The Postmodern Worldview and Contemporary Psychiatry

CONCEPTS IN PSYCHIATRY

Everyone holds a philosophy or worldview that influences how they think, whether they are conscious of it or not. More precisely, everyone operates with assumptions about what exists, what can be known, and what counts as evidence. These assumptions are shaped by the larger culture and often exert their greatest influence when they remain unexamined. Over the broad sweep of Western intellectual history, the dominant worldview shifted from revelation and God in the premodern medieval era, to reason and science in the Enlightenment, and eventually to the contemporary postmodern era, in which the possibility of absolute or objective truth itself is questioned. Psychiatry developed across these transitions and today contains elements of all 3.

Our contention is that contemporary psychiatry, and much of psychotherapy, has absorbed this postmodern worldview more deeply than is generally recognized. The influence is obvious among critics who explicitly describe psychiatric diagnoses as social constructions or instruments of social control. More paradoxically, it is also present within mainstream psychiatry, including in 2 of its most influential pillars: the DSM and the biopsychosocial model. The psychiatric establishment generally presents these frameworks as products of scientific medicine, yet when diagnostic or clinical decisions are ultimately defended by consensus, utility, or pragmatism rather than by whether they correspond to something real in nature, psychiatry moves toward the same philosophical position that its postmodern critics openly endorse.

The Postmodern Shift and Social Construction

“Postmodernism” refers to a broad and heterogeneous family of ideas, and no brief definition can capture every thinker associated with the term. We use it here in a specific epistemological sense. Modern science assumes that a reality exists independently of our descriptions of it and that human beings can acquire progressively more accurate knowledge of that reality through observation, experimentation, critique, and reason. Scientific claims are always provisional; science does not promise certainty. But uncertainty about whether we have discovered the truth is different from denying that there is a truth to discover.

The postmodern perspective challenges this Enlightenment picture. In its stronger forms, it rejects the idea that either God or science can provide knowledge independent of human beings and holds that what counts as truth is inseparable from language, culture, historical circumstance, perspective, and relations of power. Jean-François Lyotard famously characterized the postmodern condition by its distrust of universal explanatory narratives.¹ Michel Foucault emphasized the intimate relationship between knowledge and power in medicine, psychiatry, prisons, and other social institutions.² Nietzsche, an important precursor to later postmodern thought, had already reversed the familiar direction of the relationship: power does not merely follow from knowledge; relations of power help produce what a culture accepts as knowledge.

Science is practiced by human beings and therefore can be distorted by bias, institutional interests, or political power. But the existence of such distortions does not make truth itself a social construction. It provides no basis for concluding that there is no mind-independent reality or that competing claims about reality are merely social narratives. All classifications are constructed, but it does not follow that everything being classified is constructed. Human beings created the word tuberculosis; they did not create the organism that causes tuberculosis. Likewise, the fact that psychiatrists invented the term schizophrenia tells us nothing by itself about whether schizophrenia corresponds to a real disease entity. The label is unquestionably a human construction; whether the condition labeled is real is an empirical question. Postmodernism tends to blur these 2 questions, whereas scientific psychiatry must keep them separate.

Application to Psychiatry and the Anti-Psychiatry Movement

Applied to mental health, the postmodern critique has often portrayed society as enforcing its standards through the psychiatric profession, with psychiatrists functioning as a kind of medical police force. From this perspective, psychiatric diagnoses are not objective diseases discovered in nature but social labels assigned to people whose behavior, beliefs, or experiences fail to conform to prevailing norms. This critique became prominent during the anti-psychiatry movement of the 1960s and 1970s and entered popular culture through works such as One Flew Over the Cuckoo’s Nest. Not every critic of psychiatry was a postmodernist, and thinkers as different as Thomas Szasz, R.D. Laing, and Foucault should not be collapsed into a single philosophical school. Still, a shared theme was skepticism that psychiatric diagnoses represented diseases existing independently of the profession that named them.

