Social Conformity and Psychiatry’s Authority as a Science

A dialogue on the basis of psychiatric evaluations of mental disorders

Photo by cottonbro studio, on Pexels

This is a dialogue I had with former psychotherapist Pierz Newton-John about psychiatry’s scientific status and the clash between psychiatric and philosophical assessments of mental health.

Benjamin

Social scientists who yearn to be as rigorous as those in the hard sciences have always been hampered because the subject matters of psychology, sociology, anthropology, political science, and economics — namely, people and societies — are supposed to be riddled with rights. Insofar as science is roughly objectification, scientists excel at modeling and experimenting so they can understand how the facts work, not prescribing what should be done about them. The dichotomy between facts and values dashes the social scientists’ aspirations.

Psychiatrists face an acute version of this problem since they’re medical scientists who apply theories of how minds work, with the explicit intention of healing them. Perhaps psychologists can explain how brains and minds work, without broaching value-laden, normative questions about which brains or minds are best. But psychiatrists can’t just describe how a particular mind functions, or think statistically about how most minds behave in practice. This is because psychiatrists are tasked with taking regulatory action on minds, not just modelling them.

Of course, all doctors must adopt some normative conception of health, or else there would be no guidance on which medical condition counts as an ailment in need of a remedy. But we have a much easier time accepting that biology settles the functionality of our body parts than conceding that our evolutionarily formative period in the Stone Age established our mental functionality for all time. We assume that our minds changed — and ought to have changed — as we adapted to civilized environments, so our values changed too. For instance, modern secular societies posited human rights that don’t depend on tribal allegiances or superficial biological differences like skin colour.

Medical doctors can refer to biological norms in determining whether a liver is functioning properly, but this functionality isn’t the same as a moral right. Strictly speaking, a human brain, too, has no rights since it’s a physical thing. A person is more abstract than anything you could pin down with your five senses, but the person is precisely psychiatry’s subject matter. The psychiatrist assesses whether a person is doing well or needs to be socially reconditioned or drugged.

How, then, can the psychiatrist maintain the appearance of adhering to scientific methods of inquiry, while flouting the dichotomy between facts and values? In other words, what is the source of the values that inform the psychiatrist’s professional judgments about which minds are healthy and which need correction?

The answer seems to be that psychiatrists simply adopt their society’s perspective on the matter. The scientific revolution happened in Europe, and the aftermath included a capitalist monoculture found in most “modernized,” scientifically informed, liberal societies. Thus, we should expect that the social mores that have had the biggest impact on the psychiatric conception of mental health are those of neoliberalism, consumerism, or some other secular apology for the capitalist status quo that replaced medieval Christendom in Europe.

Suppose the Soviet Union hadn’t collapsed but had won its Cold War with the United States at the end of the twentieth century. In that case, we can imagine that in 2025, psychiatrists would have presupposed a collectivist conception of mental health. Your mind would be “healthy” only if you defer to the State’s interests and don’t suffer from the alienation of having to pursue your happiness on an individual basis. Anyone who practices a capitalist subculture of individualism and seeks fulfillment from a materialist lifestyle would be deemed “dysfunctional” and drugged or institutionalized.

Of course, the opposite happened, and America won the civilizational struggle, so Western psychiatrists assume an individualistic, liberal ideal of personhood.

This isn’t to say, with Michel Foucault, that all psychiatric treatments are purely political or determined by struggles for power. There are clear mental and social effects of certain neurological imbalances, as well as forms of plain insanity that few would wish on even their worst enemies. There are civilizational norms that help us understand whether a type of behaviour is beyond the pale.

But the assessment of mental health is likely also, in many cases, culturally relative. When homosexuality was deemed a sin, due to the influence of Western Christianity, psychiatrists agreed and provided a pseudoscientific rationale for that value judgment. When that influence waned in the twentieth century, psychiatrists ceased classifying that condition as a mental disorder. That decision in 1973 wasn’t strictly scientific, and neither is the normative concept of mental health.

Pierz

Your analysis is incisive, but I would put it slightly differently. The main problem for psychiatry and psychology — and the cause of both their inferiority complex and the chip on their shoulder — is that they take as their subject matter subjectivity itself, which is precisely what science has spent the past several centuries trying to excise from the world entirely. Thus we see the recurring tendency in both fields to try to reduce the person to their neurology or their behaviour. It took a long struggle to overcome the behaviourism of the mid twentieth century and reach the point where psychologists would even admit inner states as a worthy object of study — a bizarre situation.

