tag:blogger.com,1999:blog-89805176810415238492024-03-13T13:26:18.683-04:00A Myth in Creation"The others experienced nothing like it, even though they heard the same tales."Awais Aftabhttp://www.blogger.com/profile/04718828055532728613noreply@blogger.comBlogger33125tag:blogger.com,1999:blog-8980517681041523849.post-5481328233023069252022-12-17T17:18:00.002-05:002022-12-17T17:18:28.700-05:00Psychiatry at the Margins<div style="text-align: left;">A few weeks ago I started a blog/newsletter on Substack “<i>Psychiatry at the Margins</i>”: <a href="https://awaisaftab.substack.com/" target="_blank">https://awaisaftab.substack.com/</a> <br /><br /></div><div style="text-align: left;">It is a newsletter about exploring critical, philosophical, and scientific debates in psychiatric practice and the psy-sciences. I have been posting on it regularly and would encourage folks to subscribe to it.<br /><br /></div><div style="text-align: left;">I will keep this personal blog to post about matters that don’t fit within the scope of the substack newsletter.<br /><br /></div><div style="text-align: left;">I have also developed a personal website, where you can learn more about my academic and non-academic work: <a href="https://awaisaftab.com/ " target="_blank">https://awaisaftab.com/ </a><br /><br /></div>Awais Aftabhttp://www.blogger.com/profile/04718828055532728613noreply@blogger.comtag:blogger.com,1999:blog-8980517681041523849.post-31383689992436723272022-10-08T14:36:00.000-04:002022-10-08T14:36:34.444-04:00Hermeneutic Justice and Medical Practice<p style="text-align: justify;"><span style="font-family: inherit;"><b><i>Takeaway:</i></b><i>
The societal dominance of biomedical narratives requires physicians to practice
medicine with epistemic humility and in a deeply collaborative manner.</i></span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: justify;"><o:p><span style="font-family: inherit;"> </span></o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: justify;"><span style="font-family: inherit;">How medical
explanations shape our self-understanding individually as well as collectively
has increasingly been on my mind, and over time I have become acutely aware of
medicine’s complicated relationship with epistemic justice. According to
philosopher Miranda Fricker, epistemic injustice occurs when someone is wronged
“specifically in their capacity as a knower.” (1) This comes in two forms, <i>testimonial</i>
and <i>hermeneutic</i> injustice. Testimonial injustice happens when a person
is assigned lower credibility due to prejudice and not based on any reasonable
concerns about the testimony. The person belongs to a certain negatively
stereotyped social group, and this creates a credibility deficit for members of
that group. A common example would be not taking the testimony of someone as
seriously as is warranted because they are of a certain gender or race. Another
important group consists of individuals who are ill or require healthcare services.</span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="font-family: inherit;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: justify;"><span style="font-family: inherit;">Hermeneutic
injustice occurs when “the prejudicial flaws in shared interpretive resources
prevent the subject from making sense of an experience which it is strongly in
her interests to render intelligible.” (1) That is, when individuals do not
possess the conceptual resources – the concepts, vocabulary, perspectives, etc.
– which they need in order to make sense of their own experiences and their own
identities. Hermeneutic justice is a collective and structural problem; it
results from a deficiency of conceptual resources available to a particular
group. This could be because the relevant conceptual resources have not yet
been developed (Fricker gives the example of a victim of sexual harassment in a
society where the concept of “sexual harassment” does not yet exist), resources
exist but are not accessible to those who need them (for instance, a concept
has been discussed but exists only in academic journals), or because the
concepts exist and are accessible to the vulnerable group, but those concepts
have not yet been acknowledged as valid or worthy of respect by the rest of
society.</span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: justify;"><span style="font-family: inherit;">I am convinced
that medicine on the whole has historically been on the side of hermeneutic
justice. Medicine has created conceptual resources that have allowed
individuals with various states of distress and disability to make sense of
their experiences and access much-needed help. Furthermore, the medical
framework has also saved vulnerable individuals from self-blame as well as
societal blame by showing that the states in question are not under the
ordinary control of the individual. Imagine, for instance, a society in which
the medical concept of addiction does not exist, and the only way addiction can
be understood is in moral or religious terms. Fricker herself gives the example
of postpartum depression and refers to the story of a woman from the history of
US women’s liberation movement who realized after a group discussion that she
had been blaming herself and her husband had been blaming her for failings
which were in fact a product of postpartum depression, a psychiatric condition,
and realized that it wasn’t her personal deficiency (2).</span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: justify;"><span style="font-family: inherit;">The situation,
however, is not that simple. The medical framework has acquired tremendous
social power over the last half-century or so. This power also comes with a
danger of displacing and suppressing non-medical narratives that may be
necessary for self-understanding and without which individuals may be left “troubled,
confused, and isolated.” (1) Consider, for instance, an individual with autism
who has no access to the notion of “neurodiversity” and the only way she can
think of herself is in terms of abnormality or deficit. Or consider an
individual who has been told that his depression is a meaningless product of
faulty neurochemistry and has no access to conceptual resources to
contextualize his distress and understand his depression as meaning-laden.</span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: justify;"><span style="font-family: inherit;">Such instances of
epistemic injustice are not inherent to the medical framework. They arise when medical
explanations are privileged to such an extent that other modes of understanding
become inaccessible, or when medical perspectives are incorrectly assumed to be
complete and exclusive descriptions of the reality of the phenomena.
Recognizing this as one source of the problem also suggest a possible solution:
epistemic humility. Alistair Wardrope describes it as “an attitude of awareness
of the limitations of one’s own epistemic capacities, and an active disposition
to seek sources outside one’s self to help overcome these shortcomings.” (3) He
notes that this awareness is not merely a private acknowledgement but a public
expression of epistemic limits. “The epistemically humble agent is one who is
aware of the perspectival, pragmatic nature of their interpretations of given
phenomena, and actively seeks out information and perspectives that may
highlight shortcomings in such interpretations.” (3)</span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: justify;"><span style="font-family: inherit;">The problem of
epistemic injustice becomes even more complicated when both physicians and
patients have to deal with unresolvable uncertainty. For many medical diagnoses
there is no “hard” data in terms of pathological markers or neuroimaging; we
must rely on patient histories, clinical examination, and clinical judgments.
In addition, many medical diagnoses, such as chronic fatigue syndrome, are “conceptually
impoverished” (4); their scientific nature is murky and unclear, such that both
offering and not offering the diagnosis presents different challenges (see an
insightful discussion by Eleanor Alexandra Byrne (4)). This means there will be
situations where there is epistemic vulnerability to injustice but no clarity
on whether epistemic injustice has or has not occurred.</span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: justify;"><span style="font-family: inherit;">Epistemic
justice, in such situations, can only be ensured by a deep collaboration
between stakeholders that epistemically empowers both patients and physicians
(4-5). Recognizing that clinical work immerses us in epistemic challenges is
the first step in being able to deal with those challenges; by practicing
medicine in a collaborative, humanistic, and pluralistic manner, we can avoid
the pitfalls of epistemic injustice.</span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: justify;"><o:p><span style="font-family: inherit;"> </span></o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: justify;"><b><span style="font-family: inherit;">References:</span></b></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><span style="font-family: inherit; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; text-indent: -0.25in;"><span style="mso-list: Ignore;">1.<span style="font-size: xx-small;"> </span></span></span><span style="font-family: inherit; text-indent: -0.25in;">Fricker, M. Epistemic Injustice: Power and the
Ethics of Knowing. 2007. Oxford University Press.</span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><span style="font-family: inherit; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; text-indent: -0.25in;"><span style="mso-list: Ignore;">2.<span style="font-size: xx-small;"> </span></span></span><span style="font-family: inherit; text-indent: -0.25in;">Hewitt, S. Hermeneutical injustice and mental
disorder. 2020.
https://www.simonhewitt.org/uploads/7/4/0/9/74091063/herminjustice.pdf</span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><span style="font-family: inherit; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; text-indent: -0.25in;"><span style="mso-list: Ignore;">3.<span style="font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span></span><span style="font-family: inherit; text-indent: -0.25in;">Wardrope A. Medicalization and epistemic
injustice. Medicine, Health Care and Philosophy. 2015;18(3):341-52.</span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><span style="font-family: inherit; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; text-indent: -0.25in;"><span style="mso-list: Ignore;">4.<span style="font-size: xx-small;"> </span></span></span><span style="font-family: inherit; text-indent: -0.25in;">Byrne EA. Striking the balance with epistemic injustice
in healthcare: the case of Chronic Fatigue Syndrome/Myalgic Encephalomyelitis.
Medicine, Health Care, and Philosophy. 2020;23(3):371.</span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><span style="font-family: inherit; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; text-indent: -0.25in;"><span style="mso-list: Ignore;">5.<span style="font-size: xx-small;"> </span></span></span><span style="font-family: inherit; text-indent: -0.25in;">Crichton P, Carel H, Kidd IJ. Epistemic
injustice in psychiatry. BJPsych bulletin. 2017;41(2):65-70.</span></p><p class="MsoListParagraph" style="line-height: 115%; margin-bottom: 0in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><o:p></o:p></p>Awais Aftabhttp://www.blogger.com/profile/04718828055532728613noreply@blogger.comtag:blogger.com,1999:blog-8980517681041523849.post-35343135163568603212022-09-03T11:32:00.003-04:002022-09-03T11:33:36.165-04:00Psychiatric Psychodrama<p style="text-align: justify;"><span style="font-size: medium;">“The maddening ambiguity of our position is what leads to the titular psychiatric psychodrama. One cannot reconcile oneself to psychiatry because it constantly pulls in two directions – it presents one with an ideological narrative that speaks of humanism and pluralism, and a material structure that witnesses biomedical hegemony. At some level this profession just does not make sense to itself, its own ideology out of whack with the plain facts of its own existence. There are those who are tempted to focus only on the positives, and see in this a story of triumphant progress towards a scientific future. And there are those who are inclined to see in it a story of eternal recurrence, single message mythologies ever reinventing themselves. But both of these perspectives are too tidy to capture the phenomenon. For this story is of a profession in contradiction with itself.”</span></p><p style="text-align: justify;"><span style="font-size: medium;">The above passage is a modification of a particularly memorable paragraph from Liam Kofi Bright’s brilliant article “<a href="https://philpapers.org/rec/BRIWP" target="_blank">White Psychodrama</a>.” I have rephrased it in appropriate places so that it refers to psychiatry rather than whiteness and racial inequality. As I was reading Bright’s paper, I couldn’t help but think of the parallels of the situation with the discourse around psychiatry, which is subject to its own peculiar “culture war” and polarized responses to a variety of issues – hence all the fuss around “antipsychiatry” and “critical psychiatry.” The extent of the analogy is limited, but nonetheless, I hope, illuminating in some way. Vigilance is warranted. I am drawn to this idea of a profession “in contradiction with itself,” a profession that struggles to make sense of the divide between what it aspires to in practice and the actual state of care provided to the average person. </span></p><p style="text-align: justify;"><span style="font-size: medium;">A crucial piece of this analogy is that this divide exists due to broad social, political, and economic structures that cannot be modified simply by a change in the ideological attitudes of psychiatric practitioners. In psychiatry’s case, the lack of adequate funding and resources for mental health services, a shortage of trained professionals, stigma surrounding psychiatric conditions, rampant and unchecked influence of the pharmaceutical industry, managed care bureaucracies that make it more and more difficult for clinicians to spend time with patients, reimbursement structures that do not incentivize psychosocial care, society’s aversion to risks posed by various psychiatric states (suicide, violence, public disruption, etc.), and social conditions (poverty, unemployment, homelessness, etc.) that ensure a continual state of misery and stress in the population – basically all the absurdities and dysfunctions of late-stage capitalism – are fundamental obstacles that prevent meaningful transformations in psychiatric practice. The focus of psychiatric culture wars, however, is on relatively superficial matters – the merits of psychiatric diagnoses, the efficacy and harms of psychiatric medications, the coercive and dehumanizing nature of inpatient psychiatric care, the concept of “mental disorder”, etc. These are important issues as well, but the degree of polarizing attention devoted to these issues stands in stark contrast to the sociopolitical structures that are arguably the actual drivers of biomedical hegemony. </span></p><p style="text-align: justify;"><span style="font-size: medium;">I won’t summarize Bright’s article here aside from referring to some pertinent points, so I strongly recommend that readers read it. The central thesis is that deep tensions between widely held normative aspirations of racial equality and pervasive and readily observable material facts about our society produce distinct character archetypes. These include the Repenter, the Represser, and the People of Color (PoC) Intelligentsia. Bright offers a fourth archetype of “Non-Aligned” as an ideal to aspire to as a means of reconciliation for folks seeking a way out of this dynamic. The Repenter and the Represser are understood to be elite White characters, for the most part, given that culture war polarization is largely a dynamic within elite White America. PoC Intelligentsia are people of color who have become advocates and allies of Repenter and Represser ideology respectively as a way to gain access to the resources and institutions of elite White America. The analogy of character types extends poorly to psychiatry, but to a limited extent, we can think of the Repenter and the Repressor as agents within the psy-medical complex, representing the professionals who are politically conscious and engaged. In place of PoC Intelligentsia, we have patients and service users intelligentsia. This over-simplification is far from exhaustive and ultimately unsatisfactory. In particular, we are not taking into account other powerful groups and institutions in the society whose relationships with the psy-complex varies considerably.