Learning Objectives:

After reading this article, you should be able to:

1. Identify the relevance of philosophy in psychiatry.
2. Analyze the impact of philosophical understanding on treatment strategies.
3. Distinguish between psychological and neurological abnormalities

CPTR: Why, in your view, should the general psychotherapist be interested in the philosophy of psychiatry? 

Dr. Aftab: Most psychotherapists and psychiatric clinicians appreciate at some level that we have relied on concepts that have quietly distorted and obstructed our thinking. Issues around causality, reductionism, disorder, etc. are examples where a lack of clarity has been historically problematic. We can’t help but make theoretical assumptions that shape clinical assessment and treatment. We can try to pretend that these assumptions do not exist, or we can engage with them to better understand their impact.

CPTR: Can you provide a specific example from clinical practice where understanding the philosophy of psychiatry influenced treatment decisions?

Dr. Aftab: Sure. It has almost become a truism in the psychiatric profession that “mental disorders are brain disorders.” But what exactly does this mean? (for a recent philosophical treatment of this issue, see: Jefferson A. Are Mental Disorders Brain Disorders? Taylor & Francis; 2022 and Aftab A, 2023) There is a risk here that we might conflate different meanings of this statement in problematic ways. The idea that all mental phenomena must be realized by brain mechanisms and processes can be falsely conflated with the idea that mental illness must be the manifestation of a neurophysiological abnormality that requires neurobiological interventions for appropriate treatment. It is no doubt the case that mental disorders involve brain mechanisms, but we cannot simply assume that the neurophysiology represents the locus of the pathology. Given that we are dealing with mechanisms at multiple levels, both pharmacological and psychosocial interventions are often important in the treatment of mental illness.

CPTR: Can you say a little more about how we determine abnormality, and what this means in terms of the discussion around psychology and biology in mental disorders?

Dr. Aftab: We use specific standards to judge psychological phenomena (eg, whether the distress is proportional to an individual’s circumstances, whether there are intelligible and rational links between a person’s thoughts or between their thoughts and behaviors, etc). These standards are quite different from the standards we use to identify abnormalities in neurological functioning (eg, abnormal electrical discharge, demyelination of nerves, etc). So an abnormality by psychological standards of functioning might not be considered abnormal concerning standards of neurological functioning (even if the behavior itself is a result of a neurological response). 

CPTR: What does this mean for us in the context of treatment? 

Dr. Aftab: It means that our mental vocabulary is not dispensable; we can’t eliminate it and use only the vocabulary of neuroscience to describe and intervene on psychological problems. 

CPTR: A hotly debated topic these days is whether mental disorders constitute diseases, disorders, syndromes, or—to borrow a term from Szasz—problems in living. Can you tell us briefly where you stand on this issue? 

Dr. Aftab: It’s a complicated debate. Philosophers of biology tend to think of disease/disorder in terms of a failure of (evolved) biological mechanisms. That is, different organs of the body have been naturally selected to carry out certain tasks, and if there is a breakdown or disruption in one’s ability to carry out that task, it is considered a dysfunction. This position gets murky in psychology and psychiatry because our scientific understanding of the evolution of mental functions is very primitive. It may also be the case that many psychiatric conditions don’t involve breakdowns of evolved functions; rather, they may represent extreme states on a continuum of intact functions (eg, high neuroticism). They may involve evolutionary design-environment mismatches (eg, hyperactivity in a modern school environment). They may even be products of maladaptive learning with otherwise intact learning mechanisms (eg, psychological sequelae of growing up with childhood neglect).

CPTR: Do you view them as disorders? How does your view influence the way you diagnose and treat patients?

Dr. Aftab: My own view is that clinical notions of disorder and psychopathology are different from philosophical notions of disorder grounded in biological mechanisms. Clinicians don’t think of illnesses as an evolutionary failure. They are much more mindful of all the ways in which patients may experience problems in their daily lives, and their ideas of what constitutes a disorder are shaped by that. The suffering of the patient and our ability to help the patient takes priority over abstract ideas of biological functions.

CPTR: Interesting. So, what are mental disorders then? Are they medical diseases?

Dr. Aftab: Mental and medical disorders do not have one unique feature that all conditions share and that differentiates them from nondisordered conditions. What they share is a cluster of overlapping characteristics, such as inflexibility, atypicality, irrationality, maladaptivity, chronicity, distress, disability, harm, and impediments to well-being. The question of whether a psychological problem is a disorder or a “problem in living” is inconsequential on its own; it doesn’t matter, as long as we recognize that the problems in question benefit from clinical care and require scientific study for a better understanding of their nature. If we agree that a problem requires a clinical solution, whether you call it a disorder or a problem in living is simply semantic. The view held by Szasz and his followers, however, is that if something is a “problem in living,” then it is outside the purview of medicine; medicine has no authority over it or no justification to treat it. It is this assumption that I disagree with. This is not how medicine and psychology work. The Szaszian view fundamentally misunderstands what justifies clinical care.

CPTR: How might a therapist’s day-to-day interactions with a patient change based on differing perspectives on this topic?

