Integrating Academic Inquiry and Reformist Activism in Psychiatry

Awais Aftab, MD

Sandra Steingard, MD

G. Scott Waterman, MD

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.

Continued >

Aftab: You suggest: “Rather than increasing access, psychiatrists should constrain their purview. Many people who experience emotional distress do not require medical attention. They can often be helped by the many others who have considerable expertise in this area.”³

How do you think we can decide what forms of emotional distress require the attention of a psychiatrist and what don't? Does this imply that there are forms of emotional distress that are legitimate targets of medical attention and there are others which are not? Furthermore, I don’t think this is something that psychiatrists can decide unilaterally; the patients can simply go to other medical providers, such as primary care physicians and nurse practitioners (the vast majority of antidepressant prescriptions in USA even today are written by PCPs rather than psychiatrists). What would need to happen is a massive societal shift in how we as human beings conceptualize our distress and what we as a society consider to be appropriate candidates for medical evaluation.

Steingard: I agree that at this point the problem is as much societal as psychiatric. In this way, psychiatry has been hugely successful-or at least an active participant-in promoting the medicalization of human distress. The constriction of purview would come about with a more honest reckoning regarding the risks and benefits of the drugs we prescribe. The SSRIs are a good example. When they were first introduced, they were considered to be highly beneficial and generally benign. This contributed to their broad use. Over time, data have emerged that challenge their efficacy and safety. Yet, such findings have not fully penetrated into the cultural consciousness. I believe that psychiatrists have an obligation to be more open about the limitations of the drugs we use.

Aftab: Dr Waterman, you have criticized the nosological separation of ‘psychiatric disorders’ from ‘medical disorders’ in several of your writings.^4-6 Can you talk about this separation in conjunction with the question of how we can draw the boundary of what constitutes medicine?

Waterman: As you well know, efforts at defining “disease” (or its near-synonyms, “illness” or “disorder”) have failed to achieve the goal of capturing in a single formulation what turns out to be a rather diverse set of usages in actual practice. To the extent that medicine as a discipline is organized around the concept of disease, it is unsurprising that its boundaries are commensurately indistinct. And to the extent that, at least aspirationally, medicine seeks to expand its purview into the arena of “wellness,” its borders become even more effaced. None of that acknowledgement of ambiguity, though, mitigates concerns over the potential harms of medicalization of aspects of the human condition for which the implication of disease might have untoward consequences (save for shareholders in pharmaceutical companies). And those aspects of the human condition are by no means limited to the psychiatric realm. Anyone who watches television (especially programs aimed at an older demographic) is routinely directed to “ask your doctor” about treatments for an alphabet soup of phenomena like “ED” or “OAB.”

Nevertheless, the medicalization of an ever-expanding range of emotional distress might be especially problematic, as Sandy suggests. But I don’t see that demarcation question as being congruent with that involving the nosological separation of “psychiatric” from “medical” disorders. My conceptual concerns about the latter line of demarcation arose in the context of medical education, where an unsophisticated (and largely unexamined) Cartesian dualism holds sway. My aim as a medical educator was to expose the unacknowledged but unmistakable premise that “medical” (or, alternatively, “physical”) illnesses are reflections of abnormal bodily structures or functions (despite the fact that many etiologies remain unknown, and the influences of the physical and social environments can be large), while “psychiatric” conditions necessarily implicate processes of a categorically different sort. I am not averse to (for example) George Graham’s formulation that psychiatric disorders are distinguished from other conditions by the centrality of consciousness and intentionality (that is, mental states are about something in ways that states of the body are not). But I’m not sure that justifies making the medical/psychiatric distinction the first nosological branch point in differential diagnosis.

Aftab: You have been a vocal critic of the “rampant mind-body dualistic fallacies embedded in medical discourse, training, and practice.”^5[PDF] In 2006 you wrote in a commentary piece for Psychiatric Times: “Into what conceptual structure, then, does modern psychiatric science fit? The answer, I believe, is a mature biological, or “holobiological,” model. This is in contrast to the crude and naïve biological reductionism of an earlier era that discounted the role played by the interpersonal environment in the etiopathogenesis and treatment of illness and to which the BPSM was in some ways a response. This mature or holobiological model is one that accommodates within an explicitly monist/materialist framework the broad range of inherited and acquired phenomena that are salient to human disorders. Its mode of explanation is gene and environment action and interaction in the production of disease phenotypes and therapeutic responses.”⁶

Do you still lean towards such a holobiological model or have your views changed since then?

