The contemporary legitimation crisis in psychiatry
Alastair Morgan,
Sheffield Hallam University
Legitimation Crisis
“…traditions can retain legitimising force only as long as
they are not torn out of interpretive systems that
guarantee continuity and identity”. Habermas,
(1980:71).
Habermas J (1980) Legitimation Crisis, translated by
Thomas McCarthy, London: Heinemann
Three areas for legitimation crisis - Cultural
1). Tradition
 A broad interpretive framework – a “way of seeing”.
 Different historical constructions of tradition.
 Pluralist cultural tradition – psychoanalysis,
phenomenology, and psychiatry. Hybrid of
understanding and explanation
 The handing over of tradition – a mutual process of
critique and preservation – this has ossified in
contemporary psychiatry
2). Paradigms – scientific questions of
legitimation
• Paradigms generate a set of problems, questions and
horizons for scientific practice.
• Kraepelinian tradition of classifying discrete mental
illness syndromes ( often broad in nature) –
Kraepelinian dichotomy
• Neo-Kraepelinian restoration of that tradition –
attempts to exclude pluralism - DSM-III.
Klerman's neo-kraepelinian
theses
 1). Psychiatry is a branch of medicine.
 2).Psychiatry should utilise modern scientific methodologies and base its practice on
scientific methodologies.
 3). Psychiatry treats people who are sick and who require treatment for mental illness
 4). There is a boundary between the normal and the sick.
 5). There are discrete mental illnesses. Mental illnesses are not myths. There is not one
but many mental illnesses. It is the task of scientific psychiatry, as of other medical
specialities, to investigate the causes, diagnosis and treatment of these mental illnesses.
 6). The focus of psychiatric physicians should be particularly on the biological aspects of
mental illness.
 7). There should be an explicit and intentional concern with diagnosis and classification.
 8). Diagnostic criteria should be codified and a legitimate and valued are of research
should be to validate them.
 9). Statistical techniques should be used to improve reliability.
 Klerman G (1978). ‘ The evolution of a scientific nosology’, in Shershow, J (ed).
Schizophrenia: Science and Practice, Harvard: Harvard University Press.
• Kraepelinian paradigm and neo- Kraepelinian
restoration of the paradigm have both failed.
• Lack of validity and reliability.
• Proliferation of mental illnesses.
• Inadequacy of treatment, and paucity of new
treatments being developed.
3). The problem of authority – political questions
of legitimation
• What is the legitimation of authority for psychiatry ?
• Expansion of coercive treatments, without an evidence
base for their efficacy.
• Problems in justifying its own professional position
within medicine and beyond.
Research Agenda for DSM-V (2002)
–an acceptance of failure
 “not one laboratory marker has been found to be
specific in identifying any of the DSM-defined
syndromes”.
 “extremely high rates of comorbidities”
 “high degree of short-term diagnostic instability”
 “lack of treatment specificity is the rule rather than the
exception”
Kupfer D, First M, Regier D (eds) (2002) A research
agenda for DSM-V, APA.
A research agenda for DSM-V
(2002) – awaiting the messiah
 “. . .reification of DSM-IV
entities to the point that they are
considered to be equivalent to
diseases is more likely to obscure
than to elucidate research
findings”.
 A desire for an “ etiologically
based, scientifically sound
classification system”
 A demand for “fundamental
changes in the neo-Kraepelinian
paradigm.
 An “as yet unknown paradigm
shift may need to occur”
The hoped-for messiah –
neuroscience (2003)
 A desire for a “brain-based
nosology”.
 “mental disorders might arise
from abnormalities in brain
circuits” ( Hyman, 2003:98).
 “By combining neuroimaging
with genetic studies, physicians
may be able to move psychiatric
diagnoses out of the realm of
symptom checklists and into the
domain of objective checklists” (
Hyman, 2003: 103).
Hyman S (2003) ‘Diagnosing disorders’,
Scientific American, September 2003: 97103.
The failed messiah – neuroscience
(2012)
 A faith in a new paradigm
that would emerge from
“genetics, neuroimaging,
cognitive science and
pathophysiology” ( Kupfer
and Regier, 2011: 671)
 “We imagined that these
emerging . . . advances. .