Versions of this position remain common today in critiques of psychiatric medications, electroconvulsive therapy, diagnosis, and psychotherapy. Psychiatric diagnoses are described as “labels,” mental disorders as culturally produced narratives, and psychopathology as a judgment imposed upon people whose experiences deviate from social norms. Postmodern ideas are now frequently associated with progressive politics, but the underlying epistemology is not inherently left-wing or right-wing. The history of totalitarian movements, including Nazism, shows the danger of subordinating truth to political power: once objective truth is denied, those who hold power are freer to enforce their preferred ideas through propaganda, institutional authority, and social labeling. This is not to claim anachronistically that such movements were “postmodern.” It is to recognize that the mechanism—allowing power to determine what counts as truth—can serve radically different political ends. For psychiatry, the relevant question is therefore epistemological rather than partisan: Are some claims about mental illness more true than others because they correspond more closely to reality? We think the answer is yes.

The Paradox of DSM

Here we encounter a striking paradox in contemporary psychiatry. DSM-III, published in 1980, represented a major change in American psychiatry and is commonly associated with the return of descriptive diagnosis, operational criteria, reliability, and a supposedly more scientific approach. It emerged partly in response to the unreliability and theoretical sectarianism of mid-20th-century psychiatry, when psychoanalysts, biological psychiatrists, social psychiatrists, and others could examine the same patient and arrive at different diagnoses on the basis of different theories. Operational criteria were intended to reduce that problem, and to an important extent they did improve reliability. Yet reliability is not validity: 10 psychiatrists can reliably agree on a diagnosis that does not correspond to a valid disease entity, just as a bathroom scale that is consistently 20 pounds wrong can be highly reliable while remaining inaccurate.

DSM attempted to achieve consensus partly by becoming “atheoretical.” Rather than settle psychiatry’s major scientific and philosophical questions, it bracketed them so that clinicians from competing schools could use the same manual without agreeing about what psychiatric conditions actually were. That strategy had practical and political advantages, but the avoidance of theory is itself a philosophical decision. Historical scholarship on DSM-III demonstrates that diagnostic decisions reflected not only scientific evidence but also professional interests, compromise, reimbursement concerns, and the need to obtain consensus within the American Psychiatric Association.³ The construction of “major depressive disorder” is an especially revealing example: heterogeneous depressive presentations were placed under a broad diagnostic umbrella whose boundaries were influenced partly by professional compromise rather than reality.⁴

None of this means that every DSM diagnosis is false. Some DSM categories approximate genuine diseases or syndromes, whereas many others do not. The deeper problem is that the DSM framework provides no adequate scientific method for deciding which is which. In an earlier philosophical analysis, one of us (S.N.G.) noted an especially revealing defense of DSM revision: the claim that changes should ultimately be governed by “pragmatism”—what DSM leaders believe will work best for clinicians, patients, or society—rather than by science alone.⁴ Once that position is accepted, DSM becomes, at least in part, what its postmodern critics have long said it is: a social construction created to serve the preferences and purposes of a professional community rather than a scientific map of psychopathological reality.

The paradox, then, is that the critics and the establishment appear to stand on opposite practical sides while operating within the same theoretical framework. The critics explicitly adopt a postmodern, social-constructionist view of psychiatric diagnosis. The establishment defends DSM as a scientific medical standard, yet relies on consensus, utility, and pragmatism, which is postmodern through and through. The rhetoric differs, but the epistemology is remarkably similar: psychiatric knowledge is treated, in the end, as what a sufficiently authoritative group agrees to call knowledge.

Unconscious Influence and Generational Transmission

This convergence does not require DSM leaders, clinicians, or trainees to have studied Foucault, Lyotard, or Nietzsche. Philosophical assumptions do not require formal philosophical study; worldviews are transmitted culturally and institutionally and are often absorbed most deeply when they remain unnamed. Postmodern ideas crystallized in the decades following the destruction of World War II and became increasingly influential in the broader culture during and after the 1960s counterculture. The generations of psychiatrists who inherited and revised the DSM framework were shaped within that cultural environment even while the profession continued to speak the language of scientific objectivity.

