Who Gets to Define Human Suffering?
When psychiatry concedes that its critics of psychiatric diagnoses were right.
Updated June 3, 2026 | Reviewed by Michelle Quirk
For decades, critics of psychiatry Lucy Johnstone, James Davies, Joanna Moncrieff and others have argued that psychiatric diagnoses are not scientific facts and that psychiatry lacks a coherent scientific foundation for its claims. Rather than identifying naturally occurring disorders, they argue, psychiatric classifications are fundamentally shaped by social values, professional negotiations, institutional interests and cultural assumptions. The response from psychiatry has often been very dismissive, and such critics are labelled “antipsychiatry," accused of denying the reality of mental suffering, undermining treatment and/or being ignorant of the science. Times have changed. Today, some of psychiatry's more thoughtful defenders are conceding many of the criticisms that were once treated as sacrilege within psychiatry.
In a recent essay, " The Ground Beneath the Clinic ," influential psychiatrist and philosopher Awais Aftab explicitly concedes that the attempt to ground psychiatric authority in scientifically discoverable disorders is no longer justified. Aftab says, "I take it for granted that the project of defining the authority of medicine and clinical disciplines in terms of disorder concepts on the basis of objective, value-free facts has failed." This is no minor concession. It amounts to an admission that one of psychiatry's central legitimating narratives has failed, and it is a concession to a fundamental argument that critics have been making for decades.
Social Usefulness Rather Than Scientific Discovery
The crucial question, however, is what follows from this admission. Does this mean that the medical model of psychiatry itself fails? Aftab does not think so. He does not regard the failure of objective disorder concepts as fatal for psychiatry. Instead, he attempts to reconstruct psychiatric legitimacy on different grounds. Human beings suffer, and societies create institutions to respond to that suffering. Psychiatry, on this view, is one such institution, and its authority need not depend on discovering natural disease entities. Instead, he argues, it relies on its practical role as providing individuals and communities a professional, scientifically and medically minded response to psychological distress. Its legitimacy derives from social usefulness, he argues, rather than scientific discovery. He says,
"The legitimacy of medicine rests on a constellation of pragmatic and institutional considerations: the presence of suffering, impairment, and harm that exceed our ordinary capacities and the ordinary personal and social resources available to us; the illness experience, which constitutes a call to action for the healing professions; medicine’s ability to accurately understand the nature of, and effectively treat, instances of vulnerability and suffering, and to undertake research where understanding and treatment are lacking; medicine’s accountability to science and society, and the social and scientific standing of its professional training."
This is a sophisticated and attractive position, yet it exposes psychiatry to a potent problem. Once the claim that psychiatry's diagnostic categories correspond to objectively identifiable disorders is abandoned, it also relinquishes any claim to privileged access to the truth of human suffering. Psychiatry becomes one interpretive framework among many rather than the authoritative framework standing above the others. Relational, existential, social, political, spiritual and community-based understandings of distress are no longer competing with the 'science' of psychiatric disorders; psychiatry just becomes one of a number of ways of understanding the very same phenomena While Aftab does admit this under the “pluralistic" vision he proposes, the debate has fundamentally changed in a way that he does not address.
An Extraordinary, Unjustified Form of Cultural Power
The question is no longer whether alternatives to psychiatry should be tolerated as other ways of responding to what are, in fact— or are best thought of —as medical problems. The question becomes why psychiatry should continue to occupy a position of epistemic and institutional dominance over those alternatives. This issue receives surprisingly little attention in Aftab's account. Psychiatry does not merely respond to suffering; it actively participates in defining it. Psychiatric institutions influence which experiences become symptoms, which behaviours become disorders, and which forms of distress are regarded as medical problems requiring professional intervention. This is an extraordinary form of cultural power. Once psychiatric categories are recognised as negotiated and interpretive rather than objectively discovered, the justification for that power cannot be sustained.
One of the most significant implications of Aftab's argument may be one he does not intend. If diagnoses are historically contingent, if disorder boundaries are value-laden, and if multiple frameworks can make sense of the same experiences, then rejecting psychiatric interpretations becomes a perfectly legitimate intellectual position. One may reject psychiatric diagnoses not because one denies suffering—as it is usually disingenuously framed—but because one finds relational, existential, social, spiritual, political or other frameworks more persuasive and more useful. He says, “A “medical problem” is not just a medical problem, because this characterisation is not something intrinsic to it.” He admits here, as he has to, that there is nothing intrinsically medical about psychiatric problems. However, in the same breath he presumes that they also have be a medical problem, which does not follow based on what has already been conceded.
Disagreement with psychiatry is no longer a rejection of medicine, science or of the reality of suffering, and it never was—that was predicated on the myth that psychiatric disorders have an objective, scientific basis. The disagreement is how human experience ought to be understood, as critics have long argued, and medicine has no special claim to being included by any given standpoint. And this is where Aftab cannot venture, as he is a priori committed to the domain of psychiatry having to be medical.
Aftab reinforces this conclusion when he argues that questions about the scope of medicine resemble questions concerning law, education , and other social institutions, and therefore psychiatry should be treated as having equal justification as those approaches. However, modern medicine de facto derives its authority from its ability to identify and intervene in objectively observable pathological processes, with considerable success across most of medical practice on that basis. A broken leg, pneumonia, or cancer are not matters of interpretation. They are identifiable biological conditions whose existence does not depend on social negotiation or professional consensus. Psychiatry's difficulty, by contrast, is precisely that it has repeatedly failed to establish comparable foundations for its diagnostic categories. The problem here is not modern medicine, but the domain of psychiatry specifically.
Undermining the Conceptual Foundations of Modern Medicine
The lesson that follows is not that medicine as a whole resembles law, education, or counselling, because it does not. What it tells us is that the domain of psychiatry resembles the domain of those institutions far more than it resembles the rest of medicine. Aftab’s attempt to preserve psychiatry's place within medicine, as such, proves too much. To accommodate psychiatry's inability to identify objective disorders, he is compelled to broaden the concept of medicine until it loses the very features that distinguish medicine from pastoral care, education, law, or, indeed, medicine of the 17th century. The result is a curious inversion: In attempting to save psychiatry's medical status, Aftab risks undermining the conceptual foundations of modern medicine itself. He, and psychiatry more broadly, are forced into such a position by the failures of the biomedical approach. I argued something similar here in relation to other similar attempts.
The fact is that there is a simpler and more coherent conclusion: Rather than revising our understanding of the entirety of medicine to accommodate a pluralism that contains psychiatry in a pre-eminent position, we might recognise that many forms of psychological and emotional suffering are not properly speaking medical phenomena in the first place. If distress cannot be grounded in objectively identifiable disorders or diseases, the cleaner solution is to acknowledge that such experiences belong primarily within relational, psychological, social, existential, developmental and cultural domains and organise things around that reality.
In short, Aftab's argument may provide some of the strongest philosophical support for moving beyond the psychiatric framework altogether. At the very least, those who understand human suffering primarily in relational, social, developmental, existential or cultural terms can no longer be dismissed as denying scientific reality, or the reality of suffering (that has been disingenuously tied to psychiatric diagnoses). These are alternative accounts—and entirely defensible ones—of what the reality of suffering is and how it is best understood and responded to that must be respected, even if such approaches dismiss psychiatric categories entirely. Once Aftab's premises are accepted, critics no longer need to explain why they reject psychiatric concepts; rather, psychiatry must explain why it should continue to exercise medical authority in the absence of the foundations that once justified that authority. Aftab's attempted defence of psychiatry may turn out to be one of the most powerful arguments yet for its decentring.
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James Barnes, MSc., MA, is a psychotherapist in private practice, and faculty and lecturer at Iron Mill College, Exeter.
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