Conceptualising mental disorders: why psychiatry needs more than one lens

Welcome to the Brains on Brains podcast, brought to you by ECMP, where early career scientists speak with the most interesting experts in applied and translational neuroscience. Hello, my name is Stefan Yerotic, I am a psychiatrist and researcher from the University Clinic of Psychiatry in Belgrade, Serbia. I have the pleasure today of being the interviewer for this podcast on behalf of the ECMP Early Career Academy. Today, we are joined by Dr. R. Y. Saftap, a psychiatrist and the clinical associate professor of psychiatry at Case Western Reserve University, known from bridging clinical practice with philosophy of mind and the conceptual foundations of our field. He edits the widely read newsletter "Psychiatry at the margins" and leads sustained conversations that test the assumptions behind diagnosis, evidence and treatment. He is also the author of the 2024 book published by Oxford University Press "Conversations in Critical Psychiatry". His scholarly work ranges from explanatory pluralism in psychopharmacology, epistemic justice in clinical care, to conceptual education in psychiatry, and he has written influential viewpoints for the New York Times. In 2025, the Landside Psychiatry profiled him as one of the disciplines for most public intellectuals. Dr. Aftap also serves as a senior editor at philosophy, psychiatry and psychology, the journal, and on the Executive Council of the Association for the Advancement of Philosophy and Psychiatry. A clinician and educator and incisive interviewer himself, he brings a rare combination of clinical realism and conceptual rigor. So, hello, Dr. Aftap. To begin with- Thank you, Stefan. Can you tell us a bit how did your interest in conceptual foundations of psychiatry emerge? Again, I want to emphasize thank you so much for having me for this ECNP podcast. A pleasure to be here. With regards to my interest in conceptual aspects of psychiatry and philosophical aspects of psychiatry, it goes pretty way back. Even before medical school, I was very interested in philosophy and there was a point when I was even considering going into philosophy professionally, but the way it turned out, I ended up in medical school. So, I was attuned to conceptual and philosophical aspects of medicine from the very beginning. As my interest in psychiatry waltzed, I started paying more attention to that. I started reading some of the classic anti-psychiatry literature, R. D. Lang, Divide Itself, for example. I was also quite interested in existential psychotherapy illustrated by the psychiatrist and therapist, Irvin Jallam. So, these were some of my early influences in terms of thinking conceptually about psychiatry. As my psychiatric training progressed, I became more formally enrolled through association for the advancement of philosophy in psychiatry. I discovered this burgeoning academic field and the excellent academic work that has been done since the 90s in this area. Were there any particular thinkers or researchers who influenced your approach? Yes. So, Derek Bolton, who is at King's College London in the UK, he's a brilliant psychologist and philosopher. He wrote a book, 2007-2008, What is Mental Disorder? This was published at Oxford University Press. I've revisited this book multiple times over the course of my career. The first time I read it was just around the time I was starting my psychiatric residency. I was really influenced by that because it was an examination of the question of what kind of judgments are we making when we say that a behavior is disordered or that a behavior constitutes a mental disorder. It was an examination of the question of, to what extent is this a factual judgment, a naturalistic or objectivist approach, or to what extent this is something that is very valid and to what extent this is something normative? How can we understand this tension? Reading that book, I think one, it set me on a philosophical path to my psychiatric residency as well, but it also guided me in thinking better about these questions. Derek Bolton's What is Mental Disorder? A Huge Influence. The other big influence, I would say, is Peter Zakar's 2014 book, A Metaphysics of Psychopathology. Peter Zakar is also a psychologist and a philosopher based in the UK. His work is focused on taking a pragmatic approach to metaphysical questions in philosophy of psychiatry and understanding questions of classification and diagnosis through the lens of pragmatic philosophy. Instead of thinking of diagnosis as natural kinds, thinking of them more as practical kinds, as categories that serve various kinds of clinical and practical and scientific goals that we set for them. Those are two big influences, I would mention here. Kenneth Kendler is another one, a very famous distinguished psychiatrist, geneticist, and his papers on psychiatric pluralism and thinking about psychiatry through a philosophical lens have also been very influential. Since there are many ways that mental disorders can be conceptualized as you were talking about. What do you think about this biopsychosocial model which is propagated as the foremost model for understanding mental disorders? I think depending on the specific question we are interested in, there will be different kinds of models and different kinds of philosophical positions at play. The question of the biopsychosocial model refers in particular to issue of multi-level causality and the issue of how is it that different risk factors and causal factors at multiple levels of explanation, how do they interact with each other? Biopsychosocial model which originated with the physician George Engel and his seminal work in the 1970s and 80s has been conventionally a way of referring to and talking