two common fallacies in critical psychology/psychiatry

There are two philosophical arguments one encounters again and again in critical psychology and critical psychiatry. They go like this: 

1. "The diagnosis of autism and ADHD are based on the same circular logic as other psychiatric diagnoses. We decide that a certain set of problems should be called X. If you experience these problems, we say you “have X”. X is then regarded as an explanation for your problems, in the same way that having lung cancer would be an explanation for having a cough. But X is not an explanation of this sort at all. It is just a name—more like saying “coughing disorder” is the reason for your cough." 

2. "[The Fonagy Report] simultaneously endorses two contradictory conceptions of diagnosis. Alongside the idea that diagnosis identifies a neurological condition, it acknowledges that “diagnosis is based on categories of symptoms rather than established biological mechanisms” and on judgements about their “severity, persistence and impact on functioning”. Therefore, the diagnosis does not represent a neurodevelopmental disorder. Calling it one simply assumes that symptoms or difficulties that reach a certain threshold must represent a neurological dysfunction or difference. ... This assumption is not supported by evidence." 

(I've taken these from a recent blog by Joanna Moncrieff, but I don't mean to single out this particular piece; I've seen just the same concerns voiced in any number of British "critical" psychology/psychiatry pieces over the last 30 years.)

To my mind both these arguments seem decidedly over-confident. And new iterations of them never seem to consider the critical arguments made against them. In what follows I'll lay out these counter-claims as clearly as I can.

1. states that psychiatry rests on the idea that psychiatric explanations of the "your inattention is caused by ADHD" sort work, or are intended to work, in the same as the way that medical explanations of the "your coughing is here caused by lung cancer" work. But when I look at psychiatric diagnostic practice I see no evidence of this. Consider the following two different kinds of explanation we find in everyday life: 

a) We separately pick out what (following Wittgenstein's account in his Blue Book) I'll call symptoms and underlying causes of these symptom. It's because of this separate picking out, because we don't define the causes through reference to the symptoms, that we can proffer non-circular explanations of the symptoms in terms of the causes. Example: my computer suffered the blue screen of death. That's the symptom: the blue screen of death. Why did it happen? Perhaps a chip malfunctioned, or it caught a virus, or a wire came loose, or there was a bug in the operating system. These are the possible underlying causes. We identify them separately from the symptom, and then work out which gave rise to the malfunction. (Well, they are largely separate: we wouldn't identify something as a 'bug' or a 'virus' unless it caused problems like this, but you get the general idea.) 

b) We explain the occurrence of a particular behaviour or experience by situating it in one of several possible larger recognisable patterns. Why is he not getting anything much done? Is he lazy? Stupid? Self-saboutaging? Depressed? Ah, no, what it is is he struggles with attention, distractibility, etc., and this is part of a syndrome of his which is similar to what others also suffer - we call it "ADHD". Much everyday folk-psychological explanation works like this. Why is he jumping up and down? Is it anger or happiness or trying to look over the fence or... Ah, it's joy! ... Now joy and the behaviours which express it are not identified separately and then later brought into causal relation. In Wittgenstein's language, jumping is not a symptom of joy; instead it's one of it's criteria. Even so joy is a whole syndrome, as it were, of human life.

Now it seems to me that whilst certain neuropsychiatric conditions (e.g. neurosyphilis) carry with them an idea of a particular underlying cause (spirochetes), and so involve explanations of behaviour of a type a) sort, most explanations of particular behavioural or emotional problems which refer to particular psychiatric illnesses work far more like b). They are, if you like, "pattern-placing" rather than "causal" explanations. (Or, alternatively: they are formal cause citing, rather than efficient cause citing, explanations.) They tell the sufferer: here's a previously encountered, and so to-us recognisable, way of struggling in human life. We often don't know much about underlying causes, but we have a few ideas about what forms of self-management, what medications, what milieus, etc., can help. Often what helps the most about receiving a diagnosis has nothing to do with treatment. The diagnosis is already the treatment. It clarifies and simplifies things for me to see various of my problems as instances not of a particular moral flaw - as if I have the same resources to bring to bear on my problems as others, but just can't be bothered to bring them - but instead as part of a well-recognised package of temperamental distractibility, disorganisation, losing things, carelessness, etc. 

None of this is like saying "coughing disorder is the reason for your cough". Psychiatric illnesses don't just have singular criteria. They involve a whole set of behavioural and experiential troubles that hang together to some degree, and which anyway typically participate in a gestalt. (Take some of the diagnostic manuals too seriously and you might start to think that psychiatric diagnosis is intrinsically operationalised. Learn how to do actual psychiatric pattern recognition, though, and you can leave your reductionist aspirations outside the consulting room door.) Your hallucinations may be part of various different larger psychiatric pictures: schizophrenia, PTSD, bipolar (or caused instead by encephalitis). What it means to suffer them in these different contexts itself differs. So when we say your PTSD is the reason for your hallucination, it's obvious why, if the only model of an explanation we have is the underlying cause - symptom one, this may all look rather empty. But if we keep in mind that what's being said here is: this hallucination is part of this rather than this other package, and this package is one that others suffer too, and in this pattern you find the hallucinations only being evoked by rather specific trauma cues, then we can appreciate the actual, but different, work being done by this different kind of explanation. (So too, jumping, when it's jumping for joy rather than jumping because a bee stung your bum, has a different quality to it, it's a different kind of jumping, and this quality can be understood in terms of the whole of which it is a part.) 

2. states that saying that a condition is neurological doesn't mean much unless we can identify neurological causes for it. It's not difficult to see why someone would think this! But I don't think it stops to consider the actual work being done by references to the brain in these diagnostic contexts. (It's like someone noting that when we talk of "in" we typically talk of spatial containment, and then complaining that if someone says they are "in a mood" they are either spatially contained by a mood or they are not actually in a mood.) As I see it, references to neurological disorder here really amount to saying that the person is not suffering a psychological disorder - that pursuing explanations of behaviour and feelings in terms of underlying motivations, self-maintaining patterns of avoidance, conflict, unresolved trauma, etc etc will not here bear fruit.

To put it otherwise, the claim that that from which someone suffers is neurological is a claim that there is no meaningful depth behind the surface form of their troubles. We are already at the end of the psychological line. There is neither any everyday meaning to unpack (which is why they are even in the psychiatrist's office: it's not just that they are ordinarily unhappy because their friend died; they are not ordinarily anxious because redundancies have been mentioned), and there is also no hidden psychological form to uncover. (Clinical wisdom involves us learning when we would be seeking both for too little, and for too much, meaning. Those who always go straight to neurology in the clinic, or who in their research agendas just call all psychiatric troubles "neuropsychiatric disorders", are seeking for too little. That is the baleful influence of a psychiatry that is just too "biological" as we say. Those who see trauma or deep conflict behind every behavioural problem are seeking for too much. That is the hopeless influence of a psychiatry that is too "psychological"; Gabor Maté's trauma-based approach to ADHD comes to mind.) So if we do want to understand it further, then we are forced to give up such aspirations and instead change the form of our investigation, instead now looking into underlying causes of a non-meaningful sort. (And the best place to look for disturbances to behaviour and experience of this sort will often be the brain.) A building fell down. The design was fine; there was no earthquake. Sure, we've not yet worked out what the chemical nature of the flaw in the bricks was, but look at these cracks: they're of a sort which is reasonable to attribute to some or other variation in their material.

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There are well-known dangers in the current explosion of ADHD and ASD diagnoses. The concepts stretch to accommodate less severe cases, and in the process they they attenuate and become blurry; they start to offer illusions of understanding; other ways of organising one's troubles may be just as useful or just as useless. A moral responsibility-promoting lens may get unhelpfully discarded. ... And there are also well-known dangers in imagining one's problems to be psychological when they are not. Spending a lot of time and money "on the couch". Endlessly trying to look within - and in that way worsening one's neuroticism - rather than getting on with one's life. There are also less well-understood political difficulties that have to be negotiated in thinking clearly together about when a psychiatric lens should even be reached for in trying to fathom the nature of our difficulties. But what I do not think there are are difficulties of the simple (circular and self-contradictory) sort outlined in 1 and 2 above. Critical psychiatry has often wished it could stick it to psychiatry by showing how the latter makes a logical mistake. (Szasz's simple-minded claims about the logic of the concept of "mental illness" were like this.) It seems clear to me what the allure of such arguments is. If you could identify fatal logical flaws in key pillars of a social enterprise you anyway find highly problematic, then the whole caboodle can be neatly brought down from the armchair without even getting into the weeds. Very satisfying that might be! But not, I think, realistic.