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I've been involved in treating patients with florid mental illness, and among people with that experience there really isn't any question that most of these illnesses must exist with some kind of underlying pathology.

There are many open questions about the mechanism(s) behind them, as well as the extremely frustrating fact that we can never truly tell if we are actually seeing the surfaces of multiple completely separate underlying pathologies that result in somewhat related loose symptom profile clusters.

But if we were to take an extreme example I encountered, a person whose life was basically over to the point of him trying to butcher people over his delusions[1], and you find a medication with which he can regain control of his own mind, can live in society rather than prison, even hold down a job and have fulfilling friendships, and over months you see numerous patients with this same dramatic reduction in symptoms, there is no question that there must be underlying pathology at play.

There might be numerous underlying pathologies all fitting the same symptom cluster, which would (potentially) help explain why even on the same symptom cluster a medication might have drastically different levels of effectiveness on different people.

The best reason to think underlying pathologies behind psychiatric illnesses are real isn't that we have clear the biology behind them, but that there exist treatments that actually have very measurable effects on the symptoms. The other reason is that we already concede our thoughts and perceptions themselves have a biological basis, so it would just be profoundly strange if 'disorders of thought and perception' somehow didn't.

[1] Just an additional note here, I'm using a specific example of a patient with violent delusions and criminal behavior, but it's important to note that people with mental illness are much more likely to be the victims of violence than perpetrators of it, and it is important we counter the unfair stereotype that mentally ill people are prone to violence.

Thank you for bringing some light into this cavern of ignorance.

I'm glad my comments are useful to someone.

On the 'reality' of mental illnesses, if I can be a little less serious, I do still recognise (as did my favourite professor) that it is still a very odd position to be in, to say that the illness must exist because of the presence of the treatment. Suppose that the treatment had for some reason not been invented, does that mean the illness didn't? Did the illness become 'real' the moment the treatment was discovered to be effective?

It’s why Fraud advocated cocaine use for hysteria. The work he did with Fliess is worth looking into as it’s relevant to you point about pathologies being revealed by the use of medication, cocaine in their case.

> The next step is going to be neuroscience explaining the modes of action in a failure state and how these drugs restore normal function.

We've been waiting for that next step for decades without any progress. The drugs don't predictably restore normal function, we can't predict if they will and we can't explain away this failure as improper diagnosis. In point of fact, the very theories that led to the creation of many of these drugs have been debunked as incorrect.

> Modern medicine pivots on the promise that portraying human suffering as biological disease will lead to insight and cures. Inescapably, this enterprise has a sociopolitical dimension.

The point of the article is that Psychiatry hubristicly still assumes it will find these "methods of action" wholey within the brain. This is despite some pretty compelling evidence that many psychiatric diagnosis present themselves radically differently in different cultures and time periods.

The truth is, we don't know to what degree neurological structures or patterns cause these problems. How much of it is the stories we are told about what symptoms go together, how our brain works and how it can be fixed? How much of it is because of the social structure of cities, media and our work places? How much of it is simply labeling people who naturally function differently as ill and attempting to force them to conform to some ideal for our own comfort and ease?

In all likelihood, there is a complex interplay between some or all of these factors that varies from person to person.

I am very glad to hear that Psychiatry's approach has helped you personally. That does not mean there aren't structural problems with how Psychiatry approaches and talks about mental illness. Indeed, the whole point of the article is that the same structural problems that led to some horrifying results in that past century have not changed much if at all. This is cause for concern.

Could you have gotten the same benefits from talking with a priest, or a close friend / wise stranger who is skilled at asking questions?

Asking questions is the tip of the iceberg.

I'm not sure the original commenter has a clear idea of the distinction between psychotherapy (talking cures) and psychiatry (doctoring). Beyond that there is psychoanalysis (depth psychology) and at the opposite, shallow end, just talking to a psychologist. All different things.

There is such a thing as "lay psychoanalysis", not involving a professional. I wouldn't dismiss it.

What I would definitely dismiss, as someone who has spent time in a psychiatric hospital as a patient, is the bad faith pseudoscience of psychiatry. Individual doctors may be doing their best, but the profession is very much as described in this article.

We need be careful not to conflate degrees with fields. Psychiatrists can and do engage in "doctoring," psychological testing, therapy, analysis, etc. Clinician psychologists can do all of the above except for prescribing meds. So saying "this is psychiatry and that is psychology" isn't really a thing except where medication is concerned. It wouldn't even be fair, in consideration of neuropsych, to say that psychologists categorically don't treat diseases as having root biological causes.

The notion of "biological root cause" is very controversial. In fact I would say that applying the notion of root cause to a distressed individual is part of the problem with the establishment—the situation is inherently complex, involving social context and psychodynamic aspects as well as biology.

If we had a solid reductionist biological theory of mental illness, we would still sometimes discover that the cause was strictly "outside" the patient's own physiology.

Psychologists certainly go along with the fashionable talk of "chemical imbalances", but unlike psychiatrists, they don't really claim any authority when they do it.

I've heard this claimed a lot, but I'm unsure what _is_ the current status quo in psychiatry. I say this as a layman who has undergone treatment from therapists and psychiatrists for years.

I'm not sure exactly what claim you are referring to. Maybe if you articulate it I can comment properly.

My general impression is that the only way to communicate how psychiatry is would be to write a very thick novel with characters who occupy many different positions in relation to the profession. Even then it would be hard to give an all-encompassing impression.

"chemical imbalance theory". I'm aware of people saying it's not accepted as science, but I'm sure what is the current accepted science.

It's a contested field. Try this article for example: https://www.scientificamerican.com/article/is-depression-jus...

Pretty much any competent psych*gist knows "chemical I'm balance" is a total crock of shit. But, it is reassuring to (most) patients to have their lived experience explained in terms of an understood model. Pharmacological interventions are basically running through a list of candidates drugs and asking the patient how they feel. (Limited third party observation in inpatient settings, but really everyone is too overworked). There is a bit of a flow chart to determine what classes of drugs to prioritize in the search, but it is not nearly as deterministic as e.g. antibiotics; stuff is used off label all the time. For example, I knew a person who lived bipolar 1 with extremely pronounced psychotic features. She finally ended up stable on... Amphetamine, plus an snri specifically contraindicated in anything involving mania or suicidal ideation. That's like, absolutely inconceivable. Yet it's worked for the past ten years or so.

I'm interested in hearing what exactly you mean by "lay psychoanalysis." Analysis performed by someone who isn't a mental health professional? Analysis performed by anyone who never received formal analytic training?

It's an interesting question, whether there is such a thing. On one hand, Freud himself was a lay analyst. On the other hand, there's probably a reasonably large contingent of (orthodox) analysts who would assert that it can't exist for structural reasons (the setting, the lack of payment, the nature of the relationship, etc.).

It's a thing. https://en.wikipedia.org/wiki/Lay_analysis

Who dismisses lay analysts in this sense? Not even analysts do anymore (as evidenced by the acceptance of psychologists into analytic programs). You said not involving a "professional." Freud was talking about physicians.

I just meant that, if you want some kind of psychoanalysis, you don't necessarily need to go the professional route. Medically trained psychoanalysts don't really have a clear advantage over lay analysts in terms of insight.

Oh sure. Agreed.