Skepticism of the Gentle Variety

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Awais Aftab, MD

Derek Bolton, PhD

Conversations in Critical Psychiatry: Derek Bolton, PhD

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.

Dr Derek Bolton is Professor of Philosophy & Psychopathology at the Institute of Psychiatry, King's College London, UK and Honorary Consultant Clinical Psychologist at the South London & Maudsley NHS Foundation Trust, UK. He completed his doctorate on Wittgenstein’s philosophy and subsequently trained in clinical psychology. Professor Bolton is recognized internationally as a distinguished voice in philosophy of psychiatry. He has many books and article to his credit, including What Is Mental Disorder? An Essay in Philosophy, Science and Values (Oxford University Press, 2008) and the open access ebook The Biopsychosocial Model of Health and Disease: New Philosophical and Scientific Developments, co-written with Grant Gillett (Palgrave Pivot, 2019).

I have long been an admirer of Dr Bolton’s writings, and I consider him to be among the most nuanced of philosophical commentators in the field. I read What Is Mental Disorder? prior to starting my psychiatry residency (and have revisited it numerous times since) and it is difficult for me to imagine another book that has had as much influence in shaping my thinking on psychiatry. What I find the most fascinating about Dr Bolton’s work is that although he subjects the notion of ‘mental disorder’ to rigorous philosophical scrutiny and finds it seriously deficient, he presents a sympathetic philosophical defense of the institution and practice of psychiatry as a response to psychological suffering.

Awais Aftab, MD: I want to start off this interview with an excerpt from your bookWhat Is Mental Disorder? It is my favorite passage from the text and I invariably include it in my lectures when I’m teaching on philosophy and psychiatry because it’s so well-articulated:

“The place the essay has ended up can be described as sceptical – a scepticism of the gentle variety.... there ends up being, so far as I can see, no stable reality or concept of mental disorder; it breaks up into many, quite different kinds, some reminiscent of an old idea of madness or mental illness, others nothing like this at all…

That said, the scepticism is just about whether there is something stable, fixed and distinctive here, for which ‘mental disorder’ is a suitable name. It does not include doubts about the reality of the phenomena: the distress and disabilities that people bring to the clinic, and the need for psychiatric care. The domain of healthcare as a response to personal distress and disability seems to me permanent, only mistakenly seen as something to be deconstructed away. There may be no clear basis for distinguishing between mental health problems and social problems, or between mental health problems and ‘normal – more or less normal – problems of living’, but what distinguishes healthcare is the response to the person involved. The response is care for the individual, based on professional training, science and expertise, distinct from social or political action, or religious judgement, or demands for self-reliance.”^1(pvii)

I guess one way to paraphrase your argument is that what defines psychiatry is not something distinctive about the nature of mental suffering but rather a distinctive kind of response to that suffering. Would you agree with this characterization?

Derek Bolton, PhD: I would say something involving both of these factors. The problems of mental suffering that people bring to the clinic is distinctive in that it is typically unmanageable or intolerable, in effect blurring into impairments of functioning. This can be contrasted with distress that people find they can manage with, which, and in this sense, can be called ‘normal’. But when the person, with more or less support from friends and family, finds the situation unmanageable, they have reason to seek outside expert help, and, if they construe the problem as a health problem, the appropriate help would be healthcare. This is why I make use of the expression “what people bring to the clinic.”  Health problems and healthcare are entangled both practically and conceptually. In this kind of approach I have followed papers written on conceptualizing mental disorder in and around the 1970s, by commentators such as Robert Spitzer, Janet Williams and Donald Klein.^2-4 To me they are very high quality and still the best.

