A newly published study in the Journal of Theoretical and Philosophical Psychology by researchers Sara Campolonghi and Luisa Orrù from the University of Padua in Italy illuminated serious concerns about the biomedical framework psychiatry uses to treat mental disorders.
They argue that psychiatry, a discipline attempting to understand the mind using a medical approach often reserved for the body, finds itself in a perplexing position. This confusion, they say, has led to more problems than solutions, creating “more illness than effective treatment and relief.”
They point out that the conflation of medical illness and mental health has resulted in significant ethical issues and an urgent need for a more scientific and practical way to help those who suffer from mental disorders.
The authors stress that it’s time to recognize the limitations of psychiatry, stating that there are “implications of abandoning psychiatry’s biological framework in mental health care and the possibility for psychiatry to find its own specific, unique, and legitimate space of knowledge and practice.”
In modern, Western cultures, ‘mental illness; is often attributed to abnormalities in brain functioning. Whether they are described as genetic malformations, chemical imbalances, or epigenetic disturbances, the cause of depression, addiction, schizophrenia, and other mental diseases are seemingly always assumed to reside at the biological level. However, we do not diagnose mental illness via tools such as blood work or fMRI imaging, where doctors would be able to see the malformations and apply a diagnosis, leading to a set of possible treatments and cures.
Causal genes have yet to be found for mental disorders such as schizophrenia. For over a decade or more, we have known that the “chemical imbalance” theory is false (even if we still hear it in drug advertisements). fMRI imaging still can’t identify the differentiations between normal brains and those with ADHD. And the field of epigenetics, wherein a person’s genes are “turned on” or “switched off” due to environmental and experiential factors, suggests that the nature-nurture distinction cannot hold– a person’s biology is adapting to the environment.
Yet, psychiatry, especially in the United States, adheres strictly to this medical model. This model “is concerned with the human body and its parts,” “aims to ‘correct disease and restore normal functioning’ and conceptualizes disease as a biological dysfunction within the body,” the authors explain. “Since it developed primarily to cure acute infectious disease, this model is based on a monocausal theory of disease.” Monocausal means that if we look hard enough, we will find a singular, biological cause for a person’s distress.
Campolonghi and Orrù critique this approach to mental suffering by raising new and old questions about psychiatry’s stubborn adherence to this model. In their latest research, they ask questions about the implications of this model on how we understand people’s suffering, including at the cultural level, and then describe how psychiatry could abandon this model and instead “find its own specific, unique, and legitimate space of knowledge and practice.”
The Medical Model and Psychiatry
The duo starts by dissecting the medical models’ theoretical and philosophical underpinnings, first by explaining how “etiology,” or the study of causes (in this case usually monocausal and biological), became primary to medicine.
“Etiology and the related notion of causation have been central in Western medicine and pathology since the 19th century. The diagnosis explains the symptoms by indicating the cause, that is, a specific, necessary, and sufficient biological mechanism,” they write. “In bodily medicine, etiology, or the study of causes (aitìa, in ancient Greek), represents the gold standard for disease classification… which is necessary for medical diagnosis and treatment.”
Medicine groups the symptoms (clues) and works backward to find the monocausal, etiological mechanism causing the malady. For example, stiffness, fever, stuffiness, coughing, and a sore throat are usually identifiers of a viral infection. Yet, if a person also adds the symptom of loss of taste, doctors will know it is more likely COVID-19 because that biological mechanism causes that symptom in addition to the others.
This system led to the birth of modern medicine, virology, pathological anatomy, and other forms of medical science. It is within this structure that psychiatry has tried to fit itself.
“Psychiatric research and practices apply physical disease models and medical classifications to the realms of thoughts, feelings, and behaviors based on reification and on a superficial medical analogy where mind and mental disorders are assessed and treated the same way as bodily tissues/organs and physical symptoms. This happens in the absence of any reflection or discussion regarding the epistemological suitability of the biomedical criteria and concepts in its context of knowledge, nor the possibility of applying them scientifically in its praxis.”
This approach leads psychiatry to “emulate the medical approach by borrowing medical concepts such as symptom, disease, diagnosis, or syndrome, and using the health/disease axis as reference.” But does this system work for the actual ‘thing’ psychiatry is studying?