The psychiatric bible, the Diagnostic and Statistical Manual of Mental Disorders (DSM), attempts to objectify the fuzzy domain of emotional and mental dysfunction by carving up its phenomenology into a collection of cleanly circumscribed conditions with associated “criteria”, as if the mere categorisation of psychological pain represents a form of mastery of it. One might even suspect, if one were feeling cynical, that the minutely elaborated taxonomy of ailments is at some level intended to lend credibility to a profession that has been conspicuously ineffective in its aim of actually healing these conditions.

At any rate, the idea that mental illness is directly analogous to physical illness is highly dubious. With the exception of some specific cases like schizophrenia, there are few clear-cut biological markers for any mental disorders. It’s true that depression is associated with lowered serotonin levels depression, but what is cause and what is correlation in the radically interrelated world of the mind-body system is far from clear. And if low serotonin were the cause of depression in any direct way, then SSRIs would be much more effective than they are.

We’ve also seen how manifestations of mental distress vary drastically across history and culture. If you look at early psychiatric reports, they are full of something referred to as “neurasthenia” — basically the catch-all of the day for a cluster of physical and emotional symptoms that look in retrospect something like depression with some probably psychogenic physical symptoms. The current DSM has a host of “not-otherwise-specified” disorders that serve the same “everything else” function, mopping up the cases the other categories don’t capture. Many anxiety disorders overlap, co-occur or shift and change over time, suggesting that the categories themselves are more like regions arbitrarily drawn on a map rather than real underlying conditions, with symptoms caused by the diagnosed illness in the same way that, say, paralysis is caused by polio. Anxiety symptoms aren’t caused by an anxiety disorder. The anxiety is the disorder — and everyone experiences anxiety. The difference is merely one of intensity.

Yet this doesn’t mean that the suffering isn’t real, or that these conditions are entirely some kind of oppressive social construct. While many relatively mentally healthy people seek psychological treatment to reduce normal levels of unhappiness, or simply for emotional support, those who receive a psychiatric diagnosis usually do so because something is going seriously wrong for them. They frequently welcome a diagnosis, because it names and thus circumscribes a hitherto somewhat amorphous experience of subjective misery.

Where the problem arises in my view, and where psychology and psychiatry are increasingly letting us down, is in the way in which invisible social assumptions are smuggled into the way both the illness and the person are treated by the mental health system. Johann Hari makes a compelling case in his book “Lost Connections” that depression is a social symptom rather than an individual one. As we lose connection to the natural world, to one another, and to our own deeper selves, we naturally become depressed and despairing. If he’s right, the true remedy lies in repairing our disconnected condition as a society, not in medicating the suffering individual and treating them like a malfunctioning component of the social machine.

The seventies saw an explosion of imaginative experiential therapeutic modalities, but since then we have seen psychology gradually grow narrower and more sterile as it has increasingly craved and tried to prove its scientific bona fides. Cognitive Behavioural Therapy (CBT) has become almost the only game in town. CBT has its place. I found it the only way to go in the days I was working with low-functioning offenders, and it has the big advantage that a college graduate with little life experience or maturity can deliver it almost by following a recipe. Yet for more self-aware, imaginative clients, it’s horribly shallow and inadequate.

As you astutely observe, the value system embedded in our notions of psychological health and in the treatments we prescribe for them belongs to our late capitalist society. In a world that is growing increasingly sick and disordered as a consequence of those very values, it’s legitimate to wonder if the way we treat mental health problems isn’t actually part of what is making us sick.

Benjamin

Mental health professionals seem to have a dual role. They deal with real suffering that has no obvious biological cause. Whatever the cause, if the suffering is severe enough that it drastically interferes with the person’s life, the sufferer will seek treatment, and the psychiatrist or therapist will provide counseling, shelter, or drugs.

But these professional healthcare providers also defend society’s interests, so they’re not wholly advocates for the mentally ill. In the West, these professionals will divert attention to the individual to give a pass to social causes of mental suffering, such as capitalism or consumerism, because they must defer to society to motivate and justify the evaluative part of their treatment. Psychiatrists can’t appeal to their idiosyncratic tastes, since then their discipline wouldn’t have even the appearance of scientific rigour.

Also, as you’ve suggested, psychiatrists may medicalize the existential condition. If we all suffer from anxiety, that may be because we didn’t evolve in an ideal, heavenly scenario. We must struggle to survive or flourish because nature is neutral towards our welfare. Sigmund Freud was more pessimistic than late-modern psychiatrists, as he adopted an existential perspective on how social compromises are often at odds with our personal wishes. The individual is bound to clash with society, as Franz Kafka dramatized in hyperbolic terms.