Waterman: Some of my views-or, at least, my emphases-have changed since then. I was particularly motivated then by what I saw as the importance for medical students and residents, who are steeped in the study of biological and biomedical science, to understand that biology encompasses within it the responses of organisms (including humans) to their environments. Indeed, response and adaptation to the environment is intrinsic to biological understandings. Whether intended or not, the effect of the biopsychosocial model I witnessed throughout my career in medicine was to separate these phenomena such that processes conceived of as occurring entirely within people were termed “biological” while those that derive from events in the external world were considered “psychosocial.” And, crucially, the interactions of those two types of causal influences were treated (inexplicitly) as mysterious in much the same way that mind-body interaction appears intractable in Cartesian philosophy.

Although my metaphysical commitments have not changed much since I wrote what you quoted above, my priorities have-or, at least, they have been augmented by others. Specifically, I have come to recognize that even a scientifically updated and philosophically coherent “holobiological” model of the sort I suggested as a replacement for the biopsychosocial model inevitably gives short shrift to a number of major influences on human misery and dysfunction. Those include poverty, racism, homophobia, and other injustices whose effects are not specific to consumers of psychiatric services; as well as denial of autonomy, agency, and epistemic authority, the effects of which fall particularly hard on those considered mentally ill. Thus, while I continue to believe it important to challenge the dualistic fallacies that the biopsychosocial model more commonly reifies than corrects, it is even more important that the full range of drivers of human suffering be identified.

Aftab: Dr Steingard, what are your own views regarding the best philosophical framework to explain the mind-body relationship in reference to psychiatry?

Steingard: Philosophers have wrestled with this one for ages and I doubt that I have much to add to the discussion. In the absence of a resolution of the problem, though, more sophisticated treatment of its complexities might serve as an antidote to what are often muddled conceptualizations of it in our field.

I prefer to acknowledge the many uncertainties of our field rather than promulgate inadequate explanations founded on simplistic formulations of the mind-body relationship.

Aftab: You have talked about the flaws and limitations of DSM as a diagnostic manual. Clearly clinicians need to be more cognizant of these limitations and be more honest about them in interactions with patients. However, beyond that, what is the alternative? In your opinion, what would a better diagnostic system look like?

Waterman: I don’t think any topic in psychiatry has received more attention in recent years than this one. But I guess a little more can’t hurt. When designing a system of any sort, the first question to address is what you want it to help you accomplish. I am hardly the first person to observe that the goal of facilitating clinical (including education and training), research, and administrative functions was unlikely to be optimally fulfilled by any one taxonomy of psychiatric disorders. So perhaps predictably, with the possible exception of the final item on that list, the DSM system has largely failed. I would suggest further that it has not only failed to facilitate optimal clinical care, education and training, and scientific investigation in psychiatry; once it became established as a hegemonic orthodoxy (as opposed to a provisional improvement on what preceded the DSM-III), it began to exert detrimental effects by spuriously reifying the entities it defines, by diverting the attention of students and trainees from more useful learning objectives, and perhaps by retarding progress in understandings of causes and therapies (as the NIMH has apparently concluded).

Now we face the question of what can be learned from this experience. It seems to me that the notion that a psychiatric nosology should aspire to describe and catalog every manifestation and permutation of human discomfort is unrealistic. The complexities of the brain and of the social environments within which it functions are such that the proposition that psychiatric problems should come in a tractable number of packages, each sufficiently discrete (etiologically, phenomenologically, etc) to make categorical diagnosis meaningful and useful, is likely misguided. Dimensional (quantitative) approaches to taxonomy address some of these concerns but have been rejected as replacements for the DSM system, largely on grounds of practicality.

Before formulating a new system, we should remind ourselves of what diagnosis is intended to accomplish-namely, to summarize as succinctly as possible what is known about a malady with which a patient is suffering. Sometimes that can be accomplished with a single word (for example, “tuberculosis”) or brief phrase (“congestive heart failure”). To the extent that psychiatry has some such words or brief phrases that have shown themselves over time to impart useful and reasonably precise information about the symptoms they purport to describe (“acute mania,” for example), they should be retained. But for the most part, we should resist concretizing diagnostic nomenclature that can mislead at least as easily as it can enlighten. If needed for administrative purposes, something akin to the chapter headings of DSM can be retained, but clinically useful descriptions of the heterogeneous problems with which actual patients present for help often do not lend themselves to drastic abbreviation. Some will object to this suggestion, pointing out that we depend on diagnostic categorization to direct us to interventions that are likely to be helpful to patients. But the validity of that objection is belied by the recognition that the correspondence between diagnostic categories and responses to particular therapies is weak.

My answer to your question, then, is that the assumption of a need for a comprehensive categorical diagnostic system should be reevaluated in light of the likelihood that such systems might be (at least at our current state of knowledge) more misleading than helpful. And to the extent that DSM-type diagnostic categories will remain in use for the foreseeable future, efforts at educating students, trainees, our colleagues, and the public about their serious limitations will be vital to mitigating the harms associated with their reification and to steering psychiatric discourse, training, and practice in what we can hope might be more valid and fruitful directions.

Aftab: I am curious as to how you two have influenced each other’s views of psychiatry over the years. What have you learned from each other and how have you navigated disagreements?

Steingard: Scott introduced me to philosophy-he was the one who gave me Adolf Grünbaum’s book and he took (dragged?) me to a Patricia Churchland lecture around the same time. I have come to appreciate that philosophical inquiry is a fundamental component of critical discourse. Over the course of 35 years, we have had an ongoing discussion about our shared profession as we each tried, in our own ways, to make sense of our work and the ways in which we could be helpful. I appreciate that I have had a partner who is intellectually gifted because he has repeatedly challenged me to think carefully. As for how we have navigated our disagreements, I would quote our younger daughter who once wrote about family dinners that “They [the adults] called it a ‘discussion’ but it sounded more like yelling to me.” I hope that, if she were asked, she might also talk about love, respect, and laughter, but you may need to interview her to find out.

Waterman: Our psychiatric interests have been sufficiently similar that it has come naturally to share observations and ideas, but sufficiently different that we supplement each other’s experiences and perspectives in ways that (speaking for myself, anyway) have been extremely useful. My career in psychiatry has changed focus several times over the decades but has never included the kind of work Sandy does in the public sector. Without her insights into the effects of several elements of contemporary psychiatric practice on some of society’s most marginalized and vulnerable members, the range of my own awareness of the profession’s problems would have remained far more restricted. And her involvement over recent years in the growing critical psychiatry movement has brought me into contact with a wide variety of people-clinical, academic, and journalistic activists and members of the consumer/survivor/ex-patient community-who have expanded my perspectives and enriched my understandings enormously. Sandy and I rarely disagree on major conceptual matters, but of course even subtle points of contention can engender vehement argumentation from time to time (Freud’s coinage of the expression “the narcissism of small differences” comes to mind). Such disputes are, for the most part, settled through reasoned discourse, only rarely involving briefly raised voices. Our set of china remains intact after many years.

Aftab: Thank you!

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

Dr Aftab is a psychiatrist in Cleveland, Ohio. He completed his psychiatry residency at Case Western Reserve University/University Hospitals and trained in geriatric psychiatry at University of California San Diego. He is a member of the executive council of Association for the Advancement of Philosophy and Psychiatry and has been actively involved in initiatives to educate psychiatrists and trainees on the intersection of philosophy and psychiatry. He is also a member of the Psychiatric Times Advisory Board. He can be reached at awaisaftab@gmail.com.

Previously in Conversations in Critical Psychiatry

Relentless Warrior for Mental Health: Allen Frances, MD

The Structure of Psychiatric Revolutions: Anne Harrington, DPhil

Skepticism of the Gentle Variety: Derek Bolton, PhD

Explanatory Methods in Psychiatry: The Importance of Perspectives: Paul R. McHugh, MD

Chaos Theory With a Human Face: Dr Niall McLaren

The Rise and Fall of Pragmatism in Psychiatry: S. Nassir Ghaemi, MD, MPH

Disclosures:

Dr Aftab, Dr Steingard, and Dr Waterman have no relevant financial disclosures or conflicts of interest.

References:

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.