The “Mind” and the Brain
Psychiatry’s focus on the human psyche and its pathologies can be traced back to Aristotle’s view of the physical and the psyche as a united entity representing the human essence. This concept shifted with Descartes, who separated the psyche from the body, conceptualizing the body as a biological machine and psychological functions as the “mind.” This led to the mind-body dualism that underpins modern Western medicine and psychiatry.
French physician Pinel introduced the idea that psychological problems might have physiological roots, pushing psychiatry to adopt a medical perspective on the psyche. This required psychiatry to follow a reductionist biomedical model, treating the mind like the body. It focused on diagnosis and removed meaning and context, aiming for objectivity and disregarding subjectivity. However, this move away from subjectivity led psychiatry to sever its connection to its foundations, losing its theoretical and methodological groundwork.
The consequence of this shift was that psychiatry had to anchor itself in believing that mental disorders were rooted in the brain and primarily caused by underlying brain dysfunctions. The mental and physical realms were seen to have a causal relationship. To maintain its status within the medical community, psychiatry embraced the Cartesian idea that the physical world could cause issues in the non-physical realm or the mind.
Psychiatric Diagnoses and Classification
While there is an apparent connection between the brain and mental processes and pathologies, “the consistent and systematic search for biological and neurological causes of distress and problematic behaviors conducted over more than a century did not provide any evidence or support for the existence of ‘mental disorders’ as natural kinds, and the lack of progress in this line of research is striking… despite the significant technological advances [during those years].”
So, psychiatry still moves forward based on the assumption that those biological causes will be found in due time. As for now, psychiatric diagnoses (outside of identifiable neurological disorders) are identified not using technology but by gathering and applying subjective experiences (“apparent phenomena, surface characteristics”) and then grouping those to form clusters of symptoms that are then categorized via an “illusory correlation [process],” that becomes a “diagnosis.”
Yet, the criteria for these groupings “are grounded in culturally specific and locally defined judgments about normal or abnormal behaviors and feelings… and psychiatric ‘diagnostic’ decisions are mostly based on self-reports and interpretation of behaviors rather than justified by objective, empirical signs, or laboratory test.”
Even though the physiological causal links have yet to be identified, psychiatry has doubled down on this biomedical approach.
“The first and second editions of the [DSM] were at first still informed by psychological theories (i.e., psychoanalysis) and etiology… the third edition of the manual (DSM-III) saw the removal of the distinction between psychological and biological disorders, in order to proceed in a supposedly atheoretical fashion. This return… was once more undertaken to make psychiatry more credible and closer to medicine.”
Interestingly, when analyzed, this turn has led psychiatry to become less empirical and grounded in hard science. As Johnstone and Boyle describe, “A person can be told that they hear voices because they have schizophrenia, and that they have schizophrenia because they hear voices. As such… a person “has” a mental disorder simply because someone says they ‘have’ it.” There is no measurable, standardized test to prove this diagnosis.
Furthermore, there is disagreement over whether or not hearing voices is always a pathology. Must a person who hears voices, such as a religious person who believes they are hearing the voice of God, have the disease of schizophrenia?
As psychiatry continued to double down on its stance as a physiological medical practice, its approach to treating mental suffering was limited in scope. Culturally, the psychiatrist has been depicted as someone who performs talk therapy, such as in Dr. Melfi from The Sopranos. While Dr. Melfi prescribes medications to her patient, she also has hour-long talk therapy sessions now usually reserved for psychologists and therapists.
According to Campolonghi and Orrù, psychiatry’s shift away from talk therapy and towards psychopharmacology started in the 1950s and has ended with the practice becoming increasingly focused on psychopharmaceutical “cures” for mental suffering. The problem is that “the drug-centered approach of psychiatry and how medications are created fully reflects its theoretical and methodological flaws and fueled the overwhelming process of medicalization of human experience and problems of living.”
There has yet to be a psychotropic medication that was created by identifying an underlying physiological cause and then reverse engineering the drug to “fix” that cause of suffering.
Instead, “their invention originated from casual observations of their effects on mood or behavior in the absence of any etiological disease theory… As such, they do not target nor ‘cure’ any specific underlying dysfunctional mechanisms involved in producing the supposed symptoms of what we call ‘mental disorders’.”