The effect is now self-reinforcing. Many younger psychiatrists and psychotherapists have been educated entirely within a conceptual world in which DSM categories are the taken-for-granted starting point for thinking about psychopathology, while the philosophical assumptions beneath those categories are rarely examined. It can therefore become difficult to think outside the DSM box or even to recognize the distinction between a label created by a committee and the clinical reality that label is intended to describe. The problem is not that clinicians consciously endorse postmodernism. It is that postmodern assumptions operate unconsciously while psychiatry continues to imagine itself as philosophically neutral.

The Biopsychosocial Model: Postmodernism in Clinical Form

A similar problem appears in another pillar of contemporary psychiatry: the biopsychosocial model. George Engel proposed the model in 1977 as an alternative to what he considered an overly reductionistic biomedical approach.⁵ Its broad proposition—that biological, psychological, and social factors may all contribute to illness—is unobjectionable and, stated generally enough, almost certainly true. The difficulty lies in what follows from that proposition. Engel argued that biological, psychological, and social levels should all be considered in health care, but the model offers no principled method for determining which level matters most in a particular condition, how much it matters, or which treatment should follow. The result is eclecticism: the clinician is given a list of ingredients but no recipe.^6,7

Because all three domains are potentially relevant, a clinician can emphasize the biological, the psychological, or the social; medication can be added to psychotherapy, which can be added to social interventions, without the model itself specifying when one domain should take priority over another. Clinical decisions then drift toward the practitioner’s preferences. In this way, the biopsychosocial model reproduces the postmodern problem in clinical form: multiple perspectives are treated as permissible, but the framework supplies no external standard by which one can decisively be preferred or rejected. What is presented as “pluralism” therefore becomes unprincipled eclecticism. Nothing is forbidden; anything is possible: anything goes, and psychiatry becomes anarchy.

Do We Need to “Resuscitate” the Biopsychosocial Model?

A recent article in Psychiatric Times called for “resuscitating” the biopsychosocial model, arguing that contemporary psychiatry has become too biomedical and should recover psychological, social, cultural, and spiritual dimensions of assessment; it also lamented the loss of DSM’s multiaxial system and emphasized the value of a rich psychosocial history.⁸ No one but a Neanderthal would argue that psychiatrists should not know their patients as persons. Relationships, developmental history, culture, economic circumstances, religious beliefs, fears, hopes, and sources of meaning all matter, and psychiatrists should not become mere technicians who prescribe medications to DSM checklists. But none of this requires the biopsychosocial model. The H. pylori example invoked in that discussion actually illustrates why the causal question cannot be settled in advance: peptic ulcer disease became more effectively treated when scientific research identified a comparatively specific biological cause and medicine became more reductionistic about that particular disease.⁶ Reductionism is correct when reality is reducible and incorrect when it is not; philosophy cannot decide the matter beforehand.

William Osler’s medical humanism offers a better justification for knowing the whole patient than the biopsychosocial model does. One can treat disease according to the best available science while simultaneously treating the person who has the disease with humanity, curiosity, and respect.⁹ Science helps determine what illness we are treating; humanism helps determine how we care for the person who has it. These are complementary obligations, but they do not need to be collapsed into a single “model” which is not a model at all, but an excuse for postmodernist eclectic relativism.

Postmodernism in Psychotherapy

The postmodern influence is even more explicit in some areas of psychotherapy and psychoanalysis. Narrative, constructivist, relational, and intersubjective traditions differ from one another, and each contains clinically valuable ideas, so it would be inaccurate to label them all “postmodern.” Nevertheless, parts of the psychotherapy world have embraced claims distinctly congenial to postmodern thought: that there is no neutral observer; that reality is “co-constructed” within relationships; that there is no enduring mind outside of relational contexts; and that the therapist should be suspicious of claims to objective knowledge about the patient.¹⁰ Therapists are, of course, not neutral recording instruments. Their personalities, theories, feelings, countertransferences, and expectations affect what they perceive, and psychoanalysis recognized this problem long before postmodernism became fashionable. But acknowledging the influence of the observer is not the same as concluding that there is no object to be observed.¹¹