Aftab: You've mentioned your experience of suffering from life-long stammer, which as you note is one of the conditions classified as a “mental disorder” (now called Childhood-Onset Fluency Disorder in DSM-5). I am curious as to how you conceptualize your own experiences. For instance, Gary Greenberg when talking about his depression in Manufacturing Depression writes “But it simply never occurred to me to think of myself as sick.”⁵ I was very shy growing up and experienced a lot of distressing social anxiety well into young adulthood. I never thought of myself as being sick though, or as having a disorder, or a chemical imbalance (and I still don’t). I don’t think there is an objectively correct answer to this either way, but it makes a difference to us how we conceptualize our psychological distress.

Bolton: As a child into early/mid adolescence, my stammer was for me an untheorized speaking difficulty. Once serious reflective thinking clocked in around late adolescence to early 20s, I grasped eagerly for any idea and for any available therapy that might help me get over it. I don’t think I ever would have thought of myself as sick, a term that connotes for me more having a fever in bed. I don’t think I would have quarreled had a professional labelled me with having a ‘disorder’ – certainly I was in no doubt that there was something wrong with my capacity to speak when I wanted, and I was in no doubt that if there was any therapeutic help out there I would do my very best to find it. 

Aftab: Your doctorate was on the philosophy of Ludwig Wittgenstein. How did the study of Wittgenstein earlier in your career influence your approach to philosophy of psychiatry? Wittgenstein is known for many complex ideas, but two ideas that seem to come up in the context of psychiatry are language-games and family resemblance. In Wittgenstein's view that the meaning of a word is determined by how the word is used in practice within a 'language-game'. He also proposed the notion of family resemblance, that things belonging in the same category may not be connected by one essential common feature but rather a series of overlapping similarities, such that no one feature may be common to all of the things. Do you think a Wittgensteinian understanding of ‘mental disorder’ in terms of language-games and family resemblance has much utility?

Bolton: I never approached philosophy of psychiatry with Wittgenstein in mind, his texts are too distinctive and in a way abstract, and there is no way of reading from them to philosophy of psychiatry. However, the emphasis on action which I took from Wittgenstein I apply whenever I think. So, for example, I was entirely at home seeing that Spitzer and his colleagues had put in the DSM a conceptualization of mental disorder which turned crucially on impairments in action (as opposed to e.g. false beliefs). As to the second part of your question, "mental disorder" would lend itself to being seen as part of a language game involving health problems and health care, much as for example the social scientists would study the practical effects of self or professional labelling. And yes, probably mental disorder is a family resemblance term, and to some respects this approach would be similar to the prototype theory of concepts which has indeed been applied to the concept of mental disorder.

Aftab: Michel Foucault was a French philosopher and social theorist, well known for his ideas on power and social control. He emerged as a crucial influence on the antipsychiatry movement with his first major book, The History of Madness. In it he examines the social construction of Western notion of ‘madness’ (in particular the experience of 'mad' as 'the other'), tracing its social evolution through various phases of history, from the Middle Ages to modernity. It appears that Foucault’s analysis of ‘madness’ was of great influence on your thinking. How is Foucault’s history of madness still relevant to contemporary psychiatry?

Bolton: I appreciate that Foucault’s work has been criticized as history and social science. Two insights I have found helpful: first that the building of the asylums represented a massive social exclusion from physical space and social cognitive space, and second that society at large constructed the profession of psychiatry to manage madness not here butover there. The contemporary relevance is that with the closure of the asylums, madness is no longer excluded from our communities, and is therefore more familiar, more common, not so mad after all, but still somewhat to be feared, and we worry about how much of it there is; and so on and so forth. We are having to rethink. At the same time and for the same reasons, society is no longer able to assign psychiatry to worry about mental health problems all on its own, and we will all have to get involved.

Aftab: Psychiatrists appear to have a benign and benevolent view of diagnosis, as a means of capturing as much of the suffering of ailing humanity, and they lean towards over-diagnosis in order to help as many people as they can (among other reasons). Critics of psychiatry, both external and internal, tend to see psychiatric diagnoses as potentially harmful, something that may be necessary but should be limited to as small a portion of the population as possible. What are your thoughts on this?