</span></p><p style="text-align: justify;"><span style="font-size: medium;">The Repenter type in psychiatry responds to the history of the profession with an overwhelming sense of guilt and alleviates this guilt by engaging in vocal and performative criticisms of contemporary psychiatric practices and constant exhortations that the profession has lost its soul. All the while, the Repenter will either work outside the public system, such as private practice, catering to those who can afford such services, thereby contributing to existing inequities in care for the most vulnerable members of the society, or will work within the public system such that their day-to-day practices are by and large indistinguishable from those of their colleagues, both situations further aggravating their guilt and the need for performative action. The Represser rejects any admission of guilt and sees it as a sign of irrational self-hatred. They will emphasize the progress that has been made in the field, the growth in scientific knowledge, and the availability of interventions and evidence of efficacy and safety from randomized controlled trials. They will highlight the horrors patients had to endure prior to the arrival of modern psychopharmacology, and reassure themselves that although things could be better, we are not doing so bad after all. Patients and service users – at least the ones who are sufficiently engaged in this politics – are largely devoid of power and representation, but opportunities arise for them to align themselves with either the Repressers or the Repenters, and use their lived experiences to support the narratives of the two groups.</span></p><p style="text-align: justify;"><span style="font-size: medium;">“… the culture war is sustained by a material inequality that no one is seriously trying to fix. Repenters and Repressers are both responding to discontent generated by an ideology-reality mismatch, but neither of them wishes to either ideologically justify the material inequality or give away their property and superior opportunities.” “The matters disputed are sufficiently complex, and the historical narrative sufficiently contradictory, that there will always be the possibility of reasonable disagreement.” [Bright]</span></p><p style="text-align: justify;"><span style="font-size: medium;">This brings us to the fourth archetype of the Non-Aligned. The Non-Aligned person views the culture war with a certain detachment, because from their point of view the institutions engaged in this culture war are “fundamentally addressing the wrong questions.” The interest of the Non-Aligned is in making progress towards the eradication of structural inequalities. The Non-Aligned sees the ideological projects of the culture war with a certain skepticism. They realize that many on-going projects of reform are simply serving Repenter or Represser goals, and the Non-Aligned would prefer to divert attention and resources to projects more likely to make a difference.</span></p><p style="text-align: justify;"><span style="font-size: medium;">As a positive example of a Non-Aligned project with both intellectual and material elements, Bright mentions climate reparations advocated by Táíwò. When I think of the Non-Aligned archetype in mental health, I think of someone like Nev Jones, who has been working endlessly to promote “building a pipeline of [mental health] researchers with significant psychiatric disabilities and intersecting lived experiences frequently studied in public sector services research, including homelessness, incarceration, comorbid health problems, structural racism, and poverty.” (<a href="https://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.202000468" target="_blank">2021</a>) This is a strategy that is orthogonal to the issues of psychiatric culture wars but more likely to positively reshape the structural landscape of psychiatric research. The Trieste model of mental healthcare, a product of Basaglia and Democratic Psychiatry movement, strikes me as another example of a Non-Aligned response, directly tackling sociopolitical structures. Hearing Voices Movement is also a positive example with both intellectual and material elements, from which many patients and service users have benefitted. There are many other good examples as well, but these suffice to illustrate the point.</span></p><p style="text-align: justify;"><span style="font-size: medium;">Bright argues: “we must cultivate dispassion towards culture war flashpoints. Repenters, Repressers, and many of the PoC intelligentsia, will insist we ought care deeply about these issues. And there are genuinely good arguments for affective engagement with political injustices. But, where our own agenda of securing republican freedom by changes to the material base does not independently confirm their concerns to be of interest, these affectively charged flashpoints are nothing more than a distraction.”</span></p><p style="text-align: justify;"><span style="font-size: medium;">Something of this dispassion towards culture war flashpoints is perhaps much needed in psychiatry as well. </span></p><p style="text-align: justify;"><br /></p>Awais Aftabhttp://www.blogger.com/profile/04718828055532728613noreply@blogger.comtag:blogger.com,1999:blog-8980517681041523849.post-6772833477391227332022-08-25T19:32:00.000-04:002022-08-25T19:32:23.422-04:00Conversations in Critical Psychiatry<div dir="ltr" style="text-align: left;" trbidi="on">
"<a href="https://www.psychiatrictimes.com/series/critical-conversations-in-psychiatry" target="_blank">Conversations in Critical Psychiatry</a>" is my interview series for <i>Psychiatric Times</i> that explores critical and philosophical perspectives in psychiatry and engages with prominent commentators within and outside the profession who have made meaningful criticisms of the status quo.<br />
<br />
Following interviews have been published so far. I will continue to update this page as new interviews are published.<br />
<br />The list below is in the order of the original online publication.<br /><br />
1) <a href="https://www.psychiatrictimes.com/view/conversations-critical-psychiatry-allen-frances-md" target="_blank">Conversations in Critical Psychiatry: Allen Frances, MD</a><br />
<br />
2) <a href="https://www.psychiatrictimes.com/view/structure-psychiatric-revolutions" target="_blank">The Structure of Psychiatric Revolutions: Anne Harrington, DPhil</a><br />
<i>(published in print with the title 'The Many Histories of Biological Psychiatry')</i><br /><br />
3) <a href="https://www.psychiatrictimes.com/view/skepticism-gentle-variety" target="_blank">Skepticism of the Gentle Variety: Derek Bolton, PhD</a><br />
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4) <a href="https://www.psychiatrictimes.com/view/explanatory-methods-psychiatry-importance-perspectives" target="_blank">Explanatory Methods in Psychiatry: The Importance of Perspectives: Paul R. McHugh, MD</a><br />
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5) <a href="https://www.psychiatrictimes.com/view/chaos-theory-human-face" target="_blank">Chaos Theory With a Human Face: Niall McLaren, MBBS, FRANZCP</a><br />
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<div>
6) <a href="https://www.psychiatrictimes.com/view/rise-and-fall-pragmatism-psychiatry" target="_blank">The Rise and Fall of Pragmatism in Psychiatry: S. Nassir Ghaemi, MD, MPH</a></div>
<div>
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7) <a href="https://www.psychiatrictimes.com/view/integrating-academic-inquiry-and-reformist-activism-psychiatry" target="_blank">Integrating Academic Inquiry and Reformist Activism in Psychiatry: Sandra Steingard, MD & G. Scott Waterman, MD</a><br />
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8) <a href="https://www.psychiatrictimes.com/view/social-constructionism-meets-aging-and-dementia" target="_blank">Social Constructionism Meets Aging and Dementia: Peter Whitehouse, MD, PhD</a><br />
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9) <a href="https://www.psychiatrictimes.com/view/50-shades-misdiagnosis" target="_blank">50 Shades of Misdiagnosis: Susannah Cahalan</a><br />
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10) <a href="https://www.psychiatrictimes.com/view/institutional-corruption-and-social-justice-psychiatry" target="_blank">Institutional Corruption and Social Justice in Psychiatry: Lisa Cosgrove, PhD</a><br />
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11) <a href="https://www.psychiatrictimes.com/view/impoverishment-psychiatric-knowledge" target="_blank">The Impoverishment of Psychiatric Knowledge: Giovanni Fava, MD</a><br />
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12) <a href="https://www.psychiatrictimes.com/view/psychiatry-and-human-condition-joanna-moncrieff-md" target="_blank">Psychiatry and the Human Condition: Joanna Moncrieff, MD</a><br />
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13) <a href="https://www.psychiatrictimes.com/view/psychiatric-disorders-imperfect-community-peter-zachar-phd" target="_blank">Psychiatric Disorders as an Imperfect Community: Peter Zachar, PhD</a><br />
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14) <a href="https://www.psychiatrictimes.com/view/weaving-conceptual-and-empirical-work-psychiatry-kenneth-s-kendler-md" target="_blank">Weaving Conceptual and Empirical Work in Psychiatry: Kenneth S. Kendler, MD</a><br />
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15) <a href="https://www.psychiatrictimes.com/view/battle-soul-psychiatry-ronald-w-pies-md" target="_blank">The Battle for the Soul of Psychiatry: Ronald W. Pies, MD</a><br />
<br />
16) <a href="https://www.psychiatrictimes.com/view/psychoanalysis-re-enchantment-psychiatry-jonathan-shedler-phd" target="_blank">Psychoanalysis and the Re-Enchantment of Psychiatry: Jonathan Shedler, PhD</a></div><div><br /></div><div>17) <a href="https://www.psychiatrictimes.com/view/moving-beyond-psychiatric-diagnosis-lucy-johnstone-psyd" target="_blank">Moving Beyond Psychiatric Diagnosis: Lucy Johnstone, PsyD</a> </div><div><br /></div><div>18) <a href="https://www.psychiatrictimes.com/view/medical-model-theory-practice-ahmed-samei-huda-mbchb-msc" target="_blank">The Medical Model in Theory and Practice: Ahmed Samei Huda, MBChb, MSC</a></div><div><br /></div><div>19) <a href="https://www.psychiatrictimes.com/view/phenomenology-power-polarization-psychosis" target="_blank">Phenomenology, Power, Polarization, and the Discourse on Psychosis: Nev Jones, PhD</a></div><div><br /></div><div>20) <a href="https://www.psychiatrictimes.com/view/sense-making-enactive-turn-psychiatry-sanneke-de-haan-phd" target="_blank">Sense-Making and the Enactive Turn in Psychiatry: Sanneke de Haan, PhD</a></div><div><br /></div><div>21) <a href="https://www.psychiatrictimes.com/view/three-approach-psychopathology-kristopher-nielsen-phd" target="_blank">3E Approach to Psychopathology: Kristopher Nielsen, PhD</a></div><div><br /></div><div>22) <a href="https://www.psychiatrictimes.com/view/bureaucratic-takeover-american-psychiatry" target="_blank">The Bureaucratic Takeover of American Psychiatry: George Dawson, MD, DFAPA</a></div><div><br /></div><div>23) <a href="https://www.psychiatrictimes.com/view/integration-common-principles-future-psychotherapy" target="_blank">Integration, Common Principles, and the Future of Psychotherapy: Marvin R. Goldfried, PhD</a> </div><div><br /></div><div>24) <a href="https://www.psychiatrictimes.com/view/there-back-joseph-pierre" target="_blank">There and Back Again: Joseph Pierre, MD</a></div><div><br /></div><div>25) <a href="https://www.psychiatrictimes.com/view/people-history-depression" target="_blank">A People’s History of Depression: Jonathan Sadowsky, PhD</a></div><div><br /></div><div>26) <a href="https://www.psychiatrictimes.com/view/psychiatry-social-construction-sami-timimi" target="_blank">Psychiatry and the Shores of Social Construction: Sami Timimi, MD</a></div><div><br /></div><div>27) <a href="https://www.psychiatrictimes.com/view/care-coercion-psychiatry" target="_blank">Reconsidering Care and Coercion in Psychiatry: Kathleen Flaherty, JD</a></div><div><br /></div><div>28) <a href="https://www.psychiatrictimes.com/view/psychiatry-long-view" target="_blank">Psychiatry and the Long View: Paul Summergrad, MD</a> </div><div><br /></div><div>29) <a href="https://www.psychiatrictimes.com/view/global-psychiatry-crisis-values" target="_blank">Global Psychiatry’s Crisis of Values: Dainius Pūras, MD</a></div><div><br /></div><div>30) <a href="https://www.psychiatrictimes.com/view/classic-critical-integrative-psychiatry" target="_blank">From Classic and Critical to Integrative Psychiatry: Dan J. Stein, MD, PhD, DPhil</a></div><div><br /></div><div>31) <a href="https://www.psychiatrictimes.com/view/trauma-politics-diagnosis" target="_blank">Trauma and the Politics of Diagnosis: Janice Haaken, PhD</a></div><div><br /></div><div>32) <a href="https://www.psychiatrictimes.com/view/critique-of-pure-madness" target="_blank">Critique of Pure Madness: Wouter Kusters, PhD</a></div><div><br /></div><div>33) <a href="https://www.psychiatrictimes.com/view/neurodiversity-paradigm-psychiatry" target="_blank">The Neurodiversity Paradigm in Psychiatry: Robert Chapman, PhD</a></div><div><br /></div><div>34) <a href="https://www.psychiatrictimes.com/view/the-biocognitive-model-for-biopsychosocial-psychiatry-niall-mclaren-mbbs-franzcp" target="_blank">The Biocognitive Model for Biopsychosocial Psychiatry: Niall McLaren, MBBS, FRANZCP</a></div><div><br /></div><div>35) <a href="https://www.psychiatrictimes.com/view/the-fight-for-pharma-accountability-and-psychiatric-rights-jim-gottstein-esq" target="_blank">The Fight for Pharma Accountability and Psychiatric Rights: Jim Gottstein, Esq</a></div><div><br /></div><div><br /></div><div>** <a href="https://www.psychiatrictimes.com/view/past-present-future-cognitive-behavioral-therapy" target="_blank">The Past, Present, and Future of Cognitive Behavioral Therapy: Q&A with Judith S. Beck, PhD</a> (published as a standalone interview)</div><div><br /></div><div><i>(P.S. <a href="https://www.madinamerica.com/2020/07/bridging-critical-conceptual-psychiatry-interview-awais-aftab/" target="_blank">Bridging Critical and Conceptual Psychiatry: My Interview with Mad in America</a>)</i></div><div>
<br /></div>
</div>
Awais Aftabhttp://www.blogger.com/profile/04718828055532728613noreply@blogger.comtag:blogger.com,1999:blog-8980517681041523849.post-64793097935671670042022-05-13T22:10:00.002-04:002022-05-13T22:12:27.326-04:00Beyond Grammar: On the Appearance and Reality of Prediction in the Brain<p style="text-align: left;">This blogpost is a
continuation of a dialogue with Richard Gipps that started with his comments on
Anil Seth's book 'Being You'. Here is his <a href="http://clinicalphilosophy.blogspot.com/2022/04/contra-aftab-again.html">latest
response</a>.</p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;">I am grateful to Richard
Gipps for his continued engagement with me on this issue. I questioned the
value of extending this exchange further, particularly since I greatly admire
Gipps and have no desire to prolong a dialogue just for the sake of it.