.would impact faster than
what has actually occurred” (
Kupfer and Regier, 2011: 672)
Kupfer D and Regier D (2011) ‘Neuroscience,
clinical evidence and the future of
psychiatric classification in DSM-5’, Am J
Psych, 168:7, July.
What happened in these ten years
 Genetic complexity – no single genetic variant linked to
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mental illness.
The complexity of social/environmental and polygenetic
reactions.
Lack of clear findings from neuroimaging studies.
An increasingly dimensional approach to mental health
and illness.
An increasing awareness and grappling with brain
plasticity
This amounted to a complex challenge to biological
reductionism.
The split between DSM-5 and
NIMH
 DSM-5 published as
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compromise document
A “living document”
Some introduction of
dimensional diagnoses.
Many radical proposals
shelved - i.e. UHR traits for
psychosis.
NIMH – declares its split
from DSM-5.
Dr. Thomas Insel – current head of NIMH Insel’s blog post available at:
http://www.nimh.nih.gov/about/director/2013
/transforming-diagnosis.shtml
 DSM “tweaks” current
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diagnostic categories.
DSM not a “Bible”, but a
dictionary.
Lack of validity.
Re-orienting research away
from DSM-categories.
A split in the US between
research and clinical
psychiatry.
Is Psychiatry dying – the
cultural question?
Hugo Simberg – The Garden of
Death -1896
 A tending of the garden of
the tradition
 Until something better arises
 The living document of DSM5
Is Psychiatry Dead – the
scientific question?
Conceptually dead
 It declared its lack of belief in
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its own categories.
A lack of belief in validity
A lack of belief in reliability
A strong desire for
redemption
A repudiation from its
appointed and longed for
messiah
Death in the sickroom – Edvard Munch - 1893
Is Psychiatry the living dead –
the political question?
 Continues to diagnose more
mental illness.
 Continues to prescribe more
medication.
 Continues to coerce more
people into treatment.
The contemporary critical landscape
Radical pluralism
"Old psychiatry"
The "suppressed
potentials".
Kraepelinian
Cognitive or Behavioural
Neuroscience
Anti neokraepelinian
The "failed messiah"
Official psychiatry
Anti-Kraepelinian.
DSM -5.
Conservative pluralism
Neo-kraepelinian ???
The "practicing
nonbelievers".
The "penitents"
Kraepelinian.
Neo-kraepelinian
Kraepelinians
Worried about neoKraepelininans.
Postsructuralist.
Critical psychiatry
"The new epoch"
The "critical humanists"
Anti -Kraepelinian
Anti-Kraepelinian
Neo-Kraepelinian ???
Anti neo-kraepelinain
Official psychiatry – the “practicing
non-believers”
 Still officially Kraepelinian and neo-Kraepelinian
 Disputes at the edges on the boundary between
sickness and health ( 3 and 4 of neo-Kraepelinian
paradigm). Bereavement, mild neurocognitive
disorder, gender identity dysphoria, UHR traits for
psychosis)
 A compulsive and frantic concern with diagnosis ( 7).
 Agnosticism/confusion about validation and reliability
of the constructed diagnoses (8,9).
 Generally anti-pluralist tradition.
Cognitive or behavioural neuroscience
– the “failed messiah”
 Research Domain Criteria
 Dimensional system – looking at a range from normal
to abnormal – thresholds not boundaries.
 Officially agnostic about current diagnostic categories,
though highly sceptical
 Aims to generate new classifications from current
knowledge of behaviour-brain relationships.
A new pluralism ?
 Domains -negative valence systems, positive
valence systems, cognitive systems, working
memory, social processes, arousal and regulatory
processes.
 Constructs within each domain – usually
behavioural or cognitive in a limited way, that is
amenable to testing in laboratory conditions or
through fMRI.
 Units of analysis (genes, molecules, cells, circuits,
physiology, behaviour, self-reports)
 A curious disavowal of reductionism, alongside a
rigidly reductionist research agenda.