Bolton: My response to your previous question strayed into the territory of this next. The boundaries between of pathology/normal suffering, of appropriate/over-diagnosis, treat or not to treat, beneficial or harmful effects of diagnosis, are for us all complicated and contested. Both sides have valid points to make. Each side is probably thinking of different kinds of case. For example, on the pro-diagnosis and treatment side would be cases of escalating depression successfully treated, on the other side presumed self-limiting conditions; and so forth. I suspect there would be more agreement over individual cases or types of case than there is about generalizations for and against, which are, I suspect, largely supported by what Wittgenstein called a one-sided diet of examples.

Aftab: One of my problems with psychiatry is its reliance on the term ‘disorder’. Does ‘disorder’ necessarily imply that the source of suffering is an abnormalitylocated within the individual (versus not being the result of an ‘abnormality’ or being located in the relational and social context, etc.)? If that is a necessary implication, then I find disorder to be a highly problematic term. Can the term be rehabilitated in a conceptually appropriate way? By adopting a broader pluralistic view and acknowledging the value-ladenness of disorder designation, can we get rid of that implication?

Bolton: You know that psychiatry has had many attempts to find the right word. In the clinic there are legitimate terms and formulations that do not include the term “disorder.” However, given that the context is entirely ‘healthcare’, involving funding, training, research and service planning, I suspect that “disorder”, or some cognate, is here to stay. In the healthcare context it is individuals that become ill and it is to the individual – body or mind – that we look for processes that offer opportunities for change.

Aftab: You have described how the psychological approach to understanding psychiatric problems is in constant opposition to the 'medical model' and that "the psychological approach tends to undermine the concept of mental disorder itself." Could you elaborate on this?

Bolton: I would stop short of saying that psychological approaches are in opposition to the medical model, mainly because the model is elastic – which I do not intend as a criticism. The psychological approaches do undermine a particular and probably dated interpretation of mental disorder as solely deficit or absence of functionality. A broad medical model could readily envisage that the presentation may well include attempts to deal with a major challenge to psychological functioning, whether this derives from an organic problem or psychological trauma of some kind. It is helpful to recall that physical medicine or biomedicine recognizes fully the somatic functioning analogue of this: that much of the body’s resources are devoted to defending from toxins or repairing damage so that life can go on, and that, as a further complication, defensive or reparative functions can themselves also go wrong.

Aftab: You write: “the dichotomy between what is medical, natural, and scientific and on the one hand, and what is social on the other, has not survived well.” I understand your argument to a degree, but I am not sure it successfully implies that the dichotomy between facts and values (with regards to a philosophical definition of mental disorder) is also invalid. The fact-value distinction continues to play a role in definitional issues. Perhaps the implication is that the domain of “social values” needs to be reconceptualized as partly having a factual component (to the extent that social practices are a result of evolution)?

Bolton: My intended argument was that one cannot disentangle functions that are purely natural from functions that are purely social, or what comes to the same, that for many or most or all of our phenotypes natural, evolved influences are entangled with socialization factors. In this sense I would agree with your point that some social values may be construed as having a factual content in that some of them are grounded in our biological and psychological nature as social beings. I would add though that the "factual content" would be hard to isolate. I don’t think much of the fact-value distinction at least when it comes to thinking about ourselves.

Aftab: You also argue very well that neuroscience has no independent notion of order/disorder. I think this is a crucial fact that is often ignored by the biological reductionist camp in psychiatry. Consider for instance the Research Domain Criteria (RDoC). RDoC has no notion of what constitutes a disorder; for the RDoC matrix, it doesn’t matter whether the phenomenon in question is normal or abnormal.

Bolton: Here again I think it is helpful to look to biomedicine to see how it does it. If one considers elementary versions of the model of the cardiovascular system, one sees diagrams of the whole structure and its parts, and specification of the function of the whole and functions of the parts. Once all that is in place, an account of cardiovascular dysfunctions is already implicit: the cardiovascular system fails to perform its function if particular parts fail to perform theirs, from one cause or another, and this provides the basis for a classification of cardiovascular diseases.