However, I think I do have meaningful things to say in response to the points
brought up by Gipps in his last post, and this offers an opportunity for
further clarification.</p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><br /></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><b>#1. Orbits</b></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><b><o:p></o:p></b></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;">What I have been
trying to say is that when it comes to movements of objects, there are <i>aspects</i>,
or <i>relationships</i>, or <i>facts</i> (if you will) about how things are
that transcend any grammatical rule we may employ to talk about something. </p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;">For instance,
take this rule as expressed by Gipps: “What's properly said to orbit what (the
sun orbits the earth, or the earth orbits the sun) depends purely on a decision
as to what we set as our reference frame.”</p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;">Imagine a small
screw (say from the debris of a satellite) floating in the space in Earth’s
proximity. From almost any reference point, this screw is in orbit around the
Earth, but from the reference point of the screw itself, the rule would say
that the Earth can properly be said to move around it, and therefore be said to
be in orbit around the screw. This grammatical rule takes <i>relative motion</i>
to be the only thing relevant to orbital relationship. Implicit in the
grammatical rule is also the idea that any frame of reference has as much
validity as any other. Earth’s frame of reference is no more objective or valid
than that of the screw. Even if we stick by this rule and this very
counterintuitive assertion with regards to Earth being in orbit around a small
screw in space, we can meaningfully say that this rule doesn’t take into
account how objects behave in a gravitational field – in particular, the path
objects take in a curved spacetime as specified by Einstein’s field equation. Einstein’s
field equation says things about the curvature of spacetime due to Earth’s mass
and curvature of spacetime due to the screw’s mass. These predictions say
certain things about the path objects will take in a given spacetime; from
Earth’s frame of reference, the screw takes a path based on how Earth has
curved the spacetime; from the screw’s frame of reference, the Earth may <i>appear</i>
to move around it, but Earth is not taking a path around the screw in a spacetime that is curved around
the screw. Based on our grammatical rule, we may still insist that Earth is in
orbit around the screw based on screw’s frame of reference, but any scientific
explanation of the gravitational relationship will have to go beyond the
grammatical rule to describe motions in a gravitational field.</p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;">The lesson: we
have to think beyond the grammatical rules. Disagreements regarding what can be
said to orbit what may be resolved by agreeing on arbitrary grammatical rules, but there
are physical relationships governed by the laws of physics that exist outside
of our grammatical rules, and different grammatical rules may be more or less aligned with them. The fact that motion is relative to a frame of
reference doesn’t mean that paths taken by objects in spacetime continuum are also condemned to
this sort of relativity.</p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;">[BTW: At least
one <a href="https://www.google.com/books/edition/Firefly_Astronomy_Dictionary/kX_DAEsOWssC">astronomical
dictionary</a> defines orbit as “The path of a celestial body <i>in a
gravitational field</i>. (<i>my emphasis</i>) The path is usually a closed one
about the focus of the system to which it belongs, as with those of the planets
about the Sun, or the components of a binary system about their common center
of mass… To define the size, shape, and orientation of the orbit, seven
quantities must be determined by observation. These are known as orbital elements…”
(the semimajor axis, the eccentricity, the inclination, the longitude of the
ascending node, the longitude of perihelion, the epoch, and the period.)]</p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;">To tie this to
the science of perception, we can get into grammatical debates about terms like
“prediction”… when can something be properly said to “predict” something?… and
these debates are not trivial, because we do need to avoid muddled use, but my
contention is that there are processes hypothesized to happen in the brain that
some scientists describe using the term “prediction” or “inference”, and these
processes need to be taken into account regardless of the grammatical rules we
ultimately employ.</p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><o:p> </o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><b>#2. Intermediary
levels of cognitive scientific terms</b><o:p></o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;">Gipps: “to be
100% clear about this: I'm not trying to rule out a priori that enquiries and
explanations framed in cognitive scientific terms are possible. My method is
different: it's to urge that those who posit such a level a<a name="_Hlk103354574">) aren't clear about what they mean, and b) rather look as
if they've got in an unwitting muddle.”</a></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;">That's a helpful clarification.</p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><o:p> </o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><b>#3. Computers and
Predictions</b><o:p></o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;">Gipps: “<i>why</i> is
it that we say that the phone is doing something <i>like</i> predicting
but that (my imagined) pancreas is not? Well, the only disanalogy I can see
between them is that what the phone is involved with, even though of course it
knows nothing of it (since it's not a knower), is semantic information or
meaning. The marks on the phone's screen count as information because of how we
relate to them, because of the place this artefact enjoys in our rich
communicative, social, lives.”</p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><o:p> </o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;">This reminds me
of something Bennett and Hacker said: “The computer calculates” means no more
than “The computer <a name="_Hlk103364752">goes through the electricomechanical
processes necessary </a><a name="_Hlk103367480"><span style="mso-bookmark: _Hlk103364752;">to
produce the results of a calculation without any calculation</span>.</a>” (<i>Neuroscience
and Philosophy: Brain, Mind, and Language</i>, page 151)<o:p></o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;">I believe Gipps
would agree with this statement. And this l think points to a deeper
disagreement. I will not attempt to resolve this disagreement here – because
the disagreement is too deep and I’m not sure that it can be resolved here – but it
is worth pointing out. Unlike Bennett and Hacker, I don't think that it is simply the case that results of a calculation are produced <i>without any calculation</i>; I think that a relationship between abstract mathematical entities is embodied
in a physical system. The embodiment of such a mathematical relationship is independent of the place the computer has in human lives. (I suspect this takes us into a sort of Platonism
with regards to abstract mathematical entities. Something David Chalmers’s said
in his most recent book Reality+ is on my mind: “The basic idea of structural
information as strings of bits is an abstract mathematical idea, but strings of
bits gain causal powers once they’re embodied in physical systems, such as
punched cards and computers.” Gipps will likely consider this very muddled!
That’s okay. We just have to note that a disagreement exists on this point and move on.)</p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;">To go back to
the Bennett and Hacker quote, aside from the reality or non-reality of
calculation, it provides another possible point of disanalogy, although the
difference is one of degree. “electricomechanical processes necessary to
produce the results of a calculation without any calculation” … When we talk of
the pancreas predicting in the hypothetical scenario being discussed, the
nature of the biochemical processes taking place that produce the results of a
prediction without any prediction differ considerably in complexity compared to
the brain. We don’t, for instance, have to invoke “prediction error” or “internal
models” or “updating priors.” Another difference in the case of brain vs
pancreas/kidney is that when we hypothesize that the brain predicts something, we see this process as occupying an intermediate explanatory link between the
relevant mental phenomenon (say perception) and neurological processes; even if
we hypothesize that the pancreas predicts something, that predictive process is
not tied to any greater explanatory role.</p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><o:p> </o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><b>#4. Information<o:p></o:p></b></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;">Gipps: “The marks
on the phone's screen count as information because of how we relate to them”</p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><o:p> </o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;">Non-semantic
information exists in many systems in nature, including biological systems. The
“genetic code” is one example of such information: the sequence of base pairs
determines to a great degree which proteins will be formed by the cell machinery. Computers also
carry non-semantic information that can be discovered by any observer capable of such discovery just as the
relationship between the DNA and proteins can be discovered by any observer
capable of such discovery. If a computer program factorizes a number (breaks it
down into the set of prime numbers) – say 6734 into 2 x 7 x 13 x 37 – a physical
process has taken place in the circuit of the computer that embodies mathematical relationships, and any observer
(including aliens or other computers) capable of recognizing the physical
process and the mathematical relationship will be able to discern it. <o:p></o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><o:p> </o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><b>#5. Physical Information
and Prediction<o:p></o:p></b></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;">Gipps: “What I
can't yet see, however, is that this notion of physical information is going to
get us anywhere when it comes to making sense of what it is for a brain to (in
some or other similar-to-our-normal-use-of-the-terms sense) make inferences or
predictions.”</p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><o:p> </o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;">I think this difficulty
of specifying the process of inference or prediction in non-semantic terms first
requires appreciating that non-semantic “models” and “representations” can
exist in the brain. Consider the sensory and the motor homunculi, the neurological
“maps” “models” or “representations” of different parts of the body in the
brain which are employed in motor and sensory functioning. This is a
non-semantic form of information. The physical relationship between the homunculus
and the body exists independent of any meaning an observer attributes to it.<o:p></o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;">The second step
now is appreciating that non-semantic information can be manipulated in a manner that resembles “prediction.” Let’s
say I hurt my hand, and I feel pain in my hand. In order for me to feel pain<i>
in my hand</i>, a corresponding neurocognitive process has to take place in
which the brain uses the sensory homunculus to generate an experience of pain
that is localized to a certain anatomical region. One can speak of the brain using
a model to “predict” that the source of the pain is my hand; the fact that it
is a prediction only becomes apparent when the prediction goes awry, e.g. when
I experience phantom pain in my amputated hand. The brain predicts that the source of the signals in the pain nerves is my hand, but it makes a
mistake, because there is no hand there. Prediction here is a metaphor, but it is a
metaphor that nonetheless refers to or hypothesizes a process that can be
empirically investigated. We may say that based on XYZ grammatical rules that
it is not <i>proper</i> to say that the brain <i>predicts</i> that the pain is
coming from the amputated hand. If so, OK, fine, it’s not “prediction” within
the context of those grammatical rules, but <i>something</i> is happening and
we must call it <i>something</i>, and if the scientists studying the phenomena
think “prediction” works well enough, we may as well posit new grammatical
rules and call it “prediction”.</p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;">Let me make this
more palatable for Gipps: all he has to accept is that “brain predicts the
source of the signals in the pain nerves” refers to neurocognitive
processes that produce the result of a prediction without any prediction (akin to Bennett and Hacker on computers calculating). </p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;">A similar sort of
thing happens in other cases of perception. We are dealing with the
hypothesis that there are models of incoming sensory input in the brain (“predictions”),
which are compared to the actual sensory input, the discrepancy between the two
is noted, and the discrepancy is then used to update the model. “This is the
sense in which unconscious perceptual inference is inference: internal models
are refined through prediction error minimization such that Bayesian inference
is approximated.” (Hohwy, 2018)</p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><o:p> </o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;">Philosopher and cognitive scientist Andy Clark wrote in a widely cited <a href="https://www.cambridge.org/core/journals/behavioral-and-brain-sciences/article/whatever-nextpredictive-brains-situated-agents-and-the-future-of-cognitivescience/33542C736E17E3D1D44E8D03BE5F4CD9" target="_blank">2013 article</a> about predictive processing: “The best current
evidence tends to be indirect, and it comes in two main forms. The first (which
is highly indirect) consists in demonstrations of precisely the kinds of
optimal sensing and motor control that the “Bayesian brain hypothesis”
suggests. Good examples here include compelling bodies of work on cue integration
showing that human subjects are able optimally to weight the various cues
arriving through distinct sense modalities, doing so in ways that delicately
and responsively reflect the current (context-dependent) levels of uncertainty
associated with the information from different channels. This is beautifully
demonstrated, in the case of combining cues from vision and touch, by Bayesian
models such as that of Helbig and Ernst (2007). Similar results have been
obtained for motion perception, neatly accounting for various illusions of
motion perception by invoking statistically valid priors that favor slower and
smoother motions – see Weiss et al. (2002) and Ernst (2010). Another example is
the Bayesian treatment of color perception (see Brainard 2009), which again
accounts for various known effects
(here, color constancies and some color illusions) in terms of optimal cue
combination.</p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><i>The success of the Bayesian program in these arenas is
impossible to doubt…</i></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;">More promising in
this regard [establishing the shape of mechanisms] are other forms of indirect evidence,
such as the ability of computational simulations of predictive coding
strategies to reproduce and explain a variety of observed effects. These
include non-classical receptive field effects, repetition suppression effects,
and the bi-phasic response profiles of certain neurons involved in low-level
visual processing.” (my emphasis)</p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><o:p> </o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;">If various
perceptual phenomena can by neatly explained by invoking “statistically valid
priors” and if computational simulations of predictive coding strategies can
explain these phenomena, then what is the reality of these <i>priors </i>and <i>predictions</i>?