about this issue of multi-level causality in the psychiatric context. There are significant differences between how George Engel conceptualized the biopsychosocial model and how it is understood. I think that historical context also matters but generally speaking what a lot of people mean when they talk about biopsychosocial model is that causal factors at the biological, psychological, and social level all exist and are relevant to the etiology of mental disorders and that treatment at mental disorder should be targeted across all these domains as well. That works well enough in practice as a rough guide or as a rough reminder but philosophically speaking it is rather inadequate and for a couple of reasons. One is that it turns the biological, psychological, and social levels of explanations into something more concrete and that's not really how reality itself is organized. Biological, psychological, and social are human ways of talking about complexity and organization of phenomena not something that in reality how world is distributed and the second it's absent on the question of how is it that they interact? How is it that the biological interacts with the psychological and biological with the social and how is it that what kind of weight should be assigned to different domains when it comes to different mental disorders or different clinical presentations? In response to these deficiencies, different other kinds of approaches emerged. One common one is explanatory pluralism or methodological pluralism which instead of dividing this issue along biological, psychological, and social it refers instead to theoretical methods and it refers instead to various kinds of scientific approaches we are we are taking to understanding a phenomena and it talks about you know we focus on the exact method we are using what are the limitations of that method, what are the advantages and disadvantages of that method and it recognizes that complex phenomena such as psychopathology are going to require different methods to study it each offering a certain you know advantage or disadvantage. At the same time the question of how is it that the biological and psychological interact has resulted in kind of philosophical developments in the form of embodied cognition and inactivism so there's this movement in cognitive science often referred to by the 4e cognition understanding the mind as embodied, embedded, inactive, and extended and there's also in in neuroscience circles the idea of brain as a predictive processing machine has has also emerged and there are some interesting philosophical connections between the you know these things so at the moment you know in philosophies like i3 world the the biopsychol reliance on biopsychosocial model has been replaced on one side with an emphasis on methodological pluralism and explanatory pluralism and then on the other side with more sophisticated models of understanding mind-body interaction in the form of embodied cognition and in the form of predictive processing. I want to briefly mention that you know other questions you know warrant other kinds of models understanding the nature of disorder judgments has traditionally been understood as a question of naturalism versus normativism to what extent are disorder judgments grounded in objective facts you know to what extent they can be described in purely natural terms and to what versus normativism that is to what extent disorder judgments are evaluated and to what extent they're referring to human human interests and to what extent they involve social cultural judgments and then there are hybrid models as well which include both naturalistic and normative elements and currently different forms of hybrid models are our influential Jerome Wakefield's evolutionary approach called harmful dysfunction for example is a common one and they're there they are in very interesting and fierce debates between hybrid naturalism and normativism at the moment when it comes to the question of psychiatric classification the traditional debate has been between natural kinds practical kinds and social kinds is that should we understand psychiatric categories as having some kind of hidden biological essence for example or should we understand them as more practically oriented categories that that kind of carve out and map the domain of psychopathology in in ways that are practically useful to us but not necessarily capture hidden essences so I say I think again yeah depending on the question we're interested in different positions and models become relevant yeah yeah and connected with this so how do you believe so since there have been movements to kind of include more patients or service users into this conceptualization of the way that we understand mental disorders so how do do experiences of service users themselves reshape the way that we define mental disorders and what do you think about including all of these firsthand experiences into into all of these committees in kind of describing and defining these mental health conditions yeah I think appreciating the importance of first person perspectives has been a very particularly important development you know over the last one to two decades and you know in terms of thinking philosophically about it there there have been there has been interesting developments in philosophy of science where we have a better understanding of the social dynamics of the scientific method what is often called the social epistemology of science that is what is happening that kind of you know in order for science to do its job well what what needs to happen and one of the common ways of approaching this kind of like you know issue comes from the philosophy of science Helen Longino who talks about social objectivity of