), Cape Town, South Africa. To avoid compulsory service in the all-white South African army, he left for the United States, where he completed his residency in psychiatry and a postdoctoral fellowship in psychopharmacology at Columbia University. After Nelson Mandela was democratically elected president, Dr Stein returned to South Africa, where he has remained since. His research work has focused on anxiety and related disorders, including obsessive-compulsive and related disorders, and trauma- and stressor-related disorders. He chaired the DSM-5 and the ICD-11 workgroups on obsessive-compulsive and related disorders. Recognized for his contributions to multiple fields, he has received the Ethics in Psychopharmacology award from the International College of Neuropsychopharmacology and the Lifetime Achievement Award in Biological Psychiatry from the World Federation of Societies of Biological Psychiatry.

Dr Stein has been interested in both psychiatry research and philosophical writing since his residency. As a resident, he won the Karl Jaspers Award from the Association for the Advancement of Philosophy and Psychiatry in 1991. As part of the DSM-5 revision process, he wrote an article, collaborating with a number of leading figures in philosophy and psychiatry, titled “

What is a mental/psychiatric disorder? From DSM-IV to DSM-V

” that has been cited nearly 500 times.

 In 2008, he brought together his interests in psychopharmacology and philosophy in 

, and this year he has further extended his work in philosophy with the publication of 

Problems of Living: Perspectives from Philosophy, Psychiatry, and Cognitive-Affective Science

. This is an ambitious book, tackling questions not only about the nature of mental disorders, but also about the mind-body problem, the relationship between reason and emotion, happiness and suffering, morality and truth, and the meaning of life.

 You are the first African author I have interviewed for this series. Does being South African influence your work on philosophy and psychiatry?

 Well, it is notable that South Africans have made some really important contributions to psychiatry. The work of Joseph Wolpe, MD, developing behavior therapy comes to mind, as does Isaac Marks, MD’s contribution to anxiety disorders (others are detailed in a review I once wrote).

 On the other hand, critiques of psychiatry have had particular resonance here, emphasizing how social determinants and health systems are closely bound up with the history of apartheid and continue to influence mental health.

 Your specific interest in the philosophy of psychopharmacology distinguishes you from many other authors and commentators in this area. Psychopharmacology too is a field where there have been advances but also important limitations.

Yes, I fully agree. The introduction of antipsychotics, antidepressants, anxiolytics, and mood stabilizers in the 20th century was a complete game-changer for psychiatry. At the same time, the same receptors targeted by early agents continue to, by and large, remain the focus of current clinical psychopharmacology. Neuroscience has become increasingly sophisticated, and yet our understanding of how psychotropics affect symptom relief remains somewhat rudimentary. We should celebrate the fact that appropriate diagnosis and pharmacotherapy changes many individuals’ lives for the better. But we must remain aware that there is massive underdiagnosis, particularly in low- and middle-income countries, that not all patients respond to pharmacotherapy or other interventions, and that overdiagnosis and overtreatment is also an issue.

Selective serotonin reuptake inhibitors (SSRIs) and other antidepressant medications have been the subject of a lot of controversy in recent years. There is the perpetual question: Why have they performed so poorly when compared to placebos in randomized controlled trials (RCTs), and what does that say about their real-world clinical efficacy? And there is increasing awareness of the prevalence and severity of antidepressant withdrawal and other adverse effects. As someone who approaches psychopharmacology through a philosophical lens, how do you view these developments?

 In my thinking about these sorts of issues in psychopharmacology and related questions in philosophy of psychiatry, I find myself always trying to walk the line between overly hagiographic accounts and overly critical views of psychiatry. When I think of how psychotropics can impact thinking and feeling, and be so therapeutic, I am filled with awe (about the complexity of the relevant mechanisms) and with gratitude (that we are able to help individuals suffering from mental disorders). But I am also very aware of the robust criticisms of psychopharmacology’s evidence base, of iatrogenic illness, and of how far we still have to travel in psychopharmacology. I don’t think there’s a deep and readily addressed conceptual solution in psychopharmacology research. We have long been aware, for example, that neurotransmitters cut across dimensions of behavior, and that, while psychopharmacological dissection may be a useful tool, the idea that there is going to be a specific psychotropic that is particularly effective for each disorder is way too simplistic.

I do think, though, that in clinical practice it may be helpful to think about psychopharmacology not only from a molecular perspective but also from an evolutionary medicine perspective. This helps explain why anxiety is so common, why there are endogenous anxiogenic and anxiolytic mechanisms (which we can then target or mimic), why medications that target adaptive defenses can be clinically useful (an antitussive can reduce symptoms even though cough is highly adaptive), and why the motto “a pill for every ill” is far from the solution.

From a research perspective, while I love the current idea that clinical trials can be based on translational neuroscience approaches (eg, testing if a drug alters an important biomarker or endophenotype), successful bench-to-bedside advances remain fairly unusual in psychiatry, and I worry that we do not put commensurate attention and funding into pragmatic clinical trials. The United Kingdom’s Recovery Trial to quickly test drugs for efficacy against COVID-19 in day-to-day practice is inspiring. Should we not be doing the same sort of thing for mental disorders?

 You have often differentiated among the 

 positions. Tell us a bit more about these, particularly as you envisage them with regards to psychiatry.

 I have used these terms in part to find a middle path, avoiding both overly hagiographic and overly critical views of psychiatry and psychopharmacology. I have also used them as a way of integrating key philosophical views on science, language, and medicine. Thus, I use the term 

 to refer to positions that emphasize essential natural kinds and scientific laws, holding up, say, the periodic table as an example of how science should work, and arguing that diseases too have essential features, which we need to explain. And I use the term 

What is the real-world clinical efficacy of SSRIs and other antidepressant medications compared to RCT placebos?