Again, an individualistic society is likely to stress individual responsibility since, according to neoliberal myth, we’re supposed to be happy, not content with suffering — even if alienation is integral to existential authenticity. Western psychiatrists may want to help sufferers, but they’re also professionally obliged to defend their underlying neoliberal culture, even if that culture is philosophically flawed. Here, psychiatric standards are liable to clash with philosophical, existential ones.

The rise of the self-help industry in the English-speaking world may also be instructive in this context. On the one hand, this industry is as individualistic as psychiatry since it emphasizes the individual’s responsibility to improve herself and overcome obstacles. On the other hand, this industry represents an alternative to professional therapy and psychiatry, implicitly holding in contempt the conservatism of those forms of treatment.

I suspect that the self-improvement industry represents a corporate co-opting of the neoshamanic, existential perspective on mental health. The modern world frees us from oppressive castes and overbearing institutions like the Church. Thus, we’re condemned to face our harsh existential condition with little guidance or trust in authorities. Neoliberal culture comes to our aid with handy products to purchase and recipes for relieving us of that alienation or despair.

In the late-modern period, we don’t trust elites and their metanarratives since we expect that psychiatrists, for instance, are too conservative in protecting the state’s interests that sustain their professional status. Yet we’re also infantilized by consumer culture, so we lack the discipline to stomach existential insights. We want quick, easy solutions, the fast-food version of mental health advice. Even a bastardized form of Stoicism comes to the rescue, thanks to Ryan Holiday.

The self-help industry repudiates established forms of mental healthcare, even as this industry is hardly honest about how the bulk of our ordinary suffering is due to the existential condition. This industry, too, is neoliberal, so it’s rife with fraud, sophistry, and demagoguery.

Pierz

Right, psychology has a normalising function as well as a healing function. Yet to my mind the problem is less to do with the mental health profession serving or reflecting a neoliberal value system — neoliberalism is a relatively recent phenomenon after all — than it is to do with its adoption of an objectifying epistemology that is incompatible with the healing of the person.

The more “professionalized” and institutional psychology has become, the more it has been forced to adopt a blandly scientific tone, while its methods and language have become correspondingly more impersonal and rationalistic. This mode of discourse is fine for physics or engineering, but it stands in direct tension with psychology’s putative aim, which is presumably to advance the well-being of the person. How can one coherently take an impersonal approach to the person?

This tension has resulted in a strange situation, which I witnessed repeatedly while working in the counselling field. There is a status hierarchy among mental health professionals, with psychiatrists at the top, followed by clinical psychs, then counselling psychs, then the hoi polloi of less qualified or unregistered counsellors and social workers. This ordering also roughly corresponds to the degree of scientific objectification that these practitioners impose on the people they try to help. The psychiatrists treat their patients as ambulatory brains, the clinical psychs treat them as collections of irrational beliefs in need of correction, the counselling psychologists treat them as bundles of feelings in need of validation, while the counsellors and social workers treat them more or less as people.

I’m exaggerating of course, but there’s more than a little bit of truth to it. And to a significant degree I found that the very worst stories I heard about therapists were about those at the top of the pecking order. The world seems to be full of emotionally inept psychiatrists and clinical psychs who retraumatise their patients with their clueless, tone-deaf interventions.

To be clear, scientific psychology has been highly valuable in advancing our knowledge of human nature. We do need to try to stand apart from ourselves in order to reach something resembling an objective understanding of the dynamics of the human mind. Yet this reductive, rationalistic mode is incompatible with the kind of intimate human relationship that tends to actually help people in mental distress.

I doubt that the seventies were really a golden age for psychology — we’ve learnt a lot since then — but it was a time in which practitioners of psychotherapy tackled existential questions, dared to go deep, and didn’t shy away from questioning their own role in society. This history indicates to me that psychology can be counter-cultural and even genuinely redemptive, but to be so it needs to resist both scientism and absorption by the institutional mainstream.

Benjamin

That duality in psychiatry seems to have been present from the beginning, in Freud’s conception of a science of the unconscious. Even if you could objectively model the most subjective, personal aspects of the self, as in psychology, the medical question of how the self can be improved or healed isn’t so scientific. Unlike the biological understanding of our body parts’ evolutionary functions, there’s no consensus on what a self should be. There’s nothing obvious that a free person is supposed to be doing, or if there is, it’s not especially for scientists to judge.