Subjective meaning also matters greatly in psychotherapy. A delusion may have meaning to the patient (or therapist), but the fact that an illness acquires psychological meaning does not imply that meaning causes or constitutes the illness. Certain postmodern currents in psychotherapy have encouraged suspicion toward diagnosis itself, privileging subjective narratives while questioning whether objective psychopathology can be known.⁷ When the clinician becomes reluctant to say that one formulation is more accurate than another even when one more accurately explains the patient’s condition, openness gives way to a kind of disguised dogmatism: in the absence of an external standard by which formulations can be judged, clinicians tend to fall back on the theories they already prefer. A framework in which every formulation remains possible is ultimately one in which very little can be wrong.

Beyond Dogmatism and Eclecticism

Psychiatry does not have to choose between biological reductionism and postmodern relativism. Karl Jaspers offered a better approach more than a century ago by insisting on what might be called methodological consciousness: different questions require different methods, and clinicians must understand both the strengths and the limitations of the method they are using.¹² Some psychiatric conditions are best approached primarily through biological methods, others require psychological understanding, and still others are principally related to social circumstances. Many involve more than one level, but even then those levels need not carry equal causal or therapeutic weight. This is method-based pluralism rather than eclecticism.^6,7,12

The distinction presented here has consequences. Eclecticism says that many approaches may be useful and permits the clinician to use whatever seems helpful; pluralism says that different approaches are valid for different problems and requires evidence and reasoning to determine which approach best fits which problem. Leston Havens made a similar argument in Approaches to the Mind, as did Paul McHugh and Phillip Slavney in The Perspectives of Psychiatry.^13,14 Psychiatry contains different kinds of problems, and no single explanatory method applies equally well to all of them. Such a view allows us to be medical without being reductionistic, psychological without being antiscientific, and pluralistic without becoming relativistic. It also preserves a distinction that postmodernism tends to obscure: objective facts and subjective meanings can both exist without being the same thing.

Concluding Thoughts

The deepest influence of postmodernism on psychiatry may therefore be found not only among those who openly criticize psychiatric medicine but within the profession itself. A diagnostic manual constructed partly through consensus and pragmatism while presented as scientific fact, a biopsychosocial model that permits almost any causal or therapeutic emphasis, and psychotherapeutic cultures that dissolve the enduring mind into relational processes and intersubjective constructions all share the same underlying problem: the weakening of an external standard by which claims can be judged.

The irony is considerable. The anti-psychiatry critic and the mainstream DSM defender may appear to occupy opposite sides of the debate, yet both arrive by different routes at a similar conclusion—that psychiatric knowledge is ultimately what groups of people agree to call knowledge. We disagree. Psychiatry should retain what was valuable in the postmodern critique: humility about authority, attention to history and context, recognition of observer bias, and awareness of the misuse of power. It should reject, however, the slide from acknowledging that we may be wrong to denying that there is any truth by which we can be shown wrong.

The alternative is neither dogmatic biological psychiatry nor an “anything goes” biopsychosocial eclecticism. It is a scientifically grounded, humanistic, method-based approach in which the nature of the condition determines the method, rather than the preferences of the clinician or the consensus of a committee. Psychiatry must recover its commitment to truth.

Dr Ghaemi is an adjunct professor of psychiatry at Emory University School of Medicine and a lecturer on psychiatry at Harvard Medical School, Cambridge Health Alliance. He is employed by Bristol Myers Squibb. The views expressed in this article are solely those of the authors and do not necessarily reflect the official policy or position of their employers.

Dr Ruffalo is an assistant professor of psychiatry at the University of Central Florida College of Medicine, where he is director of psychotherapy training in the adult psychiatry residency program. He is also an adjunct assistant professor of psychiatry at Tufts University School of Medicine and on the faculty of the New Jersey Institute for Training in Psychoanalysis.

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