For reasons which I have to confess I struggle with, this is less easy to do for psychological functions. Psychological functions such as attention serve external purposes, task demands in particular environments, that are highly variable, and whether they are working well (enough) or not seems difficult to pin down with reference to brain circuitry alone but seems to require external contextual reference. However, as I say I do struggle with this.

Aftab: You devote a considerable portion of the book to a critique of Wakefield’s theory of harmful dysfunction, arguing that understanding dysfunction as failure of an internal mechanism to perform as designed by natural selection is “a hypothesis that would typically be, for most psychiatric conditions, uncertain, speculative, provisional, for some quite likely false-and in probably all cases controversial.” Wakefield doesn’t seem to think of this vast gap between evolutionary mechanisms and clinical symptoms as fatal, and he tends to rely on behavioral “dysfunction indictors” which suggest the presence of dysfunction. Do you think this strategy has any merit?

Bolton: Not really. For clinical determinations of diagnosis and need-to-treat, and research purposes, we need only the “dysfunction indicators” themselves, as signs and symptoms. Whether or not they indicate a dysfunction in Wakefield’s specific evolutionary theoretic sense is irrelevant for clinical and research purposes. I put forward this argument in detail in a World Psychiatry commentary in 2007.⁶

Aftab: It appears to me that you begin by accepting that the conditions currently included in the psychiatric diagnostic manuals are indeed mental disorders. You are not trying to argue that this characterization as a disorder is mistaken. Instead your thinking goes something like: if all the conditions listed in diagnostic manuals are all indeed mental disorders, then what kind of an overarching philosophical notion of mental disorder emerges? And you show that the notion that emerges is not a naturalist notion of disorder, but one that is focused on harm and suffering, and in which the personal, the social and the biological are hardly clearly distinguished. Would you agree with this description?

Bolton: Yes, I believe is so. And I think the strategy that you have described applies clearly to the approach that Spitzer took, and basically, I have re-trodden the same ground.

Aftab: Does your account of mental disorder offer any prescriptive guidance? Aside from saying ‘the stakeholders will negotiate’, how we can decide whether something like-let's say internet gaming disorder-should be considered a ‘disorder’?

Bolton: This is a very good question and a very good example. The ICD and DSM are right to say nothing gets in unless it is a reasonably well-defined and replicable syndrome. Some proposed candidates never cross this scientific-clinical first test. After that I believe that issues will include considerations of distress and impairments associated with the condition and relative harms and benefits of inclusion/exclusion as a mental disorder as viewed by various stakeholders. I don’t think the science plays much at just this stage, though of course it does, among other things, in more precise specification of syndrome and place in the overall classification.

That said, I have recently come to appreciate (somewhat late in the day) that the rapidly accelerating neuroscience especially what is sometimes called cognitive affective neuroscience and its utilization of functional neuronal imaging effectively blurs neuroscience with psychology-as neurologist thinkers such as Freud anticipated. But further, as it becomes advanced, it can provide an epistemological angle on mental functioning. This is additional to inferring mental states from behaviour and self-reports. To the extent that neuropsychological mechanisms underlying addiction are well understood in paradigm cases of chemical compound addiction, the question arises whether the same mechanisms are involved in other cases of putative addiction.

Aftab: Your deflationary approach to classification is also very interesting.⁷ You argue that classification is not the main point of science (which instead is prediction refined by causal explanatory models) and that psychiatry is preoccupied with classification for historical reasons.

Bolton: I think DSM revision processes serves many purposes but moving the science on is not one of them. Not least of which is that along with the ICD it determines access to healthcare. It also serves essential functions in epidemiology applied to planning services. I don’t think anyone has yet come up with a better system for doing these.

