Psychiatry: Medical Science of Mind or Moral Ideology?

The Scientific Revolution of the 16^th and 17^th centuries released a flood of empirical skepticism across the globe, diluting trust in religious ideology that had been dominating Western Civilization for centuries. The revolution ushered in the birth of modern sciences such as chemistry, biology, and anatomy. These new methods of understanding the world used careful observation and measurement to develop general scientific laws that describe and predict natural phenomena without resorting to religious explanations. They particularly benefited the field of medicine in its attempts to understand the origins of disease.

In the latter half of the 19^th century, medicine’s growing interest in “mental disease” was impacted by yet another new science, but one that focused on the mind – psychology. This merger of medical and psychological thinking would eventually spawn the emergence of psychiatry and the clinical versions of psychology, counseling, and social work, which I will simply refer to in combination as psychiatry. The impact of psychological science on medicine was underscored by the 1892 name change of psychiatry’s forerunner professional organization to the American Medico-Psychological Association.

However, despite its origin in the Scientific Revolution, psychiatry drifted away from this empirical foundation for two reasons. First, the subjectivity of mind prevented objective observation and measurement of it, while its individualized nature interfered with the development of general scientific laws applying to all people. Second, and relatedly, medicine’s physiological dysfunction-correction model that had been in use long before psychology’s impact was felt was poorly suited for understanding suffering that had no underlying dysfunction to correct. These two problems derailed psychiatry from continuing its intended path as an empirically based medical specialty of mind, placing it on a new path toward becoming an authoritarian moral ideology that hearkened back to earlier centuries’ religious ideology.

Drifting Away from the Mind

Psychiatry was unique in its initial science-driven endeavor because it set out to apply empirical methods to look “inside” at the subjective and immaterial mind, while all other scientific fields had interests that were objective and material “outside” the mind (note the etymological origin of the terms psychiatry and psychology – mind healing and mind study, respectively). The initial method of accessing mind was through individuals’ introspection of experiences reported to the researcher. However, this method was soon criticized as being too subjective and so psychiatry began redirecting itself in large part toward behavior and physiology as objective proxies of mind. While admittedly not mind in themselves, these proxies were presented for all intents and purposes as if they were. In hindsight, this bait-and-switch is understandable, given the Scientific Revolution’s influences on psychiatry in its oxymoronic striving to be a specialty that objectively targeted subjective mental suffering.

This early shift in psychiatry’s focus was contrary to the ideas of Harvard philosopher and psychologist William James, who is considered the father of American psychology and one of the forerunners of the scientific approach to understanding mind. His philosophy of radical empiricism departed from his contemporaries’ efforts to objectify mind, instead emphasizing that it was forever private and subjective. This implies that mind cannot be examined in an objective or nomothetic way. Relatedly, he also noted the holistic and flowing nature of mind in his well-known concept of stream of consciousness, in which mind is like an uninterrupted but ever-changing river and not a series of contiguous sections of water. Just as it is impossible to understand a river by examining buckets of its water, it is impossible to understand mind by examining “sections” of it. Most importantly, to fully understand the river one must be in it; to fully understand mind, one must be in it as well.

James further recognized the self-referential limitation of accessing mind through mind (like trying to bite your own teeth). In fact, he denied the subject-object distinction so essential for the other sciences, proposing that mind is subject and object simultaneously. Therefore, one cannot objectively access their own mind. Rather, it is done in a subjective way. This is a rejection of the dualistic idea of an independent observer objectively observing an observation. James would simply see it as observing going on – no subject, no object, just the process. Moreover, the observing is the only accurate understanding of that mind.

Perhaps more importantly, this makes it impossible for someone to access another’s mind, regardless of the observer’s psychiatric training and expertise. This is because the only thing to access would be the behavioral and physiological proxies of mind. Furthermore, such an observation would be more accurately described as the observer’s own subjective experiences elicited by the attempt to observe. Thus, any effort to access another’s mind is destined to fall short as it would either be an examination of the proxies or the observer’s subjective experience of their own mind.

The following analogy can help in understanding this limitation better. Imagine each of us living in a home that we cannot leave. We can only look out our windows at neighboring homes, giving us limited views of others as they pass by and look out their windows at us. We can only speculate about what it might be like living in their homes, based on what we know it is like living in ours. But we can never truly know what life is like for them because we cannot leave our home and enter theirs. Furthermore, any judgments we make about the apparent appropriateness, meaning, or utility of their lives would be moral speculations that reveal more about ourselves than about them.

Because of these limitations of accessing mind, psychiatry steadily diverted most of its attention away from mind and increasingly toward behavior and physiology as targets of interest. When these proxies remained secondary to mind, as happened with approaches based in phenomenological, humanistic, and existential principles that still valued introspection as a valid method, mind was all too often still viewed in an objective way as something structured with cause-effect parts that work the same for everyone, like how hearts are structured to keep us alive. But minds are immensely different than hearts and other physiological systems. Each is a subjectivity with its own legitimacy as defined by itself, and each is based on a private journey of meaning-making that generates unique realities and preferences.