What are the neurocognitive processes necessary to produce such a result?</p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><o:p> </o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;">Gipps: “This,
then, is the difficulty I see for the cognitive scientific project as it's
typically spelled out.<span style="mso-spacerun: yes;"> </span>On the one hand
it's urged that the brain is making predictions, inferences, etc., not in a
metaphorical sense but in something like the literal sense. To support this
it's pointed out that artefacts like computers and phones do after all make
something like predictions, process information, etc. However then when it's pointed
out that these artefacts are only said to engage in meaning-related activity in
a derivative concessionary sense, because of the place we confer on them within
our normative practices, and that the brain enjoys no such role - its role
being instead its causal contribution to our capacity to engage in such
practices - then notions of information etc which don't have to do with
ordinary meaning are instead invoked. But the difficulty now is that causal
operations on meaningless physical information look simply nothing like
predictions and inferences in anything like their ordinary forms.”<o:p></o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><o:p> </o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;">I have attempted
to show that causal operations on <i>meaningless physical information</i> (e.g.,
information in the sensory homunculus) can look something like predictions in
their ordinary form. Neuroscientists are routinely invoking such predictions,
and <i>if there is no there there</i>, if there isn’t even a neurocognitive process
which is being referred to that produces the appearance of prediction, why is,
in the words of Andy Clark, “The success of the Bayesian program in these
arenas is impossible to doubt…”? </p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; text-align: left;"><br /></p>Awais Aftabhttp://www.blogger.com/profile/04718828055532728613noreply@blogger.comtag:blogger.com,1999:blog-8980517681041523849.post-18170854580045404122022-04-17T23:19:00.001-04:002022-04-17T23:19:20.232-04:00Language, Science, and Perception<div>The dialogue continues! Responding to Richard Gipps's post <i><a href="http://clinicalphilosophy.blogspot.com/2022/03/contra-aftab-contra-gipps-contra-seth.html" target="_blank">contra aftab contra gipps contra seth</a></i></div><div><br /></div>Gipps is quite right to point out that Seth (and other neuroscientists) have not been entirely clear about the sense in which they are using the terms such as "inference" and "prediction" when applied to neurological processes, how this usage departs from "ordinary" usage, and that this lack of clarity leads to confusion, inconsistency, and yes, possibly erroneous inferences. On this issue I am in agreement. While the project of bringing philosophical clarity to these neuroscientific terms is not necessarily easy, it is not impossible. Where I disagree with Gipps is that he seems to think that the entire project of explaining perception is muddled because there is no meaningful question to be answered, and that there is no meaningful way in which brains can be said to "infer" anything other than in a completely metaphorical manner. My own view is that there is a meaningful scientific question to be asked and answered, and there is a meaningful way in which brains can be said to predict or infer something that is not purely metaphorical.<div><br /></div><div><b>#1. The truth about orbits</b></div><div><br /></div><div>I had stated that when it comes to orbits, there are right and wrong answers: "the scientific model according to which sun is in orbit around the earth. This scientific model is decidedly false; the sun is not in orbit around the earth..."</div><div><br /></div><div>Gipps on the other hand seems to think that when it comes to orbits, it is simply a matter of frame of reference: </div><div><br /></div><div>"when we're discussing the movements of celestial bodies, we might surely offer <i>either</i> the sun or the earth as our reference frame. We could of course stipulate the moon but, depending on the scientific context, that'd probably make the math very complex."</div><div><br /></div><div>Gipps here is referring to the relativity of motion. He is indeed correct that all motion is relative to some frame of reference, but orbital relationships are not merely about motion. They are primarily about gravity. The movement of celestial bodies are governed by gravity, or the curvature of the space-time continuum per Einstein's general relativity. Yes, if we take Earth to be the frame of reference, the relative movement of the Sun is around the Earth, but there is no scientific explanation as to why Sun would move around the Earth. On the other hand, there is a perfectly good explanation as to why Earth would move around the Sun. This is because Sun is extraordinarily more massive than Earth, it has a much larger gravitational pull, and it curves the space-time continuum around it. So contra Gipps, the <i>truth</i> of orbital relationships is not a matter of how simple the mathematical model of relative motion is, but rather what is the explanation that governs that relationship.</div><div><br /></div><div>To restate my original point, it <i>appears</i> to us that Sun is in orbit around Earth because of relative motion, but Sun is <i>not</i> in orbit around Earth because that's not how gravity works. It is <i>decidedly false</i> because it contradicts our deepest, most reliable, most empirically supported theories of gravitation.</div><div><br /></div><div><b>#2. Language and Science</b></div><div><br /></div><div>Just as Gipps seems to think that asking "does the earth orbit the sun, or does the sun orbit the earth?" <i>just isn't a good question</i> and we don't really know what the question means, Gipps seems to think that "how do we perceive?" is not a meaningful question either. I think it is perfectly meaningful to ask "does the earth orbit the sun, or does the sun orbit the earth?", as I've explained above, and similarly I think it is perfectly meaningful to ask how do we perceive. It seems to me that just as Gipps doesn't quite appreciate that we can't understand how orbits work without referring to gravity, we can't quite understand how perception works without referring to... whatever the best explanatory theory for perception will turn out to be.</div><div><br /></div><div><b>#3. Acceleration and Perception</b></div><div><br /></div><div>Dr Gipps uses the example of a car accelerating: "If I want to know how, say, a Porsche can accelerate so quickly - the acceleration admittedly being a property of <i>the whole car</i> - I'll naturally be satisfied with an answer in purely mechanical terms, one which tells me about the functioning of the carburettor etc. Sure, I'll want to know too how the carburettor is connected to the throttle and the fuel supply and the engine and thereby to the wheels - but there seems to me no requirement for an extra kind of story, told at some other level of explanation, wherein I relate all of this to the accelerating car."</div><div><br /></div><div>I don't find this very satisfying, because acceleration is a very different beast than perception. </div><div><br /></div><div>Acceleration is not merely a property of the whole car. We can talk about parts of the car -- such as the wheels -- accelerating as meaningfully as we can talk about the whole car. Not only that, acceleration is not something that emerges only at a certain level or organization. Particles can accelerate. Billiard balls can accelerate. Cars can accelerate. Comets can accelerate. </div><div><br /></div><div>There is also an explanation that connect the carburetor and the acceleration of the car; the carburetor provides energy needed for acceleration by the process of combustion. Energy is needed for acceleration, because acceleration is the rate of change of velocity per unit of time, and velocity cannot change without a change in energy.</div><div><br /></div><div>The case of perception is different in crucial ways. The DNA doesn't perceive. An individual neuron doesn't perceive. But a person or organism perceives. How does that happen? We don't quite know. Unlike energy from fuel linking carburetor and acceleration, we don't have an obvious explanation that links voltage changes in the nerve membranes to an organism perceiving. A carburetor doesn't need to make anything analogous to inferences, but maybe, just maybe, the brain does.</div><div><br /></div><div>Gipps: <i>"Now I'm not sure what it means to talk of a brain being 'confined' (perhaps 'safely contained'?) in a skull, and of it only having 'access' to this or that sensory signal."</i></div><div><br /></div><div>It may be helpful to think of this problem in terms of 'information'. Now Gipps may say here that he is not clear at all what 'information' means outside the context of knowledge in a human mind. To offer some clarity, I am using the term in the same sort of way a physicist talks about 'information' being lost in a black hole (cf. Black hole information paradox). What information means in this physical context is that the state of a system at one point in time has a discernible relationship with the state of a system at any other time (e.g. you can use an equation to calculate the state of a system at one point given the state of the system at another point). In the case of perception, let's say I see a tree in front of me, and then I copy the shape of the tree on a piece of paper. We can think of this in terms of flow of 'information' -- there is a <i>relationship</i> between the physical state of the tree, the physical state of my brain, and the physical state of the piece of paper. The relationship between the physical state of the tree and the relevant physical state of my brain is mediated by the sensory nerves. The 'information' that reaches the brain reaches <i>only</i> in the form of voltage changes in the membranes of the sensory nerves. But what is the nature of the relationship between the state of the brain and the state of the nerves? And what is the nature of the relationship between voltage changes in the nerve membranes and the actual tree? We can think of neuroscientists such as Seth trying to provide an answer to this question. </div><div><br /></div><div>To make matters complicated, while the brain contains 'information' in the physical sense described above, my mind contains information in the ordinary sense (<i>I</i> acquire information about the tree by perceiving the tree). What is the relationship between the information in <i>my mind</i> (ordinary language sense) and information in <i>my brain</i> (physical sense)? These two sorts of information cannot be entirely disconnected! If there was no relationship between the two, my knowledge of the tree would be miraculous, with no natural explanation. </div><div><br /></div><div>No such mysteries about 'information' arise in the case of an accelerating car. There is nothing unexplained about the flow of energy.</div><div><br /></div><div><b>#4. What does it mean for a system to enact a mathematical model?</b></div><div><br /></div><div>I have something different in mind than the models of how celestial bodies move or how a pancreas operates. These would be pure <i>metaphors</i>. We can talk <i>as if</i> pancreas is making a prediction, and we may usefully speak so for practical purposes, but there is <i>nothing like prediction actually happening</i> (as far as we know). What I have in mind is a system doing something that is <i>analogous</i> to humans predicting. Consider the technology of "predictive text." As I am typing a message on gmail, their predictive text feature is trying to "predict" ("anticipate" "guess" "project") how I will finish the sentence. Unlike pancreas, there is something happening here: a complicated algorithm that has gone through thousands and thousands of my prior emails has detected patterns of how I use words, and uses those patterns to anticipate what I will type next. Is this <i>literally</i> prediction in the ordinary sense? Maybe not. But it is analogous enough, it is similar enough, that we can extend the usage and it will remain <i>meaningful</i>. </div><div><br /></div><div>Prediction as metaphor: there is <i>nothing like</i> prediction (ordinary sense) happening, but we are talking as if there were</div><div><br /></div><div>Prediction as analogy: there is <i>something like</i> prediction (ordinary sense) happening; it is not identical to prediction (ordinary sense), but it is <i>similar enough</i> that the use of the term can be meaningfully extended.</div><div><br /></div><div>If there is something in the brain that approximates Bayesian inference, then something like prediction and inference can be said to be taking place.</div><div><br /></div><div><b>#5. Linguistic innovation</b></div><div><br /></div><div>Gipps: "Aftab effectively claims that I was saying that unless Helmholtz, Seth, whoever, offers an explicit definition of a term used in a new sense, that new use must be considered nonsensical or muddled. But this really wasn't <i>at all</i> what I was saying"</div><div><br /></div><div>I accept that I was being unfair in this regard, and Gipps has clarified this quite well.</div><div><br /></div><div><b>#6. On Use</b></div><div><br /></div><div>Gipps: "whether a community's deployment of an expression is meaningful is not something guaranteed simply by their using it. And whether it's meaningful will instead amount to whether it's use can be elucidated, whether it avoids oscillating unstably between different senses encouraging the making of illicit inferences, whether clear negations of propositions deploying the term can be formulated, and sometimes, yes, even whether it can be clearly defined."</div><div><br /></div><div>That seems quite reasonable to me. Gipps may disagree, but I do think that describing perception as a process of inference, eg, is something that can be elucidated and something that can be used consistently without confusion, even if actual neuroscientists have done a poor job at doing so! I would also say that use vs misuse may not always be clear, and when it comes to extension of ordinary use to analogous cases, judgments of whether that constitutes use or misuse may differ, even among members of a linguistic community. When it comes to whether brains can meaningfully infer or predict, who belongs is the relevant linguistic community? And how would we determine what the linguistic community deems to be correct in cases where a <i>new </i>extension of an old term is being considered? How are disagreements within a linguistic community to be resolved? Can an <i>entire</i> linguistic community be wrong about meaningfulness of a new usage? I can't say I have the answers to these questions, but I sure as hell don't think there are always easy answers here! </div><div><br /></div>Awais Aftabhttp://www.blogger.com/profile/04718828055532728613noreply@blogger.comtag:blogger.com,1999:blog-8980517681041523849.post-20622925255044830022022-03-25T22:35:00.021-04:002022-03-26T00:27:39.176-04:00Gipps vs Seth: The Muddle of Predictive Processing<p><span> </span><span> </span>“without a constant misuse of language, there cannot be any discovery,
any progress”</p><p class="MsoNormal"><span> </span><span> </span>Paul Feyerabend, <i>Against
Method<br /></i><br /></p><p class="MsoNormal">This blogpost is written in response to a <a href="http://clinicalphilosophy.blogspot.com/2022/03/seths-vision.html" target="_blank">blogpost by Richard Gipps</a> in which he critiques the account of perception as a
form of prediction and “controlled hallucination” as presented in Anil Seth’s
book <i>Being You</i>. Gipps takes a Wittgensteinian approach here and is
concerned with the ways in which Seth fails to define crucial terms and argues
that the account as presented by Seth is philosophically confused and muddled
to the point of being <i>not even false</i>. Gipps is very incisive in his
analysis and I would encourage readers to read his post in detail. He
particularly zeroes in what is ambiguous and murky in Seth’s descriptions and
shows how this murkiness leads to philosophical problems.</p><p class="MsoNormal">
<br />
When I read Seth’s<i> </i>book last year, I enjoyed it considerably, and
found it intelligible in an intuitive way that Gipps apparently does not. While
I have little to no scientific or philosophical expertise when it comes to
neuroscientific accounts of predictive processing and active inference, I find
myself quite sympathetic to them given what I know and understand. So I am
perturbed by the fact that Gipps finds the whole thing confused to the point of
meaninglessness. In this blogpost I will try to unpack this and show why
predictive processing accounts are still intelligible. I have to clarify: I am
not defending Seth’s book per se or the exact way he describes things in it. I
am more interested in the general scientific ideas and questions tackled by the
book with regards to the question of perception.<br />
<br />
<b>#1. Appearance and Reality<br />
</b> <br />
<i>Anscombe: ‘I suppose, because it looked as if the sun went round the Earth.’<br />
Wittgenstein: ‘Well, what would it have looked like if it had looked as if the
Earth turned on its axis?’<br />
</i> <br />
Much is made of this exchange between Anscombe and Wittgenstein, and Gipps
discusses how Seth misunderstands what the exchange is intended to convey.