Aftab: I really enjoyed your 2019 book The Biopsychosocial Model of Health and Disease.⁸ It is a fascinating reconceptualization of the biopsychosocial model as a philosophical theory of biopsychosocial causal interactions. Increasing complexity of forms leads to increasingly complex systems, and these systems have new and distinctive causal properties. Certain phenomenon can exist at certain levels of complexity (psychological or social) and they cannot be reduced to the causal properties of a less complex system (biological).

This leaves open the possibility that for many forms of psychological suffering, the best explanations may be psychological or social rather than biological. Should that possibility be seen as a threat to the medical identity of psychiatry and to the new biological psychiatry which conceptualizes psychiatric disorders as “brain circuit disorders”?

Bolton: Thanks for raising my recent book, written with Grant Gillett, which is where my thinking has been recently rather than with previous work on conceptualizing mental disorder. The book represents a return to my previous interests in the philosophy of science of psychiatry, along with a new conviction that mental health has to be theorized alongside physical health.

To pick up your particular point, yes, I think it is an implication that there is causation within the psychological domain that will be or might be irreducible to causation within the neural domain. Or to use language closer to that book: there are causal regulatory functions within the psychological domain, and this is so independent of whether they can be captured by a physicochemical description of brain processes. This would certainly fit what I know well from CBT models of OCD and other anxiety disorders. However, I would have no inclination at all to generalize across all presentations within these conditions and still less across other or even all psychiatric conditions. I have wondered whether this is a new and relatively unexplored territory and I will look into it further.

As to the medical identity of psychiatry, I have thought and written (in a World Psychiatry paper in 2013⁹) that in the multifactorial, pluralistic state of the current science having our professional trainings within the old silos of medicine, psychology and social sciences, grounded in historical traditions which we are now moving away from, is not the best place to start. Scientific findings and paradigms change-professions adapt and transform.

Aftab: Thank you!

Dr Aftab is a psychiatrist in Cleveland, Ohio. He trained in geriatric psychiatry at University of California San Diego and completed his psychiatry residency from Case Western Reserve University/University Hospitals. 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. 

Dr Aftab and Dr Bolton have no relevant financial disclosures or conflicts of interest.

Previously in Conversations in Critical Psychiatry

1. Allen Frances, MD: Conversations in Critical Psychiatry

2. Anne Harrington, DPhil: The Structure of Psychiatric Revolutions

References:

1. Bolton D. What is mental disorder?: an essay in philosophy, science, and values. Oxford University Press; 2008.

2. Klein DF. A proposed definition of mental illness. In Spitzer RL and Klein DF (eds), Critical Issues in Psychiatric Diagnosis. 1978:41-71. New York: Raven Press.

3. Spitzer RL, Endicott J. Medical and mental disorder: Proposed definition and criteria. In Spitzer RL and Klein DF (eds), Critical Issues in Psychiatric Diagnosis. 1978:15-40. New York: Raven Press.

4. Spitzer RL, Williams JBW. The definition and diagnosis of mental disorder. In: Gove WR (Ed.), Deviance and Mental Illness. 1982: 15-31. Beverly Hills, CA: Sage.

5. Greenberg G. Manufacturing depression: The secret history of a modern disease. Simon and Schuster; 2010.

6. Bolton D. The usefulness of Wakefield's definition for the diagnostic manuals. World Psychiatry. 2007 Oct;6(3):164.

7. Bolton D. Classification and causal mechanisms: a deflationary approach to the classification problem. In Philosophical Issues in Psychiatry II: Nosology, K. S. Kendler & J. Parnas (Eds). 2012. Oxford: Oxford University Press, pp. 6-11.

8. Bolton D, Gillett G. The Biopsychosocial Model of Health and Disease: New Philosophical and Scientific Developments. Palgrave Pivot; 2019.

9. Bolton D. Should mental disorders be regarded as brain disorders? 21st century mental health sciences and implications for research and training. World Psychiatry. 2013;12):24.