There’s the familiar refrain, originating perhaps from the biblical line, “Physician, heal yourself!” (Luke 4:23), that those who go into psychiatry often do so out of self-interest because they’re mentally ill, so they want to understand what’s wrong with them. Just as there’s no objective standard for human behaviour, there may be no cure for mental disorders. The suffering can be mitigated, but fixing a mind isn’t like fixing a liver or a kidney.

In that case, psychiatrists may have enduring mental problems, which they inflict on their patients. Indeed, the Faustian gambit of striving for scientific knowledge and control over the universe may itself be mentally disordered, in which case Freudian psychiatry is rooted in an illness or perhaps a vice, the vice of personhood that emerges from animality.

A science of the mind presupposes that subjectivity is at best illusory. Real, substantive (Cartesian) subjectivity would be the miraculous “spirit” or consciousness, the ghost in the machine. Scientists objectify, so Western doctors especially must condescend to patients, treating the appearance of personhood as an annoying illusion.

Yet that scientism or methodological naturalism is unsustainable because the Faustian, Promethean, or Luciferian audacity of wanting to objectify and control everything in sight is itself plainly an anti-natural anomaly. How do we explain that uncompromising, possibly self-destructive revolt without positing the self, person, or autonomous mind that’s subjective rather than objective, a pivot point at which nature tames itself?

Science is based on modernity’s rational enlightenment, the discovery not just of nature’s godless physicality, but people’s cultural creativity and godlike ambitions. Science naturalizes religion’s mystifying, mythologized conception of the self, but science also re-enchants nature. Godless, objective physical transformations of everything from molecules to solar systems must be monstrous (mindless and absurd) and thus laden with aesthetic importance. According to science, nature evolves and complexifies, but that means that nature is creatively destructive.

The human self is natural in being counter-creative, and the understanding of both natural and anti-natural creativity calls for much more than scientific modelling and technological subjugation.

Pierz

We’ve talked before about the question of whether gardens represent an intermediate space or conversation between nature and civilization, or an imposition of civilized conceptions on nature. The same question might be put about the way we attempt to tame the wilderness of our own minds, which are in the first place products of nature. Freud explored this territory in “Civilization and Its Discontents”, at the very dawn of modern psychiatry, arguing that neurosis is the inevitable price we pay for suppressing our base instincts in order to live in a society. His whole theory revolved around this tension between a basically wild and unruly nature and the demands of civilized coexistence with others, which imposes a repressive order on that chaotic cauldron of aggressive and sexual impulses.

Not too many modern psychiatrists are true Freudians these days of course, but the fundamental insight about the tension between our raw natures and the requirements of modern existence remains valid. Unruly emotions and impulses constantly threaten to upset the delicately balanced applecart of our civilised lives. A “well-adjusted” person is just one who is more successful at repressing their own wildness. The role of psychology, then, is akin to that of a gardener, helping people in the task of pruning back the irrepressible runners and vines of their wild natures.

But modern psychology — unlike Freud, who understood the compromise involved — has come to position itself in this process purely on the side of civilization. It implicitly sees the human as a rational, artificial construction rather than a partly wild being. The fact that people manifestly aren’t buildings or machines, however, and will always fall short of enlightened ideals of rationality and good sense, means that the psychological patient is always a problem child, a partial failure. In the nicest possible way, they are constantly being rapped over the knuckles for their outbreaks of irrational belief.

Earlier psychotherapeutic modalities were less wedded to this one-sided project of manicuring the human psyche into a more conventionally acceptable state. James Hillman, whose work I’ve written about before, was much more interested in psychotherapy as a form of imaginal play and exploration than as a project of normalization. Reich and the many somatically oriented psychotherapies his work inspired explored the intersections between the body and trauma, bypassing the rational mind altogether.

These more imagistic and experiential therapies might truly be regarded as neoshamanic in nature. They do not impose a preconceived notion of what psychological health should look like, or conflate it with mere adjustment to civilized norms, but allow the psyche to speak for itself, to find its own healing. Of course these therapies are still very much alive, but they are not taught in mainstream psychology, which is now thoroughly shackled to the objectivist, scientific bandwagon. Although I don’t subscribe to your “monstrous” characterisation of the natural world, I am one hundred percent with you when you say that human nature deserves better than the sterile rationalism of modern psychology, which seems committed to the dubious proposition that health and happiness will only be achieved when the last trace of wildness has been extirpated from our souls.