 A concept of human experience dependent on
evolutionary theory, behaviourism and some core
cognitive psychology.
 Limited reflexivity about their own paradigm.
 Anti- Kraepelinian
 Broadly anti neo-Kraepelinian – agree on points 6 and
7
 Psychiatry should become clinical or applied
neuroscience.
 Threshold between health and illness can be
intervened upon prior to sickness.
 It is pointless trying to validate Kraepelinian
constructs.
The “new epoch”
 Modern subjects are entering a new dispensation.
 Increasing focus on the physical somatic basis for
mental states.
 Focus on surface rather than depth.
 Somatic individuality
 Neurochemical selves
Nikolas Rose
Rose N and Abi-Rached J.M (2013) Neuro,
Princeton: Princeton University Press.
 Against medicalisation thesis.
 This is another form of
subjective formation, neither
better nor worse.
 Service users as consumers
demanding rights to better
treatments.
 Demanding labels or keeping
their labels – “Aspies”.
 “Better than well”.
 Anti- Kraepelinian, and anti neo-Kraepelinian.
 Psychiatry and medicine escape their bounds – more
concerned with health than illness alone.
 Reflexive about current paradigm – anti-realist.
 Anti or post –humanist.
Conservative pluralists – “the
penitents”
Attr. Guido Reni (1575 -1642)– the penitent Mary Magdalene
 Robert Spitzer – critique of
lack of openness of DSM-5
process
 Allen Frances – Saving
Normal.
 Nancy Andreasen – The
death of phenomenology
 Tom Burns – Our Necessary
Shadow
Frances A (2013) Saving Normal, New York: William
.
Morrow
 “Normal badly needs saving; sick
people desperately require
treatment” ( Frances, 2013: xv).
 “Understanding the whole patient
was often reduced to filling out a
checklist” ( Frances, 2013: 67).
 “The past thirty years have
witnessed a frightening vicious
cycle. Diagnostic inflation has led to
an explosive growth in the use of
psychotropic drugs. .” (Frances, 2013:
77).
Burns T (2013) Our Necessary Shadow. the Nature and
Meaning of Psychiatry, London: Allen Lane.
 “Psychiatry is a hybrid – at least
two distinct cultures (
understanding and explaining)
and draws from a range of theories
( psychological, biological and the
social)”. ( Burns, 2013: xlviii).
 “. . .the potential of the wellbeing
movement to swamp psychiatry
may be the profession’s
intellectual salvation . . . A much
needed review and retrenchment”
( Burns, 2013: 283)
Conservative pluralists – “The
penitents”
 A retrenchment for psychiatry. Treat the sick – leave
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the healthy alone.
Careful diagnosis – a return to the skills of descriptive
psychopathology ( away from the checklist).
Kraepelinian constructs may be constructs but they are
useful.
Worries over diagnostic inflation – unintended
consequences
Pluralist in a piecemeal way ( don’t just dismiss
psychoanalysis or phenomenology).
 Kraepelinian
 Broadly neo-Kraepelinian – division of sickness and
illness, but worried about over emphasis on reliability
at expense of understanding.
 A belief in pluralist roots of psychiatry –
understanding and explanation.
“Radical humanists” – Critical
psychiatry
 Emphasis on alliance with service users –co-production of
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services, treatment and diagnoses.
Concepts of recovery
Emphasis on meaning, relations and context.
Critique of the biomedical tradition in psychiatry.
Anti-Kraepelinian – calls to end diagnosis
Anti- neo-Kraepelinian – anti-positivist, although claims
for EBP.
Rational anti-psychiatry
A range of different theoretical positions – broadly
pluralist.
 A “complaint oriented approach” instead of diagnosis
– Richard Bentall
 Take the experiences that people present with and
respond appropriately.
 Start with the person in their social context and their
self-understanding and then layers of descriptions.
 A human rights critique of coercive practices.
Radical pluralism – old psychiatry –
the “suppressed potentials”
 A return to that which has been passed over and forgotten.
 An interest in Kraepelinian and pre-Kraepelinian categories
 Anti neo-Kraepelinian
 Broad constructs can be useful and are much better than
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splitting.
A different perspective on the sickness and health debate –
mental health is an illusion.
Anti-medicalisation
An emphasis on psychic structures not surface phenomena
Continental phenomenology ( EASE, Sass, phenomenology and
neuroscience work) and psychoanalysis ( Leader).
Darian Leader
Leader D(2011) What is madness ?
London: Penguin
Leader D (2013)Strictly bipolar,London:
Penguin.
 An interest in what can’t be fitted into a narrative.
 A rejection of surface symptomology
 An embrace of diagnostic failure and even failures of
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understanding.
A challenge to the service user – “psychoanalysis involves
not responding to the patient’s demands”
A critique of medicalisation
A critique of cognitive and behavioural models of
experience.
An understanding of madness as a construction - a mode
of understanding the world.
What is to be done ?
Kraepelinian psychiatry
 It is dying as a paradigm.
 The idea that there are discrete mental illnesses with
clear boundaries.
 The idea that there is a clear boundary between
sickness and health.
 The idea that we should endeavour to validate these
categories.
 Pluralists ( both conservative and radical) defend this
to some degree, but a futile gesture.
 A possibility for a critical rescue of aspects of this
tradition.
Sickness and health
 A dignity in the response to distress.
 Is it possible for a psychiatric retrenchment ?
 The impossibility of mental health.
 Alongside the ethical demand to respond to suffering.
 A notion of continuity and discontinuity when
thinking of sickness and health.
A renewal of pluralism
 The interpretive tradition that is psychiatry is not
solely dependent on Kraepelinian approaches.
 We still need conscious and explicit conceptualisations
of mental distress.
 A defence of psychiatry as a “hybrid tradition”
 Its very “hybrid” status could make it a harbinger of a
new kind of medicine.
 A different way of conceptualising understanding and
explanation in contact with less reductive concepts in
neuroscience and genetics.
Aspects of a renewed pluralism- an
emphasis on meaning
 A critical humanist agenda.
 Narratives of those with lived experience of mental
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distress.
An attention to madness – to what cannot be formed as a
story or easily understood.
A rich attempt at a deep phenomenological understanding
that is able to tolerate an inability to completely
understand.
A descriptive psychopathology that is severed from its
Kraepelinian foothold.
An emphasis on social and material context that is not
reducible to “stress”.
Against cognitivism and positivism
 Both DSM-5 and the NIMH RDoC are explicitly
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uninterested in any understanding of the meaning of
mental distress.
A desperate attempt to be rid of any phenomenology,
including descriptive phenomenology.
A reduced conception of experience – reduced to
cognitions that can be replicated in functional tests.
Behaviours that can similarly be tested
A concept of society that is reducible to stress, threat,
reward modalities.
A concept of subjectivity that is dependent on reductive
evolutionary notions of subjective agency.
 Neuroscience may consider itself pluralist.
 It only includes what can be measured.
 The NIMH are building up a vision of wellness and
distress that is constructed on a reduced notion of
experience.
 Only that which is quantified and quantifiable counts
(positivism)
 A splitting of the psyche into disconnected functions
Humanism – debating
conceptions of experience
 In different ways all parties to the critical landscape
apart from DSM-5 and the NIMH are interested in a
project of human understanding.
 The possibility of conceptualisations of mental distress
that begin with the human in a social context, and add
layers of description to this, including layers of
description from neuroscience and genetics
 Not a fixed notion of what it means to be human
Judith Butler – “Becoming
Human” – Butler J (2005) Giving an Account of
Oneself, New York: Fordham University Press.
 Embodied exposure to the world – core vulnerability and openness ( can’t just
be reduced to animal models of reward, threat and arousal – can’t be reduced
just to the brain)
 Primary relations of childhood attachment, that can’t be fully recovered or
narrated ( the unconscious)
 A narrative history of a life, with its own process of remembering and
forgetting – a primary “opacity to myself”.
 The societal structures within which I am constituted as a subject but never
completely constituted ( “something is missing”)
 A structure of intersubjective relations within which I tell my story, and within
which I am allowed to tell my story.