Explanatory Methods in Psychiatry: The Importance of Perspectives

Awais Aftab, MD

Paul R. McHugh, MD

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.

CONVERSATIONS IN CRITICAL PSYCHIATRY

Paul R. McHugh, MD, is University Distinguished Service Professor of Psychiatry at the Johns Hopkins University School of Medicine. He was the Henry Phipps Professor and Director of the Department of Psychiatry and Behavioral Sciences at the Johns Hopkins University School of Medicine and Psychiatrist-in-Chief at Johns Hopkins Hospital for 26 years. He is also the inaugural Director of the Paul R. McHugh Program for Human Flourishing. Dr McHugh is a nationally recognized figure: he was elected a member of the National Academy of Medicine in 1992, and from 2002 to 2009, he was a member of the President’s Council on Bioethics. He is the author of many books, most popularly of The Perspectives of Psychiatry (co-written with Phillip Slavney, MD), which presents a conceptual framework for the proper evaluation and understanding of psychiatric disorders.

Building on the philosophical work of forerunners such as Adolf Meyer and Karl Jaspers, The Perspectives of Psychiatry identifies four explanatory methods underlying the practice of the profession. In Perspectives, generations of psychiatrists have found a nuanced, unifying approach to the field, which the biopsychosocial model and the DSM had promised but never delivered. Although the Perspectives approach was not formally taught during my residency, I was fortunate to work with several attendings who exposed me to the book, which led me to delve into the ideas on my own. The Perspectives approach demonstrates to me what a mature, pluralistic psychiatry can look like. It is my honor that Dr McHugh accepted my request to engage in a conversation regarding his ideas.

Awais Aftab, MD: It is a rare feat for a conceptual book on psychiatry to generate as much acclaim, influence, longevity, and readership within the profession as has The Perspectives of Psychiatry. When the first edition was published in 1983, did you expect that the book would be such a hit and that people would still be reading and recommending it nearly four decades later? Why do you think the book has endured for so long?

Paul McHugh, MD: When Phillip Slavney and I conceived and wrote The Perspectives of Psychiatry, we certainly expected it to be noticed because it strove to make explicit what was often implicit (and, to patients, mysterious) in psychiatric thought. And, we expected it in some way to endure in that it identified fundamentals of mental life that would not change. We didn’t expect it to be a hit given its challenges to several established views and, for that matter, we do not think it is a hit now given that few departments of psychiatry teach from it. Although it may not have boomed, it certainly did survive-this year it is being translated and published in Japan-and mainly for the reason I mentioned: both psychiatrists and patients recognize that it clarifies the clinical enterprise by identifying, distinguishing, and reflecting on the methods psychiatrists employ in making sense of mental distress and disorder. It also heuristically directs treatment and research gives it practical value.  

Aftab: As popular as the Perspectives approach is, the biopsychosocial model remains the closest thing to an officially accepted conceptual framework in the field. From the nuanced viewpoint of Perspectives, the biopsychosocial model appears very vacuous and eclectic. Perhaps it’s the very vacuousness and eclecticism that explain the model’s widespread acceptability?

McHugh: You’re certainly correct in noting the common acceptance of the biopsychosocial model that George Engel was describing (and deriving from Adolf Meyer) just at about the time we were composing Perspectives. We think the biopsychosocial model survives because it can act as a slogan justifying any practice. It falters because it is neither refutable nor heuristic. By solemnly noting the obvious underpinnings of human life but providing no way to derive mental distresses and disorders from them-essentially offering ingredients without recipes-it’s sophistry.

Aftab: You have outlined in detail four perspectives (ie, brain diseases, personality dimensions, motivated behaviors, and life encounters), and the list has remained unchanged over your career so far. Are you open to the idea that there are valid perspectives other than these four? For instance, I can think of at least two. First, the evolutionary perspective, particularly situations of design-environment mismatch in which a brain mechanism that has evolved via natural selection thousands of years ago is now placed in a modern 21st century environment for which it was not designed, leading to distress or impairment. (There is no internal broken part, hence no disease). Second, the sociological perspective, which sees mental health issues in a population as a response to various social forces (for instance, Allan Horwitz’s work on depression). The sociological perspective is different from the individual life story perspective because it deals with complex phenomenon at the social level that cannot be described in terms of individual psychology.

