The Philosophical Defence of Psychiatry

The Philosophical Defence of Psychiatry

Lawrie Reznek

New York, NY: Routledge, 252 pp., 1991

The goal of this book is stated at the outset. It aims “to provide psychiatry with philosophical foundations.” Not a small challenge to undertake. But the author, who trained as a psychiatrist after obtaining a doctorate in philosophy from Oxford University, appears better suited than most to attempt such a task. Dr. Reznek argues convincingly that philosophy is not simply an interesting vantage point from which to discuss psychiatry, but that it is necessary in order to understand psychiatry and the criticisms that have been levelled against it.

The reason for which a philosophical approach to psychiatry is required is explained in the introduction. The author acknowledges that “psychiatry is in a theoretical mess” and implies that this state of affairs leaves the door wide open for criticism. The introduction is appropriately short, since not much space is required to support this premise. Different psychiatrists will treat the same mental condition differently, will understand the nature of mental abnormality differently and can base their entire clinical practice on formulations and assumptions that are in direct conflict with those of their peers. Reznek writes that “as a science over two thousand years old, one expects some agreement as to the basic form of psychiatric explanation.” But the way in which one psychiatrist approaches a clinical problem will likely have more to do with what the psychiatrist believes to be true, than with what can be proven to be the case.

However, after boldly acknowledging this state of affairs, the author proposes that we may not be in quite as much of a mess as some would argue. Maybe some of the different ways of understanding mental conditions are not as fundamentally opposed as they appear at first glance. Do the various formulations — psychodynamic, behavioral, neurochemical and others — truly represent different paradigms from which explanatory theories are derived, or can they be better understood as variant theories all within a more comprehensive medical paradigm?

This is the basic argument of the author and a basis for his philosophical defence of psychiatry. That seemingly disparate explanations of mental and behavioral anomalies do not represent mutually exclusive paradigms, but rather different theories that are not intolerably in conflict with a medical paradigm. The critics of psychiatry are not really hitting at the foundation of psychiatry as a branch of medicine, but capitalizing on the plethora of theories, each with its own explanatory power, its own proponents, and in its own stage of evolution, that have been proposed within the broad boundaries of the medical paradigm.

After a first chapter, in which the medical paradigm is explained in detail and meaning, seven chapters examine the ideas of prominent persons with radically different perspectives on the nature of mental conditions. Interestingly, six of these chapters debate the arguments of some of the most prominent critics of modern psychiatric practice (Hans Eysenck, Ronald Laing, Thomas Szasz, Peter Sedgwick, Thomas Scheff, Michel Foucault), while the seventh examines the ideas of Sigmund Freud. How does the author justify lumping these people together? Each has proposed theories that contradict certain core theses of the medical paradigm, thereby raising serious questions about the place of psychiatry in medical science.

For example, Eysenck argued that behavioral disorders are, in some cases, caused by organic disease (and therefore fall into the field of neurology) and, in other cases, are not diseases at all, but result from normal processes of learning or conditioning (a subject that Eysenck says is fundamental to psychology, not medicine). Others also argue that many mental conditions are not best conceptualized as disease processes, but as understandable and intentional protective mechanisms (Laing), the result of social construction (Sedgwick) or the labelling of deviance (Scheff). Freud fits in well. He proposes that everyday mental and behavioral phenomena arise out of similar psychodynamic processes, as do neurotic and delusional conditions, thereby challenging the role of disease as a cause of abnormal behavior, unless one believes that every person has a disease called psychodynamic conflict. A ninth chapter compares these explanations of mental disorders, argues against their validity as distinct explanatory paradigms and proposes a comprehensive medical paradigm that considers abnormal biological processes as a sort of final common pathway that can occur with any of these alternative formulations and that results in the signs and symptoms of mental disorder.

The remaining five chapters — “The Nature of Mental Illness,” “Is Psychiatry a Science?” “Psychiatry and Responsibility” and “The Practice of Psychiatry” — further explore the author’s argument that psychiatry can best be understood in the field of medicine and examine a wide variety of interesting and relevant topics. Forceful arguments on these topics are highly relevant at a time when debates about compensation for stress-related disorders, patients’ rights, third-party payments for psychoanalysis and the insanity defense are in the news and on our minds daily.

The manner in which the author dissects these theories and the arguments he uses to defend psychiatry in the face of forceful criticism is as interesting as the conclusions he draws. As the title of the book indicates, the goal of this book is to defend psychiatry. In the chapters on prominent and/or alternative theories of mental disorders, the formulations are demonstrated in turn to be faulty, at least as they suggest that psychiatry does not or should not be accepted as part of the medical paradigm and medical practice. But the combination of strict logic, imaginary scenarios and absurd anecdotes demonstrates a manner of thinking much more familiar to philosophers and theoretical physicists than to medical practitioners, even psychiatrists. It takes some getting used to, and the author can be criticized for not preparing the reader better for what he or she is getting into. Unless the reader is already familiar with this style, the arguments take work to truly appreciate. Another criticism is the very similar style in which the early chapters are written. Each contains a brief description of a theory, some creative arguments, and concludes that the theory is faulty. Readers may be better to pick two or three of these chapters that interest them most and then proceed to later chapters.

This book is for any psychiatrist who questions or wishes to examine the nature of psychiatry itself. It is not a casual read, but requires effort. Many ideas are given in rapid fire. Some of the arguments should and will arouse scepticism. I find it difficult to accept that because abnormal mental phenomena are coupled integrally with abnormal biological processes in some currently undefinable and unmeasurable manner, that seemingly any theory of mental disorder can fit within the medical paradigm, albeit a somewhat remodelled one that is proposed. However, this is not a criticism of the book, only my thoughts on one of the ideas presented. In fact, a strength of Reznek’s writing is that it demands that the reader be drawn into the arguments. The reader cannot help but argue for or against the propositions. As a result, the reader may agree or disagree with the author’s arguments or be irritated or reassured by them. But the reader cannot avoid taking a stand, and this alone makes reading this book highly worthwhile.