Notably, the authors are not suggesting that psychotropic medications be stopped altogether but that we better understand their long-term impacts:
“While psychotropic drugs can be useful in alleviating suffering and preventing harm in certain acute situations and conditions, in the long term, they interfere with the healthy function and reactions of neurotransmitters as they create the chemical unbalance they are supposed to resolve, leading to serious damaging effects and to cognitive and physical disability… psychotropic drugs create abnormal brain states rather than ‘cure’ them.”
Science vs. Common Sense
It’s essential to recognize that additional time, biomedical research, or technological advancement will not lead to discovering cures for mental disorders or identifying the right psychotropic drugs or therapies that will finally be effective. This lack of progress stems from psychiatry’s reliance on common sense rather than scientific principles. Its knowledge system pertains to an illegitimate level of ontology and epistemology, dealing with constructs that have never been precisely defined.
The authors argue that although psychiatry appears to fit into the medical model, its practice lacks a grounded, empirical understanding of mental suffering that would justify this alignment. Psychiatry does not rest on the foundations of physical sciences but adheres to a neo-positive-empiricist tradition. It claims to deal with observable medical phenomena independent of the observer’s interpretative process. However, its subjects of study, such as the mind, personality, behavior, and anxiety, considered dysfunctional or symptoms, are, in reality, purely hypothetical or subjective constructs.
Furthermore, unlike the language of physical sciences that focuses on concepts like atoms, gravity, and temperature and exists outside of cultural contexts, psychiatry and social/human sciences study constructs like society, norms, experiences, and emotions. These are built inductively through discussion and interpretation rather than replication and calculation. Since psychiatry doesn’t rest on physical sciences, it deals with constructs rather than concepts and employs common language similar to that of the community, like being “depressed” or having “anxiety.” Yet, it makes claims using specific language and medical terms, such as diagnosis and syndrome, akin to physical sciences and medicine. Consequently, these constructs become reified or treated as real and concrete.
“Psychiatry does not define its constructs, does not refer them to any psychological theory, and treats them as empirical objects existing a priori and factual truths as medicine does. Indeed, the biopharmacological approach applied to ‘mental health’ does not work and creates more illness and sufferance than solutions.”
Not only does the medical model of “mental health” not have empirical, theoretical grounding, but it also has not been successful in limiting mental health suffering. It has worked to remove the social and cultural dynamics of human life from our understanding of the etiology of mental ‘illness.’
External stressors, such as un/underemployment, systemic discrimination, and workplace stress, become secondary to an imagined, theoretical biological mechanism for mental suffering that has never been found.
The authors take on the idea that the old paradigm needs alternatives.
“To be able to assume scientific legitimacy and better understand the complexity of human phenomena and health, psychiatry must find a new space of knowledge and paradigm of care where to clarify and respect its theoretical foundations within which to define clear norms, aims, and objects of investigation. This is the only way for a discipline to create knowledge, operate scientifically and ethically, and find effective solutions. However, while working toward alternative approaches to psychiatry, the search for potential biological and microlevel factors and processes should not be abandoned.”
According to Campolonghi and Orrù, it must move from being reductionistic to expansive, becoming inclusive of biological, psychological, and sociological factors in describing, researching, and alleviating suffering.
However, the authors also note some interesting problems that any alternative must tackle. For example, immediately abandoning the current system would lay open the possibility that protective policies could be removed. Instead of a more empathetic structure being put in place, a more punitive one could arise. This also means that the current system that is offering some support to those suffering could lead to the deprivation of that support. Much of that concerns how diagnoses can, to a certain degree, increase the acceptability of suffering while blocking more moralized and judgmental ‘faults’-based approaches.
Whatever is to come cannot completely abandon the past nor the language and lexicon that are now part of the cultural milieu. However, it must also help the culture develop an inclusive “vocabulary that can represent and express a different reality, phenomena, and experiences.”
The authors agree with Boyle and Johnstone that, while a change will take significant work, “the need for a paradigm shift away from disease models and diagnosis is clear and urgent.”
Campolonghi, S., & Orrù, L. (2023). Psychiatry as a medical discipline: Epistemological and theoretical issues. Journal of Theoretical and Philosophical Psychology. (Link)