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.
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?
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.
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.
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.).
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.
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.
There was no guessing involved or hand-wavy incantations, just a thorough assessment of my state of mind, both in the moment and across a span of time. This required me to be honest, which I strongly suspect many people aren't (due to things like fear of judgement) and this will hamper the capability of the doctor in doing their job.
To put this into perspective, while ill I was relatively high-functioning. You wouldn't guess I was ill, but you would likely find me abrasive and prone to apparent flights of fancy. What the worst symptom was, the crippling anxiety, you never would've been able to detect without a goal-driven conversation - the type of conversation I have with my doctor when we meet.
I think we're still largely in the dark on the methods of action within the brain that leads to these problems, but we have actually found useful tools in resolving these problems. This isn't to say it is perfect, I was put onto a completely incorrect drug by a non-psychiatrist based on my self-reporting.
The next step is going to be neuroscience explaining the modes of action in a failure state and how these drugs restore normal function.
To anybody out there suffering with mental disease, I'm with you.
edit: throwaway account for obvious reasons