science is that in order for scientific communities to function well there needs to be a diversity of representation of different viewpoints people coming in with different background assumptions and you know different experiences so that so that people can ask different kinds of questions and and people can interrogate assumptions through through different vantage points and then there needs to be public and fair venues of criticism and these criticism need to be taken seriously and integrated by the scientific community in a transformative manner so within that context of social you know social objectivity it is now recognized that excluding certain groups from the scientific process comes with certain harms so traditionally for example women and racial minorities were excluded from from from mainstream western medicine and that had detrimental influences our understanding for example of women's health women's mental health kind of you know was impoverished as a result of that similarly it is now recognized in in psychiatric field that excluding the kind of you know patients with personal experience of mental illness from the scientific process has had detrimental influences and that it has impoverished our understanding of psychopathology the social objectivity idea also kind of aligns with what is known as standpoint epistemology that is different people occupy different standpoints and certain standpoints allow us to ask the kind of question that might not occur to other people so people who have personal experience of mental illness they are aware of certain kinds of challenges and certain kinds of issues that researchers who don't have that personal experience are not going to be aware of so there it is now recognized that there's a need for scientific community to diversify itself and work productively with individuals with you know lived experience of mental illness so that you know some of the traditional assumptions that have gone by unchallenged can be challenged and we can we can think about these issues in a more productive manner so I think scientific and psychiatric organizations you know across the world have now taken steps to formally incorporate patient voices in the in the psychiatric research process yeah yeah and so coming at all of this from a kind of a more personal point of view have you faced any challenges when arguing the conceptual clarity is as important as biological data have you had any challenges in in in kind of arguing for that yes I think because I think a lot of physicians don't have the kind of exposure to to philosophy or conceptual thinking there can be a kind of naive reductionism or naive positivism at play where they where they have this tendency to think about scientific theories as you know as representing absolute truth as scientific theories as lacking historical and social context and they they can have kind of like they don't I'm gonna kind of like you know restart the sentence they they might not be aware of the ways in which they are confused about psychiatric concepts so for example oftentimes when I when I work with with psychiatric trainees they might use concepts like medical disorder or or mental disorder or they might talk about mental disorders being brain disorders and from their perspective it seems pretty evident to them that you know what they are saying but once you engage in some form of psychotic questioning once you interrogate you know what exactly are we talking about when we talk about mental disorders as being brain disorders what exactly are we talking about when we talk about behavioral phenomena as being disorders it becomes evident pretty quickly that you know that they don't have the kind of clarity that is adequate for for this purpose so um so one of my efforts you know on the educational side has been this project of conceptual competence in kind of emphasizing to the psychiatric community that just as we expect uh psychiatrists to be culturally competent we expect them to be clinically competent we expect them to be structurally competent understanding you know social structures we should also expect them to be conceptually competent that they should have a certain minimum competence in understanding the complexities around psychiatric concepts such as mental disorder psychopathology brain you know brain uh mind-body relationship you know involvement of values etc and so that has been the focus of my educational effort in recent years yeah I agree completely and so when we're talking about this you know what are the ways that you know expiring in early career scientists can educate themselves or integrate this conceptual thinking into clinical research or even lab-based research if you think it's important also for for translational scientists as well um yes I think and the the good thing is that at this point we have numerous excellent role models of people who have integrated conceptual and philosophical thinking into empirical scientific work in excellent ways I think the the best example remains uh the psychiatrists and geneticists Kenneth Kendall Kendler um he has done excellent work in in trying to understand the genetics of of psychiatric problems um he has also done excellent work trying to understand multi-level causality and how to approach issues of classification and his uh his philosophical thinking was also played important role in the development of dsm 5 with uh you know clarification around the issues of external validity and how to think about external validity in the context of psychiatric diagnosis um other influential talk leaders such as Steve Hyman who's a former director of NIMH he has written about it's spoken about how to understand you know philosophical issues around psychiatric diagnosis on the neuroscience