Present-day diagnostic guidelines account for this diversity of mind at a macro level with the “expectable or culturally approved response” exemption in the Diagnostic and Statistical Manual of Mental Disorders (DSM). But this was not intended to include micro level cultural differences down to and including the unique “culture” of each person, because if it did, all problems would be exempted, and nothing would qualify as a mental illness (actually, this would be a preferred outcome).

Therefore, no mind is more legitimate than another in the same sense that some hearts are more legitimate than others. The heart’s only job is to keep us alive as a physiological organism. On the other hand, the mind’s job is not primarily to keep us alive but to enable a meaningful way of being alive. Each of us is the architect of that meaningful way, and it is dangerous for psychiatry to be in the position of countermanding that meaning. In this sense, there is no valid way for the mind to function from a science of mind perspective, like there is for hearts to function from a science of physiology perspective. Thus, any outside judgment about a mind’s functioning is necessarily a moral one, not a scientific or medical one.

It is true that through mind we can know about the environment, and this can help us avoid physiological and social dangers, for instance, knowing the risks of cigarette smoking or the consequences of violating social norms, respectively. However, each personal sense of knowing and the decisions in response to that knowing can vary greatly because of the diversity of realities and preferences mentioned above. In situations where harm is likely to result, public agencies are positioned to respond regardless of whether the suffering person is considered mentally ill. Let us not forget that sane people can still pose a great risk of harm, and those who are diagnosed with mental illness are generally less of a risk than those who are not diagnosed. A diagnosis is not the causal factor for violence; one’s experiential history is.

In summary, because of the individualized and subjective nature of mind, psychiatry increasingly focused on behavioral and physiological counterfeits. Even when individual introspection of experiences was prioritized, it was typically done in a way that tried to objectify those subjective experiences as if they had cause-effect components like physiology. But trying to synthesize mind’s proxies or cause-effect abstractions into a general model of mind completely defeats the purpose of studying it. The only way to understand mind and, thus, mental suffering, is for each mind to empirically explore itself. After all, who benefits the most from understanding a suffering mind, the psychiatric professional or the suffering person? In this way, the essence of mind was ignored, blinding psychiatry and taking it further away from understanding mental suffering and setting the stage for a system of moral ideology.

A False Medical Specialty

Just as it failed to keep its focus on its professed target of interest, the mind, psychiatry also failed to develop as a true medical specialty because it used medicine’s physiological dysfunction-correction model in its attempt to understand non-physiological and intangible mental suffering. That model assesses pathology. In other words, it speculates about underlying dysfunctions of chemical and mechanical bodily processes displayed in symptoms and that can inform optimal treatment.

To qualify as dysfunction, the physiology must be working contrary to how it is structured for its role in keeping us alive. For instance, hearts pump blood, kidneys filter waste, small intestines absorb nutrients, lungs exchange carbon dioxide for oxygen, and brains make neurochemical connections between neurons. In short, it is about how the dysfunction negatively affects our physiological viability. However, when applied to mental suffering, or psychopathology, this model becomes nonsensical because there is no natural way that mind functions, and so it cannot be dysfunctional. Remember my earlier comments about how hearts and minds are vastly different in terms of what they do – hearts help us stay alive while minds help us find a meaningful way of being alive.

Therefore, the meaning of psychopathology is not medical or scientific. It is a judgmental claim about the legitimacy of mind functioning (i.e., too much or not enough sadness, eating, reality-testing, loving, soothing, working, attention, risk-taking, excitement). Judgments like these necessarily reflect ideas about right or wrong and good or bad ways of understanding and responding to the world, and it says more about the mind of the person doing the judging than the mind of the person being judged. So, the concept of psychopathology is not a medical or scientific one, unless we are willing to grant authority over moral matters to psychiatry. Sadly, it seems we may have already done so.

This problem would be eliminated if psychiatry allowed individuals to assess their own level of mental suffering and then respected their choice of rejecting or requesting assistance. Doing so would also include allowing them to bear the potential consequences of rejecting assistance, such as legal action and social disapproval, as well as the consequences of requesting assistance, such as the potential harms of pharmaceutical interventions. But instead of doing so, psychiatry’s standard of care places it in a state-sanctioned authoritarian position of determining whether another’s mental suffering is caused by the yet-to-be-discovered mind dysfunction and thus needs intervention – informed consent be damned. This is plainly a moral intervention, not a medical or scientific one, and clearly not an ethical one.

Why does psychiatry ignore the suffering person’s wishes like this when no other medical specialty does? It is because the elusive mind dysfunction is alleged to interfere with appropriate (misleadingly called healthy) knowledge of what is in their best interest and so they must be saved from themselves. Therefore, until the nonsensical idea of psychopathology is abandoned, we will always be at risk of this attack on self-determination disguised as altruistic healthcare.

In addition to the questionable concept of psychopathology, no physiological pathology has ever been, or ever will be, discovered as the cause of mental illness because of a paradox. That is, when such dysfunctions are in fact discovered, the illness necessarily leaves the domain of psychiatry and enters that of other medical specialties. Examples are the delirium from urinary tract infections (a matter for urology) misdiagnosed as delusional disorder and the lethargy from hypothyroidism (a matter for endocrinology) misdiagnosed as depression. Neither of these is a mental illness. Instead, each is a straightforward illness outside psychiatry’s primary field of expertise.