Gipps is right that Seth misunderstands the intended lesson that Wittgenstein
was offering, but it does seem to me that there is a discussion to be had
regarding appearance and reality.<br />
<br />
<i>Gipps writes: “Recall that the ordinary use of either 'seems as though' or
'looks as if', in the context of perceptual judgement is either i) to
distinguish veridical perception from perceptual illusion or hallucination, or
ii) to express self-conscious caution.”<br />
</i> <br />
I think there is another sense in which we can use the term. It <i>seems
as if</i> the sun goes around the earth. According to Wittgenstein and
Gipps, here 'seems as if' is not being deployed with any meaning at all.
Perhaps so, but perhaps there is more to be said. If we were to extrapolate
parsimoniously from <i>what we observe, what we see, what it appears, what
it seems to us</i> (i.e. sun moving in the sky from east to west), we
would hypothesize a scientific model in which the sun is in orbit around the
earth. It is easy to see how the sense in which “it <i>seems as if</i> the
sun goes around the earth” referring to our observation of sun’s movement in
the sky can be conflated with the scientific model according to which sun is in
orbit around the earth. This scientific model is decidedly false; the sun
is <i>not</i> in orbit around the earth, <i>however things
appear to us</i>. We shouldn't be so preoccupied with the language itself that
we forget there is an independent scientific question to be asked. In a similar
way, questions pertaining to the use of language about perception should not
lead us to ignore the scientific questions at hand.<br />
<br />
<b>#2. The Scientific Question About Perception<br />
</b> <br />
Speaking about the scientific question, for Gipps there isn’t even a meaningful
scientific question to raise here. He writes in one passage:<br />
<br />
<i>“Now, one way to mobilise the 'how do we see?' question, one way to give it
at least the appearance of intelligibility, is to imagine first that we really
are somehow stuck inside our own skulls, and therefore forced to perceptually
reconstruct a now external world using images that appear on the retina. And
now the question 'well how do we do that?!' will - to say the least -
appear pressing. But undo, avoid, this alienated conception of our
perceptual encounter with the world, and it's none too obvious that there's a
question remaining which requires the provision of an alternative answer. If
'how do we see?' is to be understood as inviting an answer in neurological
terms, then all well and good. But a psychological or an epistemological
answer? What, exactly, is the psychological or epistemological problem that
the question is addressing?! I can't myself see one, and so don't see what
it is that a psychology of vision is here supposed to be doing. But perhaps there is a
good question hereabouts? Well, I'm all ears: do tell!”<br />
</i> <br />
This strikes me as a product of a confusion between “I am stuck inside my
skull” with “the brain is stuck inside the skull.” <i>I </i>am not
struck inside the skull because I am not my brain. <i>I </i>have
direct access to the world around me. <i>I</i> can look up at the sky
and see the clouds. <i>I</i> can reach out and grab the coffee cup on
the table in the front. <i>I </i>can raise my hands and say “Here is
one hand” and “Here is another”, and experience no worries about the existence
of the “external word.” But this <i>I </i>also exists in the realm of
ordinary language, of appearance, of how things as they seem. What is the
scientific reality of this <i>I </i>is not a question that can be
answered simply by an examination of the language. <i>I</i> am not
stuck inside the skull, but the brain is. This is simply an anatomical fact.
The brain is confined to the skull. The only access it has to the world outside
the skull is via sensory nerves. There is no mystery is how <i>I</i> see
thing. <i>I</i> just do. <i>I</i> look around and see the
world in all its beauty and ugliness. But in order for the brain to make this
possible, an explanation is needed. So there is a scientific question here: how
do we go from brain being confined to the skull, with access only to the
“signals” (fluctuations in the membrane potential) in the sensory nerves, to
the <i>I</i> that just looks around and sees things. What is the
explanation here? How is the latter made possible? If we are dependent for our
perception on the activity of the brain, as Gipps agrees, then what are the
processes by which perception takes place?<br />
<br />
Gipps says that it is “all well and good” if this is understood as “inviting an
answer in neurological terms.” But an answer in purely neurological terms will
not offer us the explanation we need; what will be missing will be explanation
that connects the neurological activity to the perceiving <i>I</i>. There
is, therefore, a cognitive and psychological question here as well. What
cognitive and psychological processes are involved in our ordinary experience
of perception? It is worth remembering that an explanation of how perception
works in ordinary language is not a scientific explanation of the psychology of
perception. As Gipps himself writes: “<i>what you're conscious of, when you actually
perceive something, is something that's on the desk in front of you! (To voice
this is not to engage in either naive or sophisticated or philosophical or
psychological theorising about perception: it's merely to remember how to use
the word 'perceive'.)</i>” To remember how to correctly use the word perceive
doesn’t by itself tell us what the correct scientific psychological account of
perception is, and any scientific psychological account of perception has to
take into account the fact that the brain is confined inside the skull and only
has access to signals in the sensory nerves. The relationship between the
voltage changes in the nerve membranes and the world outside the sensory organs
is not a question that has a straightforward obvious answer, and I refuse to
accept that this is a meaningless question that arises only because we are
confused about how we use the word “perceive”!<br />
<br />
Going back to the notion that scientific models can be extrapolated from <i>what
we observe, what we see, what it appears, what it seems to us</i>, it is
tempting to hypothesize that perception primarily involves a bottom-up
neurological process of “information” flowing from sensory organs to the
sensory cortices of the brain via sensory nerves. That in fact has been the
traditional framework. This sort of bottom-up information flow has a lot of
problems that both Seth and Gipps go into, and I will bypass here. But there is
a different scientific story to be told as well, a difference hypothesis to be
considered, one that would result in me being able to perceive and reach out to
grab the coffee cup in front of me. This alternative hypothesis is described,
for instance, by <a href="https://nyaspubs.onlinelibrary.wiley.com/doi/full/10.1111/nyas.14321" target="_blank">Walsh et al</a> as “perception arises from a purely inferential process
supported by two distinct classes of neurons: those that transmit predictions
about sensory states and those that signal sensory information that deviates
from those predictions.”<br />
<br />
<b>#3. Prediction and Inference<br />
</b> <br />
Gipps is of the view that brains cannot meaningfully be said to predict or
infer anything, since this is something that requires intention and agency,
among other things, and not something that “behaviourally inert, non-vocal,
non-verbal internal organs” such as brain can be said to do. Gipps allows us
that we may use the word predict in some different sense when applied to the
brain and validly complains that Seth doesn’t offer any definition in the book.<br />
<br />
I have several reactions to this. The first is that it strikes me as quite
valid to hypothesize or talk about prediction in an analogous way to ordinary
language but in a manner that doesn’t require intention or agency, etc. This is
especially because we can meaningfully talk about mathematical models making
predictions, and a variety of non-intentional, non-agential systems can enact
said mathematical models. In mathematics and computer science, therefore, we
already have scientific precedents of the use of the term “predict” in a manner
that deviates from prediction as something that humans intentionally and
rationally engage in. Helmholtz, when he described perception as an inference,
used inference in an analogous way: “[the “psychical activities” leading to
perception] are in general not conscious, but rather unconscious. <i>In
their outcomes they are like inferences</i> insofar as we from the
observed effect on our senses arrive at an idea of the cause of this effect.”
(Helmholtz 1867) [my emphasis, notice use of “<i>like inference</i>” suggesting
an analogy].<br />
<br />
The second problem I have is with the insistence that unless an explicit
definition is offered, the use must be considered muddled or nonsensical. Just
because Helmholtz does not further specify what “<i>like inference</i>” is
supposed to be, does that make it muddled and nonsensical? I don’t think so.
Scientific ideas often begin as a sort of analogy, and are further refined and
made more precise over time. Didn’t Wittgenstein have something to say about
the meaning of a word being its use? If a word is being used by an entire
community of scientists, can we not recognize that use as legitimate, even if a
formal definition is lacking?<br />
<br />
Third, we can actually describe prediction and inference in a more formal and
precise way. One way to do so (but I suspect not the only way) is to invoke
Bayes’s rule. Jokob Hohwy has a wonderful chapter “<a href="https://www.google.com/books/edition/The_Oxford_Handbook_of_4E_Cognition/eh1rDwAAQBAJ?hl=en&gbpv=1&dq=The%20Predictive%20Processing%20Hypothesis%20Jakob%20Hohwy%204E&pg=PA129&printsec=frontcover" target="_blank">The Predictive Processing Hypothesis</a>” in the <i>Oxford Handbook of 4E
Cognition</i> in which he discusses the compatibility between predictive
processing and 4E cognition. (Hohwy concludes: “The initial impression may be
that predictive processing is too representational and inferential to fit well
to 4E cognition. But, in fact, predictive processing encompasses many phenomena
prevalent in 4E approaches, while remaining both inferential and
representational.” Gipps and others may disagree with the compatibility between
PP and 4E, but that's a separate issue. My concern here is primarily about the
intelligibility of PP.)<br />
<br />
Hohwy discusses how “… subject to a number of assumptions about the shape of
the probability distributions and the context in which they are considered, a
system that minimizes prediction error in the long run will <i>approximate </i>Bayesian
inference.”<br />
<br />
“The heart of PEM [Prediction Error Minimization] is then the idea that a
system need not explicitly know or calculate Bayes’s rule to approximate
Bayesian inference. All the system needs is the ability to<br />
minimize prediction error in the long run. This is the sense in which
unconscious perceptual inference is inference: internal models are refined
through prediction error minimization such that Bayesian inference is
approximated. The notion of inference is therefore nothing to do with
propositional logic or deduction, nor with overly intellectual application of
theorems of probability theory.”<br />
<br />
“perceivers harbor internal models that give rise to precision-weighted
predictions of what the sensory input should be, and that these predictions can
be compared to the actual sensory input. The ensuing prediction error guides
the updates of the internal model such that prediction error in the long run is
minimized and Bayesian inference approximated”<br />
<br />
References to internal models are not subject to the “fallacy of double
transduction” here, since it is not being asserted that these internal models
are then being mysteriously perceived in the form of inner images. Rather, the
process of perception itself involves the generation and updating of models.