side we have examples of figure figures such as Carl Friston the you know the person who proposed the the predictive processing um an active inference model uh through the free energy principle and he has demonstrated how engagement with philosophy can be productive for for neuroscience and another example that comes to my mind is the American psychiatrist Thos Unger who is the current editor-in-chief of JAMA psychiatry and in his in his uh lab which is devoted to psychosis research he has engaged productively with questions of philosophy questions of phenomenology and his work also exemplifies how engaging with conceptual questions and philosophical questions it's not an embediment it does not slow things down but rather it enriches the scientific work that we do yeah and so when you're mentioning uh Kenneth Candler for example or Stephen Hyman and most of these other thinkers they have done extensively they have written about psychiatric classifications and have critiqued them in in some ways so do you think that future psychiatric classifications and now I'm talking about specifically ICD and DSM do you think that they will change that they will look radically different given all of these issues that they have some of them are which are evident even from your from this interview that you've mentioned um or do you think they will evolve gradually or maybe they won't change at all since from the 80s to this day they haven't changed as much as we as we kind of maybe hoped even it is hard to predict what direction they will they will take as there are there are many um factors at at at play and these are in the organizations that develop these manuals the indications at the moment is that um they are looking for slow iterative um improvement so they're they're looking at um minor improvements over time minor changes to diagnostic criteria minor changes to diagnostic classification um that accumulate but there are some there are exceptions to this I think you know the the switch from a categorical to a dimensional model of personality disorders for example was a big switch you know it was made in ICD 11 successfully and you know it was partially made in DSM 5 with the alternative model of personality disorders and in all likelihood the dimensional model of personality disorder classification is going to become the dominant one and I think that dimensional thinking is likely going to be manifest in in other areas of psychiatric classification as well so so we will see how this happens but I think in all likelihood we can expect the gradual iterative improvements with you know increasing influence of dimensional thinking as well as you know influences from computational neuroscience and complex dynamics systems perspectives um another thing I expect would happen is that these manuals can become more transparent about the theoretical assumptions that guide them um I think DSM 3, DSM 4, DSM 5 were relatively silent on the issue of what are the foundational assumptions and what are the foundational kind of philosophical ideas that animate them and I think that created a lot of confusion because it allowed the DSM despite a descriptive nature to sneak in a kind of neuro reductionism that that was harmful and so I hope that that the DSM and ICD can become more transparent about the philosophical ideas and theoretical assumptions present in them but I want to point out that within scientific and philosophical circles the authority and power held by the DSM and ICD have also been diminished and there have been you know other influential psychiatric classifications that have that have been developed and that are getting more and more attention in particular high top hierarchical taxonomy of psychopathology which is a dimension and hierarchical classification has become quite influential and prominent in psychological circles and I'm part of the high top high top consortium and in fact right now we are working on a on a paper which explicitly outlines the theoretical assumptions and philosophical assumptions that play in the in the framework the psychodynamic community has produced its own diagnostic manual as well psychodynamic diagnostic manual and different neuroscientific communities are also trying to figure out how to best make sense of you know issues of psychiatric diagnosis so so one healthy development has been this kind of diagnostic and nozological pluralism that the scientific community is relying less and less on ICD and DSM which I think is a good development yeah and circling back for a moment to neuro reductionism that you mentioned so if neuroscience provides ever more biomarkers how do we ensure that they are conceptually meaningful and not just statistically significant I think we have to understand that you know biomarkers can take can take many different different forms a biomarker can sometimes be causally informative so for example you know a spirochete for neuro syphilis is you know it's a biomarker that explains the etiology and you know provides an essence for that for that construct similarly you know the genetic mutations for Huntington disease for you know Huntington's disorder for example but other forms of biomarkers they may not tell us much about the etiology for for a condition they might for example allow us to predict certain things they might a biomarker might allow us to predict whether a person is going to respond better to a certain medication or respond better to a certain type of psychotherapy but it's not it might not be etiologically informative um other biomarker for example may help us stratify patients based on their risk factors but it may not you know guide treatment very well or it may not be predictably very useful in other in other capacities so we we have to think of specifically regarding what it is that the biomarker is doing and what kind of explanatory power it it has I think there's a naive idea that if we find a biomarker we have somehow you know discovered the biological essence of the syndrome we have biologically violated validated that in some manner that that is naive and outdated and I think we have to recognize the complexity that comes with biomarker associations and we are seeing that in the you know in the functional neuroimaging world where for example last year there was a there was a major paper in nature medicine in which they outlined six different biotypes of depression anxiety based on fmri activity both kind of resting state and based on different kinds of research tasks and they identified profiles of brain circuit connectivity that had small correlations with either clinical presentation or small correlations with either the whether the person would respond better to antidepressant medication or to behavioral therapy so we are seeing the you know such kind of biomarkers emerge but we have to understand them in a in a dimensional kind of manner and we have to understand that different biomarkers may be better at this or that task without providing us a unified biological explanation for the condition yeah and so when you mentioned also all of these different approaches high-top dsm icd phenomenological you know approach that is clinical staging what is your vision you know about a psychiatry let's say that gets conceptualizing mental disorders correctly if there is an answer to such a question and you know should we behave in a kind of an agnostic way when using these differing perspectives so should we should we pick and choose kind of or should we um allow for you know kind of or hope for an integration of these differing approaches well what my hope is that um we we get a better sense of the advantages and strengths of each diagnostic approach and we are able to utilize them in a manner that improves clinical outcomes and and kind of you know improves the the state of patient care um I think I think it is it is it is right that the dominance of dsm is kind of weakening and and clinicians are relying and bringing in other models of thinking too at the moment it is happening in a somewhat informal and eclectic fashion um because we don't have systematic research on how to best juggle and integrate um these different diagnostic frameworks you know in in the clinical context so it's happening in a somewhat haphazard and um uh in a inconsistent manner and um if uh you know hopefully we some kind of systematic research and uh systematic uh data emerges that allows us to get a sense of how these different frameworks can be used um in coordination with each other and and how we can use them in a manner that improves clinical outcomes um in the current clinical state um I think just becoming aware of the different goals and methods and strengths of these frameworks can be quite useful and how to use them to create a comprehensive formulation or conceptualization of a person's problem can be quite useful and um there was a paper we published last year with alan francis in in journal of nervous and mental disease on the issue of diagnostic pluralism in particular the question of categorical versus dimensional approaches how can we use categorical and dimensional approaches uh productively you know together in clinical practice and I would refer readers to that paper for for further discussion of that issue thank you and finally if you could give one piece of advice to young researchers about how to think about mental disorders what would it be um I would I would encourage them to be mindful of what assumptions are guiding their understanding of mental disorders and um and and how they can think about the nature of mental disorders and the ideology of mental disorders um you know through through other lenses and and other perspectives um I think the biggest problem right now is that there's a kind of implicit reductionism present in the minds of many psychiatrists and psychiatric researchers that that doesn't become obvious until they engage in some far some more some form of conceptual thinking or in some form of philosophical collaboration so I think becoming aware of implicit assumptions is the most important step because once we make those assumptions explicit then we can interrogate them and um and we can discover what assumptions have been holding us back um in the neuroscience world in the behavioral neuroscience world one of the biggest thing that has happened is that instead of a focus on molecular um you know neuroscience molecular genetics uh people are recognizing that we have to look at these problems through the lens of complex dynamic computational systems and that only happened once we interrogated what our assumptions about the nature of these problems were and once those were made explicit um it you know we realized that we need to look at these issues from a systems level and we have to look at how different components are interacting with each other and if we look at those components in isolation you know without regard for context we're going to miss out on on a lot of what is what is happening thank you always both for this interview and for your work in general and for introducing us and educating us on the richness that is philosophy of psychiatry and more specifically conceptualizing different approaches to conceptualizing mental disorders thank you for having me thanks for listening to this podcast from ECNP the views and opinions expressed in this podcast are those of the interviewee and do not necessarily reflect the official position of ECNP the content of this podcast should not be used in any way as the basis for treatment decisions