Certainly, if psychiatry is invited to do so, it could have a role in prescribing drugs to provide comfort (although non-psychiatric prescribers can do the same) or in psychotherapeutically helping people cope with the angst and challenges of having these kinds of illnesses. But psychiatry does not have a role in treating the dysfunction that causes the illness, even though it includes several illnesses like these in the DSM. Examples are Central Sleep Apnea, Opioid Withdrawal, Neurocognitive Disorder Due to Parkinson’s Disease, and Substance/Medication-Induced Anxiety Disorder. It seems absurd to claim these are mental illnesses just because they have mental or behavioral symptoms. Taken to the extreme, most all physiological illnesses would be considered mental illnesses.

So, as medical science becomes more successful in identifying physiological dysfunctions that explain mental and behavioral symptoms, fewer and fewer conditions would be considered mental illnesses. This paradox renders irrelevant present-day debates about chemical imbalances, faulty brain circuitry, and genetic anomalies as the putative causes of mental illness (importantly, this research so far only demonstrates differences in brain activity and genetics, not dysfunctions). These debates are pointless since the problem would no longer be a mental illness if causal physiological dysfunctions were discovered. It would instead be within the bailiwick of medical specialties that already assess and treat dysfunctions of those bodily systems.

Notwithstanding the above, the American Psychiatric Association’s (APA) website still maintains that “Mental illness is nothing to be ashamed of. It is a medical problem, just like heart disease or diabetes.” One glaring problem with this statement is the first part in which the APA creates the situation it then denounces. It declares in the DSM that certain categories of thoughts, feelings, and behaviors are abnormal. Then it discourages people who fall within those categories from feeling abnormal.

That aside, let us examine the second part of APA’s statement that claims mental illness is “a medical problem, just like heart disease and diabetes.” The way diabetes is diagnosed is through an investigation of symptoms such as frequent urination and fatigue, which can be indicative of diabetes, but also could be symptoms of other illnesses like kidney failure and prostate cancer. So, the physician must check other information to increase confidence about the offending cause, which in this case would include laboratory testing that might show elevated glucose in the blood, while kidney and prostate numbers are within normal limits. This would support a diagnosis of diabetes, which is based on the internal dysfunction, not just the external symptoms. But if the physician merely assumes diabetes based on the symptoms alone and decides to prescribe insulin, it could be lethal.

This crucial medical process of symptom > hypothesis > testing > diagnosis > treatment does not happen with mental illness. Instead, psychiatry goes from symptoms and then straight to diagnosis and treatment. There is no hypothesizing or testing involved because there is no theorized or confirmed causal mental dysfunction to hypothesize about, for which to test, or to be treated. Even with the so-called medical syndromes, which are collections of symptoms that indicate an as-yet-unknown underlying dysfunction, there are hypotheses about the dysfunction, and treatment is intended to address that dysfunction in addition to alleviating symptoms.

Psychological tests do not fulfill the above testing role. Psychology graduate students are commonly taught that they are not tests that detect internal dysfunction but instruments that measure and analyze patterns of thoughts, emotions, and behaviors. Psychological or developmental issues like repressed mental conflicts, operant conditioning, and attachment styles, while impactful in a person’s life, are not examples of minds failing to function as naturally structured. Rather, they are moral judgments about proper ways to experience the world and act within it. At best, they affect how well a person might function in society, and appropriate social functioning is based on moral judgments.

As every psychiatric professional knows, mental illness diagnoses are not based on hypothesizing and testing. Instead, they are derived from an increasing array of DSM checklists of common experiences and behaviors, misleadingly called symptoms, that are a priori assumed to be dysfunctional. But these diagnoses are not medical decisions based on dysfunction; instead, they are bureaucratic decisions about which DSM categories the person best fits. To highlight the non-scientific and non-medical nature of the diagnoses, they result from the political wrangling of appointed members of DSM committees that meet periodically to issue new editions. Still, despite this moral and bureaucratic foundation, the DSM continues to claim that mental illness reflects “dysfunction in the psychological, biological, or developmental processes underlying mental functioning” without ever providing robust theory or evidence of such a dysfunction.

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Psychiatry has a long history, originating in the Scientific Revolution and continuing to the present day. As with other developing scientific endeavors of its time, psychiatry’s original intent was to use empirical inquiry as a substitute for sacred religious ideas about the natural world. What distinguished it from the other endeavors was its interest in the mind, more specifically, mental suffering.

Notwithstanding the momentous effects of its emergence, psychiatry would abandon this empirical journey very early on in its development. In its eagerness to join the Scientific Revolution, it failed to keep the immaterial and private nature of mind in focus, and it overlooked the misapplication of its physiological dysfunction-correction model to the non-physiological mind. The only thing left for it to do was to make judgments about the appropriateness of people’s experiences and behaviors, and to attempt enforcement of appropriate ones. As such, psychiatry morphed into a moral ideology, returning us back to the days when a sacred religion ruled over people’s lives.