Again, one may disagree with that, but the claim is not itself meaningless or
nonsensical.<br />
<br />
So here we have an articulation of predictive processing and inference as a
process that approximates Bayes’s rule. Does the brain approximate Bayes’s rule
in the process of perception? This is an empirical question, to be settled by
scientific inquiry, but it certainly cannot be settled or eliminated by an
analysis of ordinary language.</p>Awais Aftabhttp://www.blogger.com/profile/04718828055532728613noreply@blogger.comtag:blogger.com,1999:blog-8980517681041523849.post-65530660428755363522021-10-08T09:50:00.004-04:002021-10-08T11:34:23.710-04:00Understanding the "Understandable" in "Understanding Depression"<p>A <a href="https://twitter.com/drgipps/status/1446374091506790411?s=21" target="_blank">twitter thread by Dr. Gipps</a> prompted me to look at the use of the term "understandable" more closely in the document "<a href="https://www.bps.org.uk/sites/www.bps.org.uk/files/Member%20Networks/Divisions/DCP/Understanding%20depression.pdf" target="_blank">Understanding Depression</a>" by the British Psychological Society. It appears to me that the term is used in an ambiguous and polysemous manner in the document, drawing on multiple themes and analogies, that are not only different but also generate different implications and subsequent questions. In this post I identify some of the different ways in which this term is used. A recurrent theme in the document, at least implicitly, is that depression being "understandable" poses some sort of a problem for a medical approach to depression; there is a crude sense in which it can be the case, but not necessarily. I briefly discuss this aspect of the problem as well. </p><p>1) <i>"Another idea is that, rather than being an experience thrust upon us by biology, depression, like other emotions, is often an understandable human response to the world around us that involves complex evaluations of events."</i> <i>Understanding Depression</i> (p. 23)</p><p>The document appears to be offering emotions as the template of "understandability" in this particular instance</p><p><a href="https://dictionary.apa.org/emotion" target="_blank">The APA dictionary</a> defines emotions as:</p><p>"a complex reaction pattern, involving experiential, behavioral, and physiological elements, by which an individual attempts to deal with a personally significant matter or event. The specific quality of the emotion (e.g., fear, shame) is determined by the specific significance of the event. For example, if the significance involves threat, fear is likely to be generated; if the significance involves disapproval from another, shame is likely to be generated. Emotion typically involves feeling but differs from feeling in having an overt or implicit engagement with the world."</p><p>So "understandable" in this sense would imply</p><p>- the presence of an experiential element (along with physiological elements)</p><p>- it is generated in response to or as a way of dealing with a significant matter or event </p><p>However, this statement in the document also implies that experiences that are "thrust upon us by biology" are not "understandable." This is a somewhat odd thing to say given the embodied nature of emotions. Presumably, this refers to a biological cause along the lines of neuropathological processes such as tumors. This does generate a problem because as all physicians are well-aware, brain lesions can influence our emotions, depending on their location. Emotions of all sorts can be exaggerated or distorted in problematic ways due to brain diseases. Do emotions stop being "understandable" if they have been influenced by biological processes in this manner? I suspect the authors of the document may say "yes" but this means that there are assumptions being made around the use of understandable that go beyond any simple analogy with emotions. These assumptions have not been clearly articulated, which makes any critique difficult. Nonetheless, this brings up the dilemma of emotions being abnormal in some sense, yet still simultaneously understandable in another, a dilemma that "Understanding Depression" doesn't quite seem to appreciate. </p><p>Another issue is that emotions are also a response to a wide variety of psychological ways in which the interactions with world have been "internalized" during the course of our development. The ways in which our interactions with others has generated, say, a sense of deep insecurity, of being unlovable, or being inadequate, etc. Emotions that are generated in response to such psychological conflicts can ultimately be traced back to an interaction with the world at some point in development, but it would be a mistake to think that these emotions are a response to a world <i>here and now</i>; rather, they are a response to a world that once was, and now exists deep inside us. I don't think the document fully appreciates these dimensions of the analogy with emotions.</p><p> </p><p>2) <i>"Many life events and circumstances can lead to depression, particularly ones involving threat or loss. It is common, natural and understandable to feel low and hopeless if faced with a situation of ongoing threat in which we have little control, for example a life-threatening illness, discrimination, financial problems, violence in a relationship, exploitation, bullying or homelessness."</i> (p. 30)</p><p>The use of "understandable" here is not fully discernable, but it appears to be along the lines of "typical" or "it is to be expected."</p><p>This meaning of understandable also has analogues in medicine. Obesity can be an understandable (i.e. typical, or expectable) response to poor diet, stress, sedentary lifestyle, and social practices that make healthy food inaccessible to many. Therefore, this sense of "understandable" doesn't divorce depression from the realm of medicine in a way that the authors of the document may like it to be. </p><p><br /></p><p>3) <i>"A key message of this report is that depression is a very difficult but common human experience, but also an understandable one. In particular, it highlights how the events and circumstances of our lives often play a powerful role; countering the misleading but widespread idea that depression is usually the result of something going wrong in the brain."</i> (p. 39) </p><p><br /></p><p>"Understandable" here appears to be appealing to a sort of causality; depression is a result of, is caused by, circumstances of our lives, rather than something going wrong in the brain. That is, the connotation is that of psychosocial etiology.</p><p>If such an etiological interpretation is correct, this brings up other sorts of concerns, given that etiology of depression in clinical settings is typically complex, multifactorial, and involves multiple levels of explanation.</p><p><br /></p><p>4) <i>"The most important message of this report is that depression is not a disease but a human experience: a complex, understandable set of psychological responses to the events and circumstances of our lives. It is understandable in both evolutionary and psychological terms and has a function: it often tells us that things need to change in some way."</i> (p. 51)</p><p><br /></p><p>The use of "understandable" here is clearly polysemous; there are the prior themes of response to the world and etiology, but it goes further and says that depression is understandable in "evolutionary" terms and serves an evolutionary function of telling us that something needs to change. The idea is that depression is an evolutionary adaptation. This sense of understandable in evolutionary terms is quite broad and overlaps greatly with evolutionary adaptations of other sorts in medicine. Consider, for example, this discussion by <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3395863/" target="_blank">Randy Nesse and Dan Stein</a> about how evolutionary perspective informs the medical model: </p><p>* "Physicians in other medical specialties routinely distinguish direct manifestations of bodily malfunction from symptoms that are normal protective responses. Seizures, paralysis and dyskinesias arise from abnormal bodily mechanisms. Cough, pain and fever, by contrast, are normal protective responses shaped by natural selection in conjunction with regulation systems that express them in situations where their benefits are likely to exceed their costs...</p><p>Capacities for anxiety and mood also exist because they offered selective advantages to our ancestors. Emotions adjust diverse aspects of physiology, cognition, behavior and motivation in ways that increased ability to cope with situations that influenced fitness during our evolutionary history. Their utility is confirmed by the existence of systems that regulate their expression; such systems could evolve only if the responses were useful in certain circumstances...</p><p>Defense regulation systems can fail, giving rise to responses that are abnormal in any circumstance. Most defensive responses are aversive, so their inappropriate arousal causes much suffering. High prevalence rates for chronic pain, chronic fatigue, anxiety disorders and depression suggest that the regulation mechanisms underlying cognitive/emotional symptoms are especially vulnerable to failure. Most such failures are not complete but involve responses that are too soon, too strong or too prolonged for the situation." *</p><p><br /></p><p>"Understandable" in evolutionary sense, therefore, views depression as analogous to cough, pain, fever, and other evolutionary adaptive responses. However, evolutionary responses can fail, or these responses can be inappropriately excessive or prolonged in relationship to our present context, hence, this use of understandable is entirely compatible with depression being abnormal yet understandable in the same sense as cough or pain may be abnormal yet understandable. Again, I don't think this implication is fully appreciated or articulated by the document.</p><div><br /></div>Awais Aftabhttp://www.blogger.com/profile/04718828055532728613noreply@blogger.comtag:blogger.com,1999:blog-8980517681041523849.post-63421271843696053092021-09-16T16:54:00.005-04:002021-09-16T16:54:34.843-04:00On Disease Attribution and Medical Legitimacy<p><i>In this blogpost I am collecting
some of my recent tweets on the topic of attribution of “disease” or “disorder”
in medicine and psychiatry, and whether legitimacy of medicine depends on that.
I have edited the tweets for clarity. (Also see the post <a href="https://awaisaftab.blogspot.com/2021/09/beyond-definitional-disagreements.html" target="_blank">Beyond Definitional Disagreements</a> for additional background.)</i></p><div><br /></div>
<p class="MsoNormal" style="margin-bottom: 0in;">Suffering, impairment, harm,
neurobiological and psychological differences, these exist independent of
anyone’s wishes, but whether we see them through the concept of “disease” is a
different issue that can be validly debated without committing a philosophical
or scientific error. (<a href="https://twitter.com/awaisaftab/status/1436824096914956290">link</a>)</p><p class="MsoNormal" style="margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="margin-bottom: 0in;">There are indeed truths out there,
but “disease” is not among those truths. What does exist is suffering,
impairment, harm, and various sorts of neurobiological and psychological
differences, etc., but our conceptualizations of these phenomena do not
constitute fundamental truths. (<a href="https://twitter.com/awaisaftab/status/1436855192641851393">link</a>)</p><p class="MsoNormal" style="margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="margin-bottom: 0in;">While characterization of
distress/incapacity as “disease” is coherent and historically respectable, it
is not <i>obligatory</i> for others to adopt the same definition because this
isn’t some objective, natural fact about the world. I think what happens is
that people seem to think that calling something a “disease” or denying that it
is one justifies whether we can approach it and treat it medically. I think
such arguments are fallacious. That justification doesn’t and cannot come from
mere disease attribution.</p><p class="MsoNormal" style="margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="margin-bottom: 0in;"><br /></p>
<p class="MsoNormal" style="margin-bottom: 0in;">***<o:p></o:p></p>
<p class="MsoNormal" style="margin-bottom: 0in;">The same issues apply in principle
across all of medicine, but in paradigmatic cases of disease attribution such
as cancer, there is such strong agreement about the presence of bodily changes,
the negative consequences, and the need for medical care that “disease”
attribution is basically uncontested. (<a href="https://twitter.com/awaisaftab/status/1437036588261838848">link</a>)</p><p class="MsoNormal" style="margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="margin-bottom: 0in;">Imagine someone saying, “cancer is
not a disease.” What could they mean by this while being factually accurate?
Any alternative perspective would have to contend with the facts of
uncontrolled cellular proliferation that if left unchecked results in a high
chance of death. While we may imagine such alternative perspectives in theory,
in practice they are either absent or in extreme minority (Ivan Illich died
from cancer, refusing medical treatment on philosophical grounds).</p><p class="MsoNormal" style="margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="margin-bottom: 0in;">Things are different (in degree,
not kind) in the realm of mental health. There is disagreement not only on the
nature of bodily changes, psychological differences, negative impact, and the
necessity of “medical” care, but there is also more than one game in town when
it comes to available perspectives. If someone says “psychosis is not a
disease,” they can mean so many different things while remaining true to the
facts. They could point to the absence of reliably identifiable biological
differences and absence of any consensus on what makes such differences
“pathological,” they could point to a variety of ways of understanding
psychosis that don’t rely on the concept of “disease” (psychoanalytic,
existential, spiritual, enactive, etc.), could point to a variety of
non-medical treatments & management approaches, and individual
self-understandings.</p><p class="MsoNormal" style="margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="margin-bottom: 0in;">To clarify: I’m not saying that
the concept of “disease” doesn’t apply to psychosis. It is applicable, but it
doesn’t have the force, the explanatory power to contain disagreements & to
dominate over other perspectives in the way it dominates over others in the
case of cancer.</p><p class="MsoNormal" style="margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="margin-bottom: 0in;"><br /></p>
<p class="MsoNormal" style="margin-bottom: 0in;">***<o:p></o:p></p>
<p class="MsoNormal" style="margin-bottom: 0in;"><a href="https://twitter.com/MarkLRuffalo/status/1437377699304116229">Mark Ruffalo</a>:
This is interesting to me, Awais. I have thus far assumed that what grants
medicine the authority to treat a problem is the “disorderedness” of that
problem. This is, in a way, a Szaszian argument, i.e., if mental disorders are
not diseases, then medicine should have nothing to do with them. But what you
are saying, I think, is that disorderedness does not or should not bear on
whether medicine (in this case, psychiatry) has a legitimate claim to treating
these problems.</p><p class="MsoNormal" style="margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="margin-bottom: 0in;"><a href="https://twitter.com/awaisaftab/status/1437402146530598919">Awais Aftab</a>:
I think the problem is that while you reject Szasz's conclusion, you still play
by the rules he has set for this debate :) Let's try to unpack the claim that
the legitimacy of medicine depends on how we define what a disorder is. How
could that be?</p><p class="MsoNormal" style="margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="margin-bottom: 0in;">How could a definition have so
much power that we can legitimize or de-legitimize an entire profession simply
by our choice of words? It's a bit like bringing God into existence simply by
defining him as existing! Accepting this leads you into a conundrum. If a
concept is to provide such a foundation, it needs to be a naturalist one
(grounded in facts about the world), but at the same time you want to defend a
concept of disease that is "pre-scientific" and decidedly not
naturalist.</p><p class="MsoNormal" style="margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="margin-bottom: 0in;">On one hand you define
disorder/disease as “suffering & impairment,” on the other hand you also
want to make the claim that “disorderedness” is some natural fact that exists
out there in the world. But if you want to believe that suffering and
impairment come naturally stamped as disordered or not-disordered, then you
need naturalist criteria for “disorderedness” in addition to the presence of
suffering & impairment, otherwise the claims are not consistent.</p><p class="MsoNormal" style="margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="margin-bottom: 0in;">Does disorderedness have a bearing
on medicine's legitimacy in treating certain problem? Yes, it has a bearing in
the sense that judgments of disorderdness are relevant, but these judgments
don't need to be naturalist and the legitimacy is not dependent on them.</p><p class="MsoNormal" style="margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="margin-bottom: 0in;">Where does the legitimacy come
from? It comes from things such as presence of suffering/impairment, medicine's
ability to accurately understand the nature of and treat certain instances of
suffering safely and effectively, medicine's accountability to science and
society, the social and scientific legitimacy of its professional training,
etc. Nothing in this requires we rely on the notion of “disorder” or “disease,”
let alone that we rely on a notion of “disorder” that requires “disorderedness”
to be a natural fact.</p><p class="MsoNormal" style="margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="margin-bottom: 0in;"><o:p> </o:p></p>
<p class="MsoNormal" style="margin-bottom: 0in;">***<o:p></o:p></p>
<p class="MsoNormal" style="margin-bottom: 0in;">I don’t think all suffering is
mental illness, clearly it’s not. We carve out certain forms of