Dr. Aftab: Receiving a diagnosis or hearing that what you are experiencing is disordered can change as you understand yourself. Clinicians and psychotherapists need to be aware of this. Psychopathological phenomena don’t always indicate complete dysfunction. Similar to issues in general medicine, mental health problems involve a mix of function and dysfunction. For example, fever and cough are functions. They serve a protective role in the face of some physiological problem. Similarly, many psychological phenomena, such as anxiety, low mood, hypervigilance, possibly even delusions, play important functions that can nonetheless become clinical problems and require intervention. For instance, withdrawal can serve to protect a patient from feeling overwhelming anxiety in social situations, but eventually it comes at greater cost. Patients often find this comparison between the function of medical and psychiatric symptoms helpful.

CPTR: Yes, like we say in psychoanalysis, a symptom is at once a problem and a solution to a different problem.

Dr. Aftab: Precisely 

CPTR: Why, in your opinion, is it important for psychiatrists and psychotherapists to consider the views of those with lived experience in their thinking about mental illness? 

Dr. Aftab: The direct experience of mental illness and its treatment can allow patients to consider things and ask questions that may not be obvious to psychiatrists and psychotherapists. The priorities of patients can also be quite different from the priorities of clinicians. For instance, antidepressant withdrawal as a clinical phenomenon was historically neglected because clinicians have had a bias to interpret symptoms in the context of dose reduction/discontinuation as relapse, forcing many patients to form online communities and figure out ways to help themselves.

CPTR: Can you give us a specific clinical example of how incorporating a patient’s lived experience can lead to a better clinical outcome or improved therapeutic rapport? 

Dr. Aftab: Sure. In the realm of psychosis, clinicians often focus on symptom suppression, but for many patients, it is less important to suppress their hallucinations, and more important to engage with the voices and learn to live with them. This is why peer groups such as Hearing Voices are appealing to many patients who experience hallucinations. Activism based on lived experience has also been important in diagnostic reform, such as the exclusion of homosexuality from the DSM, reframing of transgender identity, and ongoing reassessment of autism from a neurodiversity lens. It is true that lived experience is as fallible as any other perspective, but the science of psychopathology would be impoverished if we were to exclude it 

CPTR: Could you describe a real-world scenario where a therapist’s lack of philosophical clarity hampered the therapeutic process? How might a clearer philosophical stance have altered the outcome?

Dr. Aftab: Some therapists have an overly reductive understanding of psychiatric diagnosis. They seem to think a diagnosis of mental disorder necessarily implies there is some intrinsic brain abnormality. They think if someone’s symptoms can be explained with reference to a history of abuse or trauma, then a diagnosis doesn’t apply to them. The logic is so incoherent that it’s amazing that anyone believes it, but I’ve encountered many therapists who believe some version of it. They think you can’t diagnose depression, bipolar disorder, or a personality disorder, if their symptoms are “understandable” as a response to some sort of psychological injury. But psychiatric diagnoses are descriptive characterizations, compatible with a history of abuse or trauma, or the putative “understandability” of symptoms, and if we miss the appropriate descriptive characterization, we can deprive a patient of treatment options they can benefit from.

CPTR: What practical skills or tools do you think could be added to current training regimes to better prepare clinicians for real-world scenarios?

Dr. Aftab: There needs to be a lot more active exposure with relevant conceptual issues as well as opportunities to discuss them. Psychiatry and psychological textbooks are often organized around diagnostic schemas that reify them, and it is a good idea to have components of the training that challenge that reification. In the context of psychiatric training, I have argued in support of the idea of “conceptual competence.” (Aftab A and Waterman GS, Acad Psychiatry 2021;45:203-209) This sort of competence involves the awareness of background conceptual assumptions held by clinicians and patients about the nature of psychopathology and their influence on various aspects of clinical practice, research, and education. A reading and discussion elective is a good format to facilitate such competence. Jonathan Shedler has said that a purpose of psychoanalytic therapy is to insert spaces for reflection where they have not previously existed; I think current training programs would also benefit from creating spaces for reflection where trainees and supervisors can both step back and reflect on the ideas that guide us (Shedler J, in interview with Aftab A. Psychiatr Times. Accessed April 17, 2024. https://www.psychiatrictimes.com/view/psychoanalysis-re-enchantment-psychiatry-jonathan-shedler-phd).

CPTR: Thank you for your time, Dr. Aftab.

Editor’s note: For more information, see the table below. 

References in the order of appearance in this article:

Aftab, A. (2023). Mental disorders in entangled brains. Philosophical Psychology, 1-13. 

Jefferson, A. (2022). Are Mental Disorders Brain Disorders? Taylor & Francis.

Midgley, M. (1992). Philosophical plumbing. Royal Institute of Philosophy Supplements, 33, 139-151.

Aftab, A., & Waterman, G. S. (2021). Conceptual competence in psychiatry: Recommendations for education and training. Academic Psychiatry, 45, 203-209.

Shedler, J., & Aftab, A. (2020, July 29). Psychoanalysis and the re-enchantment of psychiatry [Interview]. Psychiatric Times. https://www.psychiatrictimes.com/view/psychoanalysis-re-enchantment-psychiatry-jonathan-shedler-phd