McHugh: Although we believe that together the four perspectives we’ve outlined broadly and inclusively address the clinical explanatory problems of psychiatrists, we are open to the idea of other perspectives.  We certainly have had many such proposed to us, including a developmental perspective, a neurobiological perspective, a sociological perspective, and many others, but we have usually concluded that the proposers have not grasped what we mean when we speak about psychiatric perspectives and what we were doing in choosing these four.

Specifically, we were not writing a book that could carry the title “Causes of Psychiatric Disorder.” We were writing a treatise on the different methods psychiatrists need and use to make sense of mental disorders, and we were proposing that they derive those methods from what they can “see” of conscious mental life. We think psychiatrists are (or should be) aware of four basic, interactive, functional features of the mind that represent the compositional attributes structuring conscious mental life. Each of them can be viewed as a potential site of mental unrest. Those four are:

1. The intrinsic features-consciousness itself, memory, language, cognition, affect and the like;

2. The self-defining features-the individual’s intelligence, temperament, maturity, etc.;

3. The teleological features-hunger, thirst, sex, etc., and the wants and ‘needs’ tied thereto; and

4. The extrinsic/experiential features-responsivity to life events, social networks, education, etc.

Together, our four perspectives offer a way of making sense of mental disorders by drawing on these features and simultaneously offer a way of making sense of (ie, formulating) mental disorders in particular patients where a mix of perspectives can be expected. The disease perspective describes how psychiatrists strive to make sense of how neurobiological injuries can come to disrupt the functioning of one of the intrinsic features, as with delirium, dementia, or bipolar depression.  The dimensional perspective describes how psychiatrists strive to make sense of the vulnerabilities of some individuals to emotional unrest tied to aspects of the self-defining features characterizing them, such as the intellectually disabled, the histrionic, or the compulsive.  The behavior perspective describes how psychiatrists strive to make sense of such problematic, habit-sustained activities that arise from the teleological features, as with anorexia nervosa, alcohol dependency, or the sexual paraphilias. The life story perspective describes how psychiatrists strive to make sense of the emotional distresses that are generated by the play of events upon the extrinsic/experiential features of mind, as with grief, post-traumatic stress disorder, or demoralization.

This separation of the perspectives must not presume their independence of one another given that the functional features on which they rest interact. For example, an anxious patient (dimensional perspective) may develop an alcoholic dependency (behavior perspective) that could cause a demoralizing job loss (life story perspective) thereby prompting an increase in drinking, all leading to his clinical presentation with delirium tremens (disease perspective).

Given all this, we would view your two suggestions not as new or separate perspectives but as causal factors either shaping one of the mind’s basic features or an element in one of the four we describe. Thus, the evolutionary facts you identify as presenting problems in the contemporary era usually do so by altering the teleological features of mental life. So, for example, the genetic controls on food intake and calorie storage that evolved in some peoples and were useful for survival in times of shortage and deprivation can lead, if persisting amongst them, to overeating and obesity in times of plenty in today’s world. Still, the presenting problem of the patients would be behavioral in expression and emerge as alterations needing therapeutic attention in the drive, conditioning, and decisional aspects of their food intake. The social forces (including those studied by Allan Horwitz or Nicholas Christakis) provide the setting of the subject’s life experience and would be grasped in the life story perspective, where the triad of setting, sequence, and outcome make sense of the problems. While we are open to new perspectives, we argue, from what we mean by perspective, that a new one awaits the description of another compositional feature of the mind.

Aftab: What conceptual issues in psychiatry are the most important in your view? Issues that the new generation of psychiatrists and their conceptual comrades should focus on?

McHugh: The most important issue for psychiatrists to recognize today is that their discipline is at stalemate; it’s hesitating to come of age. This is an obvious problem of leadership.  Officially, the discipline will only codify the disorders it takes for its concerns rather than strive to classify them by their presumed nature as does internal medicine. Many psychiatrists are at a loss as to what disorders their discipline should claim. Instead of boldly stating that this discipline takes responsibility for any expression of human mental disarray from Alzheimer disease to zoophilia, many psychiatrists wonder whether mental disorders with known brain derivations shouldn’t be surrendered to neurologists. They anticipate that the advance of neuroscience will deprive them of their professional position, rather than enhancing what they could know and do.

The solution? Psychiatrists must understand that all aspects of mental life (including the mental disorders) are derived in some way from the brain but not in the way urine is derived from the kidney or bile from the liver. The derivation of mind from brain takes the form of an emergent property with constituent features and functional rules that cannot be directly reduced to knowledge of the neural systems from which it, the mind, emerges. Psychiatry is thus an autonomous medical discipline dealing with the kinds of clinical problems that present within the emergent mind. It’s time for its practitioners to start thinking and acting accordingly, perhaps by officially noting the ways those clinical problems can be organized according to what’s known of their natures.       

Aftab: In your opinion, what determines whether a particular condition is or is not a mental disorder? Is there an objective, fact-based answer to this (at least in part), or is it a thoroughly value-laden determination?

McHugh: We hold, and have specifically stated in our book, that because psychiatrists must employ several distinct methods to make sense of all the various disorders and distressful states they see, the definition of psychopathology, what is meant by normal, and the treatments that are suitable will differ with the perspective or perspectives that fit.

For example, the identification of a broken part or pathologic entity confirms the categorical designation of abnormality by the Disease Perspective. A patient here is somebody who has something “normal” people don’t. Similarly, the Dimensional Perspective makes sense of a troubled person as “abnormal” only in a statistical and arbitrary sense by showing their  vulnerability or at-risk status for emotional unrest depends upon their psychological deviation from the mean along the normal Bell-shaped distribution curves of human intelligence or temperament. One is identified as a psychiatric patient because of who one is.

The Behavioral Perspective encompasses people who are patients because they persist in enslaving activities that bring physical, psychological, and social disasters in their wake. They are identified as patients because they are doing something ordinary people don’t. Those whom psychiatrists recognize as people responding to a set of circumstances-such as the grief stricken, the demoralized, the traumatized, and the like-and whose plight psychiatrists grasp within the Life Story Perspective are patients primarily in the sense that they are people seeking professional (ie, diagnostic, prognostic, or therapeutic)  help because of the persistence or severity of their “normal” suffering, and those features usually depend not on them but on the intensity and significance of their loss or injury. They are patients because of what they’ve encountered. We think all these matters are of an objective fact-based nature and relate coherently to the complex issue of “normality.”

Aftab: In The Mind Has Mountains: Reflections on Society and Psychiatry, you wrote: “It certainly was no coincidence that Engel’s biopsychosocial concept, a restatement of Meyer’s position, emerged into prominence in the same decade as DSM-III. It met and satisfied the same felt need as had its predecessor. Psychiatry in the United States is replaying a set of themes from earlier in this century. It is both neo-Kraepelinian and neo-Meyerian.”

Your approach in some ways channels a different 20th century predecessor-Karl Jaspers. It’s interesting that more than a century later the Kraepelinian, Meyerian ,and Jasperian ghosts are still alive in psychiatry.

McHugh: We have, as you know, made no secret of the influence of Karl Jaspers on our thought. He did produce the first coherent study of methods of psychiatric reasoning that emphasized their strengths, weakness, and apt employment. Inspired by his example, we have striven to advance from Jaspers by both operationalizing methodological themes that he recognized and specifically differentiating methods of reasoning tied to distinct patient populations from one another. We believe that we have succeeded in that The Perspectives of Psychiatry has proven its value in advancing teaching, treatment planning, and research in our department at Hopkins in a way that the abstractions of Jaspers alone could not.   

Aftab: The Perspectives approach applies to individual patients, but you also talk of Perspectives approach as applying to particular conditions or disorders. Unless we can demonstrate that individuals with a particular condition are highly homogenous in terms of etiology (which is rarely the case in psychiatry), I am not sure we can validly talk about Perspectives applying to a disorder as a uniform category rather than individual patients, since whatever is said of a disorder may or may not be applicable to a particular individual with that condition?

McHugh: What you are saying is of course the very reason why we chose the metaphor perspectives-to remind ourselves and our students that an approach to an individual patient requires us to take into account several different aspects of their life and state of mind in making sense of their presentation; reminds us to formulate rather than simply diagnose the problem.  A Perspectival review structures and operationalizes the several elements of a formulation. On the other hand, it would be wrong to ignore that, for many clinical presentations, one perspective is so salient it can stand for the generative nature of the case. Some presentations are those of disease, some are behaviors, etc. Such examples can be used to develop a psychiatric classificatory system that will move from a denotative one (DSM-III et al.) in which disorders are named, described, and listed as would a field guide to birds or flowers  to a connotative one in which psychiatric conditions are distinguished and separately classified according to what’s understood of their primary cause, provocation, or generative mechanism as is standard with medical classifications.    

Aftab: In the heyday of psychoanalysis, it was a particular version of the life story perspective that reigned tyrannically, and these days the disease perspective threatens to engulf all the other perspectives. This problem is evident in the rhetorical statement “‘all mental disorders are diseases’” that has become the de facto mantra of not just psychiatrists but also patient and mental health advocacy groups. It seems to me the term disease is now being used in such a flexible manner that it is beginning to lose any specificity with which it may originally had.

McHugh: We, of course, are in full agreement with your view and attribute it to the commitment of psychiatry to the top-down checklist method of diagnosis tied to DSM. Steve Sharfstein said something of the same when he noted in his APA presidential address that the biopsychosocial approach had become the bio-bio-bio approach. However, there are many defenders of this development, some believing that it’s the way to advance a sense of the neuroscientific foundations of psychiatry; others believing that it reduces stigma and helps psychiatric patients by fundamentally making them all “victims” of some impersonal entity or afflicting disease. As far as the addictions are concerned, it has become an ideology-and one that will ultimately frustrate progress and patient care.    

Aftab: What are your thoughts on how to address psychiatry’s uneasy medical identity? For me, there are two ways to think about it. One, we can expand the boundaries of medical model to include all mental health conditions within it. This is the approach that we seem to have adopted at present. Since there is no hard and fast distinction between disorder and problems of living, it brings with it the downside of medicalization and pathologization (which is a constant complaint we hear these days). The other option, in my mind, is to acknowledge that psychiatry is a branch of medicine but that it is not just a branch of medicine; there are aspects and traditions within it that extend beyond the domain of medical model as traditionally understood (psychoanalysis, for instance-Freud never wanted to restrict it within the domain of medicine) and medicine does not have sole authority over psychological distress.

McHugh: This is an awkward question for me to answer given that I’ve never felt uneasy in my medical identity, that is, of being a doctor working to understand and treat patients with problems in mental life. I’ve also never felt the salvationist urge that provoked Freud to venture forth with his presumptions about human civilization and take on the mantle of Moses. In fact, I’m happy to accept the traditional, patient-centered limits to psychiatric service by devoting my thoughts and actions to the care of people who in one way or another are expressing distress or dismay in how they’re thinking, feeling, or behaving.

I’m happy to leave to other professions-those of law, education, government, and the like-the problems and solutions that they develop and derive from their experience and traditions. I’m happy to help-and sometimes to correct-if any enterprise in these arenas touches upon psychiatric matters or seems to be moved by erroneous views of disordered mental life. Those are rare. There is, though, one sense that all doctors including psychiatrists should extend their services beyond the strictly medical enterprises of diagnosis and treatment and that is in the public health arena of prevention and flourishing. I hold that psychiatrists have their own understandings about human development and welfare that, like physical hygiene, offers not only protection against illness but also advice on life directions and social protections that facilitate a person’s full, natural, healthy flourishing. I just don’t see that this kind of effort stretches the medical identity of psychiatry.

Aftab: You’ve been vocal about various cultural fads of diagnoses in which psychiatrists have been complicit. Do you have any hope that psychiatrists of the new generation are in a better position to protect themselves against such trends, or does your experience lead you to a state of despair in this regard?

McHugh: I have spoken out on a variety of psychiatric misdirections in my time, considering it my duty as one holding a distinguished academic position in the country. Along with that experience, I have occasionally wondered whether it is the fate of this discipline to take up some new craze every 15 or 20 years. Like physical health, mental health is open to social enthusiasms and presumptions that can sway the thought and actions of practitioners. Physical medicine, in contrast to psychological medicine, is protected from persisting in a craze by following fairly objective criteria-often laboratory based-in assessing success and failure. In the realm of the mind, fads run more freely and critics of them don’t often face convincing, reassuring data from the fad’s champions but insulting charges of bad faith and personal hang-ups. Sigmund Freud’s savagery against any critic of his views is the classical example. Also, to win a place in the medical taxonomy requires more than the simple votes of practitioners that brings admittance to DSM. New and protective demands thwarting fads might be found if the psychiatric classificatory method moves beyond the descriptive DSM. Demanding a place in one of the Perspectives might be a good start.  

Aftab: A lack of reliability has plagued psychiatry since the very beginning. DSM’s agnostic approach to psychiatry was partly meant to remedy that. Does reliability tend to be a problem for the Perspective approach? Since many individuals present with a mix of affective problems, anxiety, personality traits, traumatic life stories, and behavioral addictions, I’m sure psychiatrists can and do disagree on which perspective to consider most salient in a particular individual case.

McHugh: Like everyone in the early 1980s, I supported the reliability enterprise that Bob Spitzer advanced in the midst of the diagnostic confusions in psychiatry that came with the collapse of psychoanalysis and the rise of psychopharmacology. Much good came from this amazing feat of statesmanship on Bob’s part, as in pacifying clinical argument and in providing consistency for cross-laboratory case identification and for a population-wide census of mental disorders understood in DSM terms. It gradually dawned on me that DSM functions in identifying mental disorders just as does a naturalist’s field guide for naming birds, wildflowers, or trees with all the seductive ease and narrow purposes of that artificial classificatory method. It ran on the hope that future research-which with its “agnostic”, a-heuristic approach, it could not even suggest-would rescue it.  I had my doubts, then and now, closing on forty years later. I see that we’ve not advanced but are practicing psychiatry with checklist diagnoses and rule of thumb therapies, and we are still hypnotized by reliability as a gold standard. With the Perspectives of Psychiatry, we’ve striven to replace the DSM mantra of “reliability first, validity second” with the more challenging, future advancing one of our own: “intelligibility first, explanation second.”

And so to finally answer the question you’ve asked: Does our approach produce diagnostic and therapeutic disagreements? Indeed it does, but disagreements of the healthiest kind in which the arguments are about what makes the most sense for the patient at hand given the mixture of generative sources of distress and disorder the Perspectives bring to light. These disagreements (mostly over what to emphasize in a formulation and what to do given what we agree on) matter because they identify what doctors and patients want to know. That is,  have you really thought through the issues this patient presents and formulated them and the linkages between them coherently? Will your experience with this patient add to your capacity to care for others like him or her? And, finally, what research tied to your conclusions should we encourage to confirm or refute them so as to advance us all? When this is the daily enterprise of psychiatrists everywhere, the field will, at last and like medicine and surgery, have come of age.

Aftab: Any words of advice for psychiatry trainees?

McHugh: Know where you are and where this discipline must eventually go. In the process, see many patients, study each of them with a bottom-up method of assessment similar to that originally described by Adolf Meyer, then formulate and discuss the patients according to the interactive themes that The Perspectives of Psychiatry suggest. When possible, alone or with others, launch some research into questions your patients present. If you do all that, you’ll play a role in advancing your times. And I’m assuming that’s what you wanted to do when you joined the profession.  

Aftab: Thank you!

Dr Aftab is a psychiatrist in Cleveland, Ohio. He trained in geriatric psychiatry at University of California San Diego (2019) and completed his psychiatry residency from Case Western Reserve University/University Hospitals (2018). He has been actively involved in initiatives to educate psychiatrists and trainees on the intersection of philosophy and psychiatry. He can be reached at awaisaftab@gmail.com.

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

Previously in Conversations in Critical Psychiatry

• Allen Frances, MD

• Anne Harrington, DPhil

• Derek Bolton, PhD