suffering/impairment/harm (and identify their etiologies & investigate
treatments) by designating them as “disorders” but this carving out is not
naturalistic (not determined by objective, natural facts) but rather this
carving out is a value-laden process driven by folk-psychological judgments of
abnormality (at least in current clinical practice). Furthermore, medicine’s
legitimacy doesn’t depend on how exactly we carve out this space and whether we
use a naturalist notion to do so. (<a href="https://twitter.com/awaisaftab/status/1437442303275175943">link</a>)</p><p class="MsoNormal" style="margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="margin-bottom: 0in;">Regarding suffering, I don’t mean
“distress” narrowly, I mean the variety of ways in which harm can be generated,
whether it is personal distress, impairment in functioning, or harm to others. If
a condition is not associated with some form of harm or risk of future harm, it
is not really captured by our current notions of disorder nor is there any
reason for medicine to tackle it as a condition of interest.</p><p class="MsoNormal" style="margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="margin-bottom: 0in;">I have not maintained any
separation between medicine and psychiatry in this regard. There are
differences of degree, since psychiatry is comparatively more value laden and
there is comparatively more disagreement, more variability, lack of
neurobiological dysfunctions, but all medicine is value-laden and the concept
of “disease” or “disorder” faces problems of the same kind, whether in medicine
or psychiatry.</p><p class="MsoNormal" style="margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="margin-bottom: 0in;"><o:p> </o:p></p>
<p class="MsoNormal" style="margin-bottom: 0in;">***<o:p></o:p></p>
<p class="MsoNormal" style="margin-bottom: 0in;">We have to be careful here and
distinguish between the question of the nature of the construct(s) being
considered and the question of disorder/disease attribution. These are very
different questions! Whether disorder attribution is naturalistic or not
doesn’t tell us anything about the nature of the construct in question (which
could very well be a natural kind or be a discrete identity with single
etiology -- COVID-19, e.g. --, or may be highly socially constructed -- hysteria,
e.g.) The following figure is something I use in presentations with students is illustrate this point. (<a href="https://twitter.com/awaisaftab/status/1437761697566048259">link</a>)</p><p class="MsoNormal" style="margin-bottom: 0in;"><br /></p><div class="separator" style="clear: both; text-align: center;"><a href="https://1.bp.blogspot.com/-5vFthjBIXuI/YUOuwJz7pjI/AAAAAAAACSE/ccQ0NP6vTKEniWtoqKK_IAGkBCu7mv-pACLcBGAsYHQ/s1036/GAD.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="583" data-original-width="1036" height="225" src="https://1.bp.blogspot.com/-5vFthjBIXuI/YUOuwJz7pjI/AAAAAAAACSE/ccQ0NP6vTKEniWtoqKK_IAGkBCu7mv-pACLcBGAsYHQ/w400-h225/GAD.jpg" width="400" /></a></div><br /><p class="MsoNormal" style="margin-bottom: 0in;"><br /></p><p class="MsoNormal" style="margin-bottom: 0in;"><o:p></o:p></p>Awais Aftabhttp://www.blogger.com/profile/04718828055532728613noreply@blogger.comtag:blogger.com,1999:blog-8980517681041523849.post-37463747594576432492021-09-07T22:43:00.001-04:002021-09-07T22:43:14.866-04:00The Laws of Ambiguity<div style="text-align: left;">Something I posted on <a href="https://twitter.com/awaisaftab/status/1434633991529902081" target="_blank">twitter</a><br /><br /></div><div style="text-align: left;"><b>First Law of Ambiguity:</b> <i>What happens in vagueness stays in vagueness, unless acted upon by a clarifying force.</i></div><div style="text-align: left;"><br /></div><div style="text-align: left;">"What happens in vagueness stays in vagueness" is a common enough phrase that it even appears on some t-shirts. It is also a play on the "What happens in Vegas stays in Vegas". So I can't take credit for this particular phrase. But as I came across it a few days ago, my mind immediately made a link to Newton's first law of motion, resulting in my specific version articulated above.</div><div style="text-align: left;"><br /></div><div style="text-align: left;"><a href="https://twitter.com/AllenFrancesMD/status/1434642309027565570" target="_blank">Allen Frances</a> proposed in response to my tweet the <b>Second Law Of Ambiguity</b>: <i>Often there is no clarifying force and we must learn to live vagueness.</i></div><div style="text-align: left;"><br /></div><div style="text-align: left;">In response to that, <a href="https://twitter.com/d_galasinski/status/1434648222958563331" target="_blank">Dariusz Galasiński</a> proposed the <b>Third Law of Ambiguity</b>: <i>Ambiguity is hard to spot, certainty prevails. Even when spotted the desire to reject it and replace it with certainty prevails.</i></div><div style="text-align: left;"><i><br /></i></div>Awais Aftabhttp://www.blogger.com/profile/04718828055532728613noreply@blogger.comtag:blogger.com,1999:blog-8980517681041523849.post-30187046024325570712021-09-07T22:16:00.005-04:002022-03-02T15:10:22.063-05:00Beyond Definitional Disagreements<div style="text-align: left;"><i>This blog post is derived from a <a href="https://twitter.com/awaisaftab/status/1435423373924999177" target="_blank">twitter thread</a>, in response to <a href="https://www.psychologytoday.com/us/blog/freud-fluoxetine/202109/meaningful-symptoms-are-still-symptoms" target="_blank">this blog</a> by Mark Ruffalo</i>.<br /><br /></div><div style="text-align: left;">I’ve been thinking a lot about how to navigate debates where participants strongly disagree on definitions of concepts such as “disease” and “pathology.” These concepts don’t have a single, privileged definition, so if we are confronted with two internally consistent definitions it seems rather futile in my opinion to insist that one definition must be abandoned in favor of the other. In this scenario, on one hand we have a biological essentialist notion of disease as a demonstrable neurobiological abnormality or lesion, on the other hand we have a notion based on distress and impairment, defended by Ruffalo & Pies. Mark Ruffalo does a good job showing that the prospect of symptoms being “meaningful” does not pose a threat to the internal consistency of the notion of disease as severe distress and impairment. However, the authors of Understanding Psychosis don’t deny that psychosis can be severely distressing and impairing. So, if both sides agree on the relevant facts, i.e., the meaningfulness of psychosis and the presence of severe distress and impairment, where then is the <i>real</i> disagreement? <br /><br /></div><div style="text-align: left;">The disagreement cannot simply be that one side uses the words “disease” and “pathology” to describe the facts relevant to psychosis & the other side declines to use those words?! So if the disagreement is not merely terminological, what is it about? <br /><br /></div><div style="text-align: left;">I do think there are factual disagreements but they are subtle, murky and difficult to point out clearly, obscured by the rather superficial “disease vs experience” debate. I suspect a big component of the disagreement lies in the sociocultural narratives surrounding “disease,” and the legitimacy these narratives confer on things such as the professional authority of the physician, the role of medications and other somatic treatments, the power to detain and coerce, and the carte blanche to carry out grand research programmes on biological etiologies. <br /><br /></div><div style="text-align: left;">I suspect that the discussions tend to get intense because of the perception that the applicability and legitimacy of the medical model rests on whether we call something a “disease”, “disorder,” “illness,” “pathology,” “medical condition.” The critics seem to think that they have administered a coup de grâce by denying that psychosis is a disease while the defenders seem to think that they have successfully defended the legitimacy of the medical model by establishing that psychosis is one by their definition. I do think that the applicability and legitimacy of the medical model can be defended (as can the applicability and legitimacy of non-medical models) but I don’t think this legitimacy depends on whether we use this or that definition of disease. <br /><br /></div><div style="text-align: left;">So I find myself increasingly impatient with definitional debates. Any debate of substance needs to move beyond definitions to an exploration of disagreements of facts and values, something we seem to be increasingly incapable of, devoted as we are to our solipsistic models. <br /></div>Awais Aftabhttp://www.blogger.com/profile/04718828055532728613noreply@blogger.comtag:blogger.com,1999:blog-8980517681041523849.post-14082581176035542002021-07-26T20:15:00.000-04:002021-07-26T20:15:24.624-04:00On Constructs and Mental Illness<p>Constructs are abstract concepts
we use to organize available information for the purpose of (scientific)
description and/or explanation. Constructs are ubiquitous in science in this
sense; “gravity” and “temperature” are constructs, so are “intelligence” and “self-esteem”.
Constructs can be immensely powerful when they capture features of the natural
world (vs merely reflecting features of human interest), such as elements of
the periodic table or fundamental particles in the standard model. But many
scientific constructs do not map onto the world in such a powerful way as to “carve
nature at its joints”. These constructs, while they do reflect features of the
world (they are organizing information after all) also reflect human interests
and goals to varying degrees. </p><p class="MsoNormal" style="margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="margin-bottom: 0in;">Diagnostic constructs in
psychiatry are typically ways of organizing observed behaviors and reported
experiences into particular categories or dimensions. To emphasize, for
instance, DSM categories as “constructs”, is to emphasize the <i>contingent</i>
nature of the organization and categorization. Major Depressive Disorder is <i>one</i>
way of organizing observed behaviors and reported experiences, but we could
adopt a different organization instead if we wanted to (“depressive neurosis”, “manic
depressive illness”, “neurasthenia”, etc.)</p><p class="MsoNormal" style="margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="margin-bottom: 0in;">Ideally, we want to “validate” our
diagnostic constructs. That is, we want our organizations of behaviors and
experiences to correspond with other “objective” things of interest, such as
family history/genetics, neuroimaging, response to treatment, long-term
outcomes, etc. If our constructs had such power, we might conveniently forget
that they are <i>constructs</i> (we don't tend to think of “gravity” or “electron”
as constructs). But in the absence of such validation (it would be more
accurate to think of degrees of validation), to forget their contingent nature
is to hinder our own scientific progress and to base our practical decisions on
erroneous assumptions. To say that they are constructs is to remind ourselves
of this contingency. It is in this sense that mental illnesses, i.e. specific
diagnostic categories or dimensions, are “constructs”.</p><p class="MsoNormal" style="margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="margin-bottom: 0in;">What about “mental illness” (the
over-arching concept, not individual diagnoses or illnesses)? It too is a construct
in the broad sense but compared to specific diagnoses such as Major Depressive
Disorder, it is fuzzy and vague, residing more in ordinary language than in scientific
theory. A lot depends on what we think the concept refers to. If someone sees “mental
illness” as an explanatory concept – that by calling something a mental
illness, we are hypothesizing the existence of a pathological process – they understand
the concept very differently from someone who sees mental illness as a way of
referring to problematic behaviors and experiences that have been identified as
“abnormal” based on folk judgments (of proportionality, rationality, meaningful
connections, etc.) and require professional care due to the associated distress,
impairments, or harm. This means that it is less clear <i>how</i> we can think <i>differently</i>
about the designatum of mental illness. Those who favor the explanatory view (erroneously
in my opinion) would propose a different explanation, but given that I think
the explanatory view is incorrect to begin with, these alternatives
explanations don’t fare any better. I think the real question often boils down
to: when someone says that mental illness is a construct that can be replaced
by a different construct, are they referring to a different designatum, or are
they referring to the same designatum (behaviors identified by folk judgments
as abnormal, requiring some form of professional care)? If the designatum is
the same, is this merely a preference to use a different term for the
designatum because of perceived connotations of the relevant terms? A lot of
the time I think the debate is merely terminological but gives the illusion of
being about something deeper.</p><p class="MsoNormal" style="margin-bottom: 0in;"><o:p></o:p></p>Awais Aftabhttp://www.blogger.com/profile/04718828055532728613noreply@blogger.comtag:blogger.com,1999:blog-8980517681041523849.post-56888856378071992452021-05-03T13:44:00.000-04:002021-05-03T13:44:07.750-04:00Common Conceptual Mistakes in Psychiatry & Psychology<p>Some common conceptual mistakes in psychiatry and psychology, in my opinion:</p><p>1. Thinking that scientific explanations must necessarily reside at a certain level of explanation [good scientific explanations are not constrained by reductionism or holism]</p><p>2. Thinking that the mental/psychological and the physical/biological are mutually exclusive [we need to avoid false binaries between mind and body]</p><p>3. Thinking of the mind in terms of entities and "mental stuff" rather than dynamic interactions and regulatory processes</p><p>4. Thinking that we can infer the nature of specific phenomena from definitions of disease concepts [<a href="https://awaisaftab.blogspot.com/2020/05/medical-disorders-from-definition-to.html" target="_blank">we cannot</a>]</p><p>5. Thinking that if a phenomenon exists on a continuum, we can't/shouldn't categorize it [we can categorize based on our pragmatic goals]</p><p>6. Thinking that if a phenomenon exists naturally on a spectrum, there cannot be qualitative differences between two ends of the spectrum [quantity becomes quality]</p><p>7. Thinking that meaningful scientific progress necessarily requires a paradigm shift [it doesn't]</p><p>8. Thinking that seeming incommensurability prevents us from adopting a plurality of perspectives [different perspectives are not necessarily antagonistic or mutually exclusive just because they approach and explain things differently] </p><p>9. Seeing fallibilism as a weakness [fallibilism is a virtue]</p><p>10. Thinking necessarily in terms of linear causality rather than organizational causality</p><p>11. Thinking that operational constructs provide a <a href="https://awaisaftab.blogspot.com/2020/06/can-symptoms-be-caused-by-descriptive.html" target="_blank">causal explanation</a>.</p><p>12. Mistaking pragmatic kinds (such as "medical") for essential kinds</p><p>13. Thinking that socially-influenced is socially-constructed</p><p>14. Thinking that value-ladenness precludes a scientific approach</p><p>15. Thinking that the world is divided into the "natural" and the "social", and the psyche either belongs to one or the other, or has to be fractured between the two.</p><p><br /></p><p>Some additional mistakes, brought up by <a href="https://twitter.com/DrGipps" target="_blank">Dr Richard Gipps</a></p><p>16. Confusing an unproblematic duality for a problematic dualism. </p><p>17. Assuming that psychiatric distinctions (like organic/functional) map neatly onto metaphysical distinctions (like mind/body) -- i.e. making presuppositions about, rather than patiently investigating, the actual nature of psychiatric language games. </p><p>18. Assuming that formal causes are efficient causes (e.g. assuming that when someone says ‘schizophrenia causes hallucinations’ they are trying to provide an efficient cause).</p><p><br /></p>Awais Aftabhttp://www.blogger.com/profile/04718828055532728613noreply@blogger.comtag:blogger.com,1999:blog-8980517681041523849.post-30645244228707534092021-05-03T13:26:00.000-04:002021-05-03T13:26:09.010-04:00Types of Psychiatry Papers (xkcd spin off)<p>xkcd recently made a <a href="https://xkcd.com/2456/" target="_blank">comic</a> about types of scientific papers, which went viral on social media. Inspired by it, here's a spin off that I made about types of psychiatric papers; I shared it on <a href="https://twitter.com/awaisaftab/status/1388133087356325888?s=20" target="_blank">twitter</a> and facebook earlier with quite an enthusiastic reception!<br /></p><p><br /></p><div class="separator" style="clear: both; text-align: center;"><a href="https://1.bp.blogspot.com/-HdlZUue--wE/YJAxz-YPIMI/AAAAAAAACKU/9gPsvKpxl9A_mKZioB1T7-9Y3CGckNdRACLcBGAsYHQ/s2048/Types%2Bof%2Bpsychiatry%2Bpapers%2B02.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="2048" data-original-width="1200" height="1067" src="https://1.bp.blogspot.com/-HdlZUue--wE/YJAxz-YPIMI/AAAAAAAACKU/9gPsvKpxl9A_mKZioB1T7-9Y3CGckNdRACLcBGAsYHQ/w627-h1067/Types%2Bof%2Bpsychiatry%2Bpapers%2B02.jpg" width="627" /></a></div><br /><p><br /></p>Awais Aftabhttp://www.blogger.com/profile/04718828055532728613noreply@blogger.comtag:blogger.com,1999:blog-8980517681041523849.post-14696744513224383092020-11-13T01:03:00.006-05:002022-02-28T14:36:56.155-05:00Understanding Depression: A Pluralistic Approach<p>The controversy surrounding the
report “<a href="https://www.bps.org.uk/sites/www.bps.org.uk/files/Member%20Networks/Divisions/DCP/Understanding%20depression.pdf">Understanding
Depression</a>” by British Psychological Society has prompted much reflection
on my part. In particular, it appears to me that it is no longer sufficient to
criticize. What is needed is an alternative answer, one that can do some
justice to the complexity of the issue at hand. What is also needed is not a <i>medical</i>
answer, for that is already dominant and pervasive. Rather we need an answer
that goes beyond the medical, and that provides a space for societal dialogue.
