Defending Dissensus as a Democratic Principle

A love letter from a troublemaker to Chantal Mouffe

Defending Dissensus as a Democratic Principle

As long as I can remember, I have felt a deep, almost instinctive attraction to dissensus. Whenever there is an opportunity to be in opposition, I embrace it with gratitude. There is, to me, nothing as vital or invigorating as a genuine, well-grounded disagreement. It keeps me awake, alert, and alive — a safeguard against the slow suffocation of intellectual stagnation. And a source to publish scientific papers from as seen here.

As someone with these personality traits, I know firsthand that I can be hard to like, and even harder to love. This has sometimes led to existential loneliness, born from being, at times, a proverbial “pain in the ass.” It was only recently that I discovered Chantal Mouffe, the political philosopher, who gave me a theoretical foundation for defending it my love for dissensus. In her work, she elevates dissensus to a democratic virtue: disagreement is not a pathology to be cured but the very engine of democracy. Without dissensus, there is no genuine politics, only the quiet coercion of consensus. I therefore love Mouffe.

Mouffe distinguishes between antagonism and agonism. Antagonism is the empire of enemies, where dissensus is perceived as a threat to be eliminated. Agonism, by contrast, transforms the same tension into a space of respect — where opponents, not enemies, engage in a struggle that acknowledges the legitimacy of each other’s positions. For agonistic pluralism to flourish, there must be a basic acceptance of the other person’s legitimacy in holding a different point of view.

Psychiatry is inherently saturated with dissensus, yet it continually strives toward consensus in order to be taken seriously by other medical professionals and politicians. In this pursuit, dissensus is often framed as problematic and something to be abolished, managed, or resolved. It becomes antagonistic: dissenters are treated as enemies rather than legitimate interlocutors.

Psychiatry`s strategies for handling dissent vary across levels. Individually, dissenting patients or clinicians may be labeled as lacking insight or possessing the “wrong” educational background. Institutionally, groups that critique mainstream psychiatry are often dismissed as anti-psychiatry, unscientific, or even linked to controversial movements. Societally, dissenters may be excluded from decision-making and marginalized from discourse altogether. Within this framework, disagreement and resistance is dismissed, and critical voices are silenced. As I have written earlier, disagreements are pathologized, the ultimate power move for a hegemonic field.

From a Mouffe-inspired perspective, this shows the danger of antagonism: disagreement is framed as a threat, and dissenters as enemies. An agonistic approach, by contrast, treats dissensus as legitimate, transforming opposition into a constructive force. “Troublemakers” — patients, clinicians, philosophers — are not threats but essential participants in the ongoing negotiation of knowledge, meaning, and values.

Can psychiatry move toward agonistic pluralism? Seen through Mouffe’s lens, the challenge is not to suppress dissensus for the sake of coherence but to institutionalize agonism: to create structures and cultures where disagreements can be expressed, explored, and negotiated without fear of exclusion. Only then can psychiatry remain intellectually alive, ethically accountable, and genuinely democratic.

In my work as a psychiatrist and researcher, I have observed two major reasons why debates in mental health often derails into antagomism. First, there is often unclear understanding of the disagreement’s core: is it about evidence, values, interpretation, or language? Too often, semantic noise is mistaken for genuine intellectual engagement. Second, there is a lack of epistemic humility, which limits powerful perspectives, often the biomedical, from acknowledging that their models and scientific approaches is only one among many, and equally based on biased assumptios. The medical-scientific worldview occupies a hegemonic position: its concepts of diagnosis, treatment, and evidence claim neutrality, yet define the boundaries of what counts as legitimate knowledge.

Both issues can be addressed by cultivating conceptual competence, defined by Awais Aftab as:

“…the transformative awareness of how background philosophical assumptions held by clinicians, patients, and society at large influence and shape aspects of clinical care, research, and education. Conceptual competence provides the tools to grasp the core of disagreements while cultivating the epistemic humility that reveals our own limitations and biases.”

Now, based on this paper, let us examine some commonly debated statements in psychiatry to illustrate how conceptual clarity and humility can cultivate agonism:

“Psychiatric diagnoses are unscientific”

This statement calls for two obvious conceptual clarifications: what counts as “scientific”, and what kind of “thing” a diagnosis is.

If we assume that a diagnosis refers to a pathological condition that can be objectively identified through biological or naturalistic methods, then yes—the statement is correct: psychiatry would indeed appear “unscientific,” since reliable biomarkers or biological correlates have not yet been found for most mental disorders.

However, if we instead understand a diagnosis as a pragmatic tool—a way to classify and communicate about different kinds of mental distress or psychological phenomena—then the question of its scientific status changes. In that view, the scientific method may not be limited to biological objectivity, but can also include phenomenological and hermeneutic approaches that aim to describe and understand lived experience systematically.

It is useful, I think, to imagine diagnoses along a spectrum that stretches from strong naturalism to strong normativism.

• At the naturalist end, diagnoses are treated as natural kinds—entities that exist independently of human interpretation and can, in principle, be identified objectively.

• At the normativist end, diagnoses are seen as social constructs—categories we create to make sense of certain patterns of suffering, behaviour, and experience within a given cultural and historical framework.

The statement under discussion may implicitly adopt the naturalist position, and therefore judge psychiatry to be “unscientific,” since there are no empirical markers confirming a natural-kind status. Yet, such a conclusion misses a different kind of scientific value that lies in psychiatry’s descriptive and structural understanding of symptoms.

For instance, if a person experiences prolonged low mood, they are also more likely to lose appetite, sleep poorly, and develop low self-esteem. The recognition of such regularities and patterns across individuals gives descriptive diagnoses their epistemic legitimacy. They capture recurring constellations of experience that can be observed, compared, and studied systematically—even if they do not correspond to discrete biological entities.

Whether we choose to label these constellations as “disorders” according to the medical model is, therefore, not a strictly scientific question, but a pragmatic and normative decision—one shaped by cultural values, institutional frameworks, and historical contingencies.

“Psychiatric disorders are disorders like any other disorders”

This statement invites several conceptual clarifications. Most importantly, it raises the question: what do we mean by “disorder”? And are mental disorders ontologically and epistemologically comparable to somatic ones?

If we adopt a naturalist perspective, it suggests that mental disorders, like diabetes or cancer, are grounded in identifiable biological dysfunctions. This framing supports the idea that psychiatry is fully integrated into medicine, thereby helping to counter stigma and affirm the legitimacy of psychiatric suffering as “real.” However, this naturalist understanding presupposes that psychiatric conditions can be explained by reference to a distinct underlying pathology—something that can, at least in principle, be measured, localized, or causally identified in the body. So far, however, such biological markers have proven elusive, making the statement false. However, we do not know if there in the future will be such an explanation.

Alternatively, if we take a phenomenological or hermeneutic stance, psychiatric disorders are not “disorders like any other” because they are not merely biological malfunctions. They are disorders of meaning, experience, and relation. Other frameworks rather than framed strictly as “disorders” may be equally valid ways to understand these experiences. For example as a trauma reaction, or a spiritual or existential transformation.

Engaging with these multiple explanatory models requires epistemic humility: the recognition that the biomedical narrative is only one lens among many for understanding human experience. By acknowledging that the medical narrative is one of many possible narratives, clinicians, researchers, and patients can open space for dialogue, interpretation, and shared meaning-making.

“Psychoactive drugs should not be called medication”

This statement raises a fundamental question about what qualifies a substance as a “medication.” Is the defining feature of a medication its pharmacological effect, its therapeutic intention, or its social and institutional framing within medical practice?

If we take a strict biomedical definition, a medication is a substance used to treat or prevent disease by correcting an underlying pathological process. Within this frame, calling psychoactive drugs “medication” implies that they target the biological mechanisms that cause mental disorders, just as insulin corrects insulin deficiency in diabetes or antibiotics eliminate bacterial infections. However, this causal or disease-modifying model remains largely unsubstantiated in psychiatry. No psychoactive drug has been shown to specifically correct an identified pathophysiological abnormality underlying conditions such as depression, schizophrenia, or anxiety.

Instead, psychoactive drugs alter consciousness, mood, and behaviour—they change mental states rather than cure underlying mechanisms. Their effects are experiential and context-dependent: the same drug may relieve suffering for one person, induce distress in another, or serve as a tool for coping, sedation, or self-regulation.

I do not agree that this disqualifies the term medication, but certainly calls for transparent communication.

“Modern psychiatry is evidence based”

The term “evidence-based” is often treated as if it were a binary category—something either is or is not evidence-based. This, however, is misleading. Being evidence-based does not mean a treatment can be neatly classified as effective or ineffective. Rather, it refers to decisions made on the best available knowledge at a given time. In practice, this means that clinical trials may show that an intervention produces certain effects and side effects on a group level—but this information cannot fully determine outcomes for individual patients. Individuals may respond differently from the group average, and they may weigh risks and benefits in unique ways. What counts as an evidence-based decision for one person may, therefore, be the opposite for another.

Furthermore, we must clarify what we mean by knowledge. In recent decades, randomized controlled trials (RCTs) and meta-analyses have been elevated as the “gold standard” of evidence. While these methods are valuable, this perspective only holds within a naturalistic paradigm that treats mental phenomena as purely biological events.

Mental phenomena—sadness, anxiety, delusions, despair—are not merely biological occurrences; they are lived, interpreted, and socially embedded experiences. Methods such as phenomenology, hermeneutics, and qualitative inquiry are better suited to capture this complexity. They produce a different kind of evidence—contextual, narrative, and interpretive, rather than purely statistical—yet this evidence is no less legitimate for guiding thoughtful clinical decision-making.

Moving towards agonistic pluralism

It should be evident from these examples how different conceptual approaches can yield different answers. Being explicit about these underlying assumptions is essential for having a fruitful discussion about any statement or claim. Equally important is the cultivation of epistemic humility. For decades, the biomedical model—legitimized through naturalistic scientific methods—has been prioritized, often at the expense of other scientific approaches, which have been regarded as less valid.

Seen through this lens, the persistent debates and disagreements in psychiatry are not failures to be eradicated but opportunities to practice agonistic pluralism. In Mouffe’s sense, pluralism is not about diluting differences in pursuit of consensus; it is about institutionalizing spaces where dissent is legitimate, and disagreement is recognized as a driver of critical thought and democratic vitality. By accepting the legitimacy of multiple perspectives—whether naturalistic, phenomenological, hermeneutic, or social—psychiatry can move toward a culture where differences are negotiated, not suppressed, and where patients, clinicians, and researchers can engage in ongoing, respectful struggle over meaning, evidence, and values.

By looking in the mirrors that critical voices show, with conceptual competence and humility, psychiatry is allowed to remain intellectually alive, ethically accountable, and genuinely democratic, transforming dissensus from a problem to agonistic pluralism.