CONVERSATIONS IN CRITICAL PSYCHIATRY
Conversations in Critical Psychiatry is an interview series aimed to engage prominent critics within and outside the profession who have made meaningful criticisms of psychiatry and have offered constructive alternative perspectives to the current status quo.
Sandra Steingard, MD, is Chief Medical Officer, Howard Center, Burlington, Vermont and Clinical Associate Professor of Psychiatry at the University of Vermont Larner College of Medicine. She is chair of the board of the Foundation for Excellence in Mental Health Care, a member of the board of the American Association of Community Psychiatrists, and on the advisory board of Mad in America Continuing Education. She is editor of the book, Critical Psychiatry: Controversies and Clinical Implications, published by Springer in 2019. Beginning January 2020, she has also assumed the role of Editor-in-Chief of the Community Mental Health Journal.
G. Scott Waterman, MD, is Professor of Psychiatry Emeritus at the University of Vermont Larner College of Medicine, where he served at various times as Director of Psychopharmacology, Director of Medical Student Education in Psychiatry, and Associate Dean for Student Affairs. Upon his retirement, Dr Waterman enrolled in the graduate program of the Department of History at the University of Vermont, where he studied extremist social and political movements of modern Europe and America and received his MA a few years ago. He is a member of the executive council of the Association for the Advancement of Philosophy and Psychiatry and teaches courses in philosophy of psychiatry at the University of Vermont.
Dr Steingard and Dr Waterman have been married for 33 years.
I got to know Dr Waterman through the Association for the Advancement of Philosophy and Psychiatry—an organization I would recommend to all readers—and I have been impressed with his intellectual rigor in the course of our interactions. He began his career with research interests in the neurobiological foundations of childhood-onset mental illness but eventually shifted his academic focus to philosophy of psychiatry. I became more acquainted with Dr Steingard's ideas after I read Critical Psychiatry: Controversies and Clinical Implications, published earlier last year. The volume presents an overview of the critical psychiatry movement with impressive clarity and is highly accessible to clinicians and trainees. The happy coincidence that these two intelligent and accomplished psychiatrists are married allowed me to engage them in this joint interview where their complementary views, side by side, make the whole greater than the sum of its parts.
Aftab: Dr Steingard, can you tell us briefly about how you got involved with the critical psychiatry movement and how this involvement has changed how you practice as a psychiatrist? Also, since a disappointingly large number of people think of the critical psychiatry movement as being synonymous with the antipsychiatry movement, can you shed some light on why that is not the case?
Steingard: There is not an absolute delineation between critical psychiatry and antipsychiatry. Bonnie Burstow of the University of Toronto characterizes antipsychiatry as an abolitionist movement whose proponents consider psychiatry so fundamentally flawed as to be beyond reform. Critical psychiatry, on the other hand, includes both critical academic inquiry and reformist activism. It encompasses critiques that range from questioning the validity of our diagnostic system and investigating the effects of conflicts of interest on clinical practice to examining the impact of structural societal forces—poverty, sexism, racism, for example—on mental well-being and the manifestations of psychiatric disorders. Critical psychiatry also acknowledges the important contributions of those with lived experience of receiving psychiatric treatment or being labeled with psychiatric conditions not only to evaluating clinical care but also designing and conducting research. Those are some of the areas that have had great salience for me.
The evolution of my critical stance toward psychiatry began early. I entered the field because I was fascinated by psychoanalysis. When I was introduced, as a psychiatry resident, to various critiques of psychoanalytic theory such as Adolf Grünbaum’s work, I was disappointed at my teachers’ inability to address them. That contributed to my decision to leave psychoanalytic training and shift my focus to studying and caring for people who experience psychosis. Many new drugs came on the market in the 1990s. I was initially hopeful that they would improve care but was demoralized to witness the blatant hype that was carried out, not only by the pharmaceutical industry but also by academic leaders. Initially, I was comfortable thinking about psychosis as reflective of brain disease—or at least a disruption of brain functions—but in more recent years, as I have been introduced to the perspectives of the critical social sciences, as well as to people who have been treated for a variety of psychiatric disorders, I have broadened my perspective on the conceptualization of psychosis (and all psychiatric phenomena).
It is difficult to summarize how this has changed my practice, but I have been influenced by Joanna Moncrieff’s drug-centered approach to pharmacotherapy and need-adapted treatments. These ideas have helped me to embody principles that are not inherently controversial but, nevertheless, hard to implement. They include adopting a patient-centered focus, practicing with humility and transparency, and acknowledging that our medical perspective may not be the only (or best) way to conceptualize the nature of our patients’ distress.
Aftab: Dr Waterman, do you also identify with the critical psychiatry movement? How would you describe your identity as a psychiatrist?
Waterman: I would like to think that, throughout my career, I was a critical psychiatrist in the generic sense of challenging prevailing conceptualizations and practices. And while I have in recent years been largely an observer from the periphery of what has come to be called the critical psychiatry movement, I share a number of its formulations and priorities. Thus, my former preoccupations with matters like mind-body dualistic fallacies in medical discourse and training, the conceptual problems of the biopsychosocial model, and the multiple shortcomings of the DSM diagnostic system have moved aside to make room for concerns about personal autonomy, coercion, epistemic justice, and the commercial corruption of the empiric database of medicine. Although I continue to be deeply involved in philosophy of psychiatry, my “identity as a psychiatrist” is as a retired one—if, indeed, I remain one at all.
Aftab: Dr Steingard, you and Dr Moncrief write: “We live in the era of evidenced-based practice. If an approach is not funded, then it will never acquire the kind of data that would allow it to be considered evidence-based. This creates a closed loop: only research that is hypothesized to be of value is funded; understudied approaches that might be of value are ignored because they are not considered evidenced-based.”1
That's a very important point. A lot of people don’t appreciate the institutional and political forces which determine what gets funded and what gets studied. It certainly suggests that looking only at evidenced-based literature can be a recipe for confirmation bias. How should we approach this situation?
Steingard: There is no good answer, but it begins with a recognition of the problem. In addition, it is important for psychiatrists to understand what questions randomized controlled studies do and do not answer. For instance, they can detect differences that are not necessarily clinically meaningful. Often, the emphasis is put on the statistical rather than clinical significance of findings and then an echo chamber of public relations promotes a narrative in the absence of more critical examination of the data. On the other hand, I appreciate that it is extremely time consuming to parse out all of the available data on each topic that might be of interest to a busy clinician. One has to decide at some point to trust expert sources. I wish we could have more confidence in the academic establishment.
Aftab: Dr Waterman, one of the reasons you were drawn to psychiatry was the promise that a neuroscientific understanding of psychiatric conditions is on the horizon and it will transform the way we practice psychiatry. What do you think explains the failure of neuroscience so far to have the revolutionary impact on clinical psychiatry that was expected? Do you have conceptual reasons to think that such a revolution may never happen?
Waterman: When we were residents, Sandy and I attended a lecture by the renowned philosopher of mind and of neuroscience, Patricia Churchland (whose arguments—along with those of her husband, Paul Churchland—for a particular brand of materialism exerted great influence on me). She recounted an anecdote involving their son, who I believe was about six years old at the time. He reportedly asked of his philosopher-parents at breakfast one morning, “What if the brain is more complicated than it is smart?” While doubtless not the first person to pose that question, it seems unlikely to be one that has occurred to many first-graders!
The profound complexities of the brain are only half of the equation. The expectation that advances in neuroscience would revolutionize clinical psychiatry seems to me to be predicated on anticipation of sufficient understandings of two (at least currently) disparate arenas: the brain being one and the other being the psychiatric phenomena whose neuroscientific foundations are being sought but which manifest at the level of the whole person. Those phenomena entail both subjective/first-person (emotions, cognitions) and objective/third-person (behaviors) components that are themselves both complex and heterogenous from person to person. The complexities they present include things like the “looping effects” of which Ian Hacking writes,2 whose material instantiation in the brain might be intractable. So what comprehension of psychiatric phenomena—how best to capture, define, describe, and classify them—will allow us to “match up” such understandings with our growing grasp of neuroscience? Moreover, what levels of neuroscientific understanding—genes?, gene products?, neurons?, neural circuits?, regional or whole-brain physiology?, combinations of them?—should we expect to “match up” with our still-elusive grasp of psychiatric phenomena? I remain enough of a materialist to believe that advances in neuroscience might well translate into significant advances in clinical psychiatry, but enough of an empiricist to recognize that a “revolution” is not in the offing and that explanatory pluralism (and its clinical extensions) are our best bet for the foreseeable future.
Aftab: Dr Steingard, can you elaborate for the readers your approach to psychopharmacology that you have espoused in Critical Psychiatry?
Steingard: This approach has been characterized by Joanna Moncrieff as a drug-centered approach to psychopharmacotherapy. It considers the drugs we use as psychoactive substances that alter brain function in ways that may be experienced as beneficial. This is distinct from a disease-centered approach which posits that the drugs work by “fixing” something that is not working correctly. There has been much discussion in our field (including in articles in Psychiatric Times) about whether or not psychiatry as a field promoted the so-called “chemical imbalance” theory. I would argue that most people have come to believe that the drugs we prescribe work by correcting problems thought to underlie psychiatric conditions. Thus, for example, SSRIs are said to fix a problem in the serotonin system and antipsychotic drugs fix a problem in the dopamine system. However, what we have learned is that while the drugs’ clinical effects might be related to the way they alter these systems, evidence is lacking that depression results from low levels of serotonin and psychosis reflects high levels of dopamine. Nevertheless, these beliefs persist and influence the way physicians talk to patients about these drugs.
Aftab: You write “The challenge is that psychiatrists are currently charged with being the gatekeepers to psychoactive drug use . . . Rather than putting psychiatrists in the role of determining who can and cannot have legitimate access to such drugs, psychiatrists can be the experts on drug action.”3 How does the drug-centered approach change the “gatekeeper” role of psychiatrists, since whether you adopt a drug-centered approach or disease-centered approach, psychiatrists still have the prescribing power and therefore they still have the responsibility to determine “legitimate access”?
Steingard: As long as psychiatrists (and others) hold prescribing privileges, there is no way for us to avoid acting as “gatekeepers” to drug access. However, what I prefer about the drug-centered approach is that it avoids what I think is a false distinction between “good” and “bad” drugs or between “good” and “bad” uses of drugs. The disease-centered approach fosters the notions that “good” drugs are those that are used to treat diseases or disorders while “bad” drugs are those that people use recreationally. Such thinking leads to the tortured distinction we see in discussions of cannabis between so-called “medical” and “recreational” marijuana. From a drug-centered perspective, our role would be to educate not only our patients but our communities about what these drugs do, what problems they can cause, and the challenges of discontinuation, among other things. We would help people make judicious decisions about their health. People have sought out psychoactive substances for a very long time and this is not likely to abate. If we push aside the moral judgements and the sometimes-arbitrary distinctions between “medical” and other uses, we would have a more honest and transparent discussion about what these drugs do and do not do.
Dr Aftab, Dr Steingard, and Dr Waterman have no relevant financial disclosures or conflicts of interest.
1. Moncrieff J, Steingard S. What is Critical Psychiatry? In: Critical Psychiatry: Controversies and Clinical Implications. Steingard S (Ed). Cham, Switzerland: Springer; 2019.
2. Hacking I. The Looping Effect of Human Kinds. In: Sperber D, Premack D, and Premack AJ, eds. Causal Cognition: A Multidisciplinary Debate. Oxford: Clarendon Press; 1995.
3. Steingard S. A Path to the Future for Psychiatry? In: Critical Psychiatry: Controversies and Clinical Implications. Steingard S, Ed. Cham, Switzerland: Springer; 2019.
4. Waterman GS, Batra J. Biopsychosocial psychiatry. Am J Psychiatry. 2003;160:185.
5. Waterman GS. Why I am not a psychiatrist and Responses to commentaries. Bulletin of the Association for the Advancement of Philosophy and Psychiatry. 2019;26:2-3,9-12. https://philosophyandpsychiatry.files.wordpress.com/2019/07/aapp-bulletin-vol-26-1-2019-.pdf. Accessed January 3, 2019.
6. Waterman GS. Does the biopsychosocial model help or hinder our efforts to understand and teach psychiatry? Psychiatric Times. 2006;23(14):12-13.