In this blog post, I attempt the beginnings of such an answer. While I have
confidence in the earnestness of my attempt, I have less confidence in its
success.</p><p class="MsoNormal" style="margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="margin-bottom: 0in;"><o:p> </o:p></p>
<p class="MsoNormal" style="margin-bottom: 0in;"><b>Understanding Depression: A
Pluralistic Approach<o:p></o:p></b></p>
<p class="MsoNormal" style="margin-bottom: 0in;">Depression is a common human
experience characterized by feelings such as unhappiness, despondency,
dejection, sadness, despair, or misery. However, the depression that is the
subject of our discussion, the depression that comes to the attention of clinical
professionals, and the depression that is characterized as a “mental disorder”
is not entirely the same as this commonplace understanding of depression. This
notion of depression as a clinical entity is continuous with the more ordinary
understanding of depression, but also differs from it in important ways.</p><p class="MsoNormal" style="margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="margin-bottom: 0in;">One of the ways in which
depression as a clinical entity (“clinical depression”) differs from our
commonplace understanding is that clinical depression is understood as a
constellation of related problems. These problems include experiences such as
inability to experience joy, changes in appetite, changes in sleep, low energy,
slowed movements, guilt, difficulty thinking and concentrating, and thoughts of
death or suicide. That clinical depression exists as a cluster of problems is
an empirical observation, repeatedly made across time and space, although the
exact configuration of the cluster varies. In clinical depression, these
problems are understood to be pervasive (present most of the time and in most
settings) and persistent (continuing on beyond fluctuations of mood in ordinary
life). Furthermore, these problems are severe enough to cause distress or
impairment in one's daily life such that these problems are recognized by the
person or their family/friends as presenting a challenge to the person's
well-being. That is, depression as a clinical entity is understood to be
typically unmanageable or intolerable, such that the ordinary means of support
in one's life have failed to offer relief.</p><p class="MsoNormal" style="margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="margin-bottom: 0in;">Depression as a clinical entity is
often described as “major depressive disorder”, but that is not necessarily the
case. “Major depressive disorder” is the typical diagnosis given by healthcare
professionals when individuals present with clinical depression, but what may
look like depression to a person or their family may not be understood by a
healthcare professional as “major depressive disorder”. It may very well be the
case that what looks like depression is interpreted by the healthcare
professional as belonging to a diagnostic category different than major
depressive disorder, such as adjustment disorder, bipolar disorder, anxiety
disorder, or dementia. This is because the experience of depression can exist
in many different ways and can exist alongside many different problems. This
matters a great deal in clinical contexts, but less so for the purposes of our
discussion.</p><p class="MsoNormal" style="margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="margin-bottom: 0in;">How to make sense of depression is
a question that throws us into the complicated debates surrounding the
relationship between mind and body, the nature of psychiatric diagnoses and
explanations, and the colors and quirks of human subjectivity. These issues,
like most philosophical problems, are open-ended, unsettled questions. We live
in a society where narratives of depression as a medical condition have become
dominant. These narratives take many forms. A common narrative widely promoted
by pharmaceutical companies that has permeated our popular culture is the
notion that depression is caused by a “chemical imbalance” in the brain. This
narrative has encouraged a predominantly biological understanding of depression
and has been used successfully to market antidepressant medications. However,
our best scientific and philosophical understanding of depression is
inconsistent with any simplistic explanation in terms of brain changes.</p><p class="MsoNormal" style="margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="margin-bottom: 0in;">Understanding depression as a
medical condition is not simply a matter of hypothesizing brain changes.
Rather, from a practical standpoint, something becomes a medical condition when
it is deemed appropriate to be assessed using the methods of medicine and to be
treated with the tools of medicine (with the recognition that the methods and
tools of medicine are themselves evolving and fluid). Individuals with
depression have sought the care of physicians since the early days of medicine.
Depression was recognized as a clinical entity by ancient physicians such as
Hippocrates and by medieval physicians such as Avicenna.
However, the depression that has been recognized as a clinical entity for much
of history is, from today’s perspective, depression of a more severe variety,
such that often its subjective experience feels qualitatively different from
ordinary unhappiness; it is often profoundly disabling, and often complicated
by unusual experiences such as delusions or hallucinations. Over the 20<sup>th</sup>
century, the boundaries of what is considered clinical depression have steadily
expanded to include milder forms of depression, such that a lot of what is
considered clinical depression today is probably closer in its subjective
experience to intense ordinary unhappiness than it is to melancholia of yore.
Thus, clinical depression is a spectrum, ranging from mild to severe, from
qualitatively familiar to qualitatively unfamiliar, and from distressing to
disabling.</p><p class="MsoNormal" style="margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="margin-bottom: 0in;">From a medical perspective, clinical
depression is a syndrome that results from a complex interaction of biological
factors (such as genetics, neurotransmitters, inflammation), psychological factors
(such as personality styles, cognitive styles), and social factors (such as abuse,
poverty, social adversity, social discrimination). There are, however, other perspectives
available to us. From a psychodynamic perspective, for example, experiences such
as clinical depression are woven into the fabric of our lives and rooted in
enduring patterns of thinking, feeling, motivation, attachment, coping,
defending, and relating to others<sup>1</sup>; from this perspective, clinical depression
cannot be understood as an entity separate from the person experiencing it. Individuals
with depression want relief from depression, but this may exist in the context
of problems of living, such as inability to connect with others or feelings of
shame, such that it may be meaningless to attempt to relieve depression without
dealing with those problems of living.</p><p class="MsoNormal" style="margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="margin-bottom: 0in;">From an interpersonal and
relational perspective, the experience of depression may be related to the
events and circumstances of a person’s life, both in the past and the present,
together with the meaning those events have for them<sup>2</sup>. From a social
perspective, the experience of depression may be related to social oppression,
economic inequalities, and societal expectations of individual productivity.
From a spiritual perspective, the experience of depression may be related to our
disconnection with sources of meaning in our lives and opportunities for
transcendence. From an environmental perspective, experience of depression may
be related to our increasing isolation from nature. From an existential
perspective, experience of depression may be related to our struggle as
conscious beings in an apparently absurd universe facing inevitable death.</p><p class="MsoNormal" style="margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="margin-bottom: 0in;">That multiple perspectives are
available to us means that no single perspective can offer us all that we need to
make sense of the multifaceted reality of depression. The perspectives
available to us allow us to see depression as a problem inside or outside the
individual, as a problem requiring a scientific explanation or a difficulty in need
of an existential narrative, as a syndrome to be understood medically or an
experience to be understood psychologically, as a disorder that requires medication
or as a spiritual crisis that compels one to undertake an 1,100-mile hike on the
Pacific Crest Trail.</p><p class="MsoNormal" style="margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="margin-bottom: 0in;">To reduce this plurality of
perspectives to a single dominant narrative, whether it is medical or inter-personal,
is to impoverish our existence and to deprive us of the tools we need to make
sense of our selves in relation to our worlds. It is inevitable that
different professionals will utilize different perspectives as tools, and
different individuals will find that their depression makes more sense from a
particular perspective. The perspectives that we find valuable will depend on our
specific questions and specific interests. A clinician asking “How can I offer
relief to this individual in great distress sitting in front of me in my
office?” requires adopting different perspectives than a politician asking, “What
services should be funded and made available to reduce the burden of depression
in my community?”. An anthropologist asking, “How do I make sense of the
experiences of depression across different societies and cultures?” requires
adopting different perspectives than a depressed individual asking, “What meaning
does my depression hold for me?”</p><p class="MsoNormal" style="margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="margin-bottom: 0in;">Our task, the arduousness of which
cannot be over-estimated, is to do justice to the plurality of perspectives, and
to the plurality of pluralities. This is a responsibility that cuts across our
divisions of individual and social, secular and spiritual, and medical and psychological.</p><p class="MsoNormal" style="margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="margin-bottom: 0in;"><br /></p>
<p class="MsoNormal" style="margin-bottom: 0in;">---<o:p></o:p></p>
<p class="MsoNormal" style="margin-bottom: 0in;"><b>Footnotes<o:p></o:p></b></p>
<p class="MsoNormal" style="margin-bottom: 0in;">1. <a href="https://www.psychiatrictimes.com/view/psychoanalysis-re-enchantment-psychiatry-jonathan-shedler-phd">Jonathan
Shedler</a> in interview with me: “This is a radically different way of
thinking about depression. It is less about what we have and more about who we
are. Our difficulties are woven into the fabric of our lives and rooted in
enduring patterns of thinking, feeling, motivation, attachment, coping,
defending, and relating to others—that’s what we mean by personality. From this
perspective, depression is an effect, not a cause. It cannot be treated in a
vacuum, separate from the person experiencing it.”</p><p class="MsoNormal" style="margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="margin-bottom: 0in;">2. BPS. Understanding Depression.
Executive Summary. “Often, the experience of depression is related to the events and circumstances of
a person’s life, both in the past and the present, together with the meaning
those events have for them.”</p><p class="MsoNormal" style="margin-bottom: 0in;"><o:p></o:p></p>Awais Aftabhttp://www.blogger.com/profile/04718828055532728613noreply@blogger.comtag:blogger.com,1999:blog-8980517681041523849.post-35151775838054820482020-11-05T23:28:00.003-05:002020-11-05T23:30:03.338-05:00The Users and Abusers of Psychiatric Criticism<p>This post
continues the dialogue between James Barnes and me on the topic of criticisms
of psychiatry. See last post by Barnes <a href="https://awaisaftab.blogspot.com/2020/11/critics-and-their-psychiatry.html">here</a>.</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">I am going to
respond to some of the specific points raised by Barnes, but in order for this
exchange to be more meaningful, I want to do so in the context of some larger
theses about the common ways in which criticisms of psychiatry can be
problematic. In line with my previous post, the intention is not to shut down
or suppress criticisms, but rather to encourage more thoughtful and more
nuanced criticisms. </p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">1) On analysis,
many (certainly not all) criticisms about psychiatry are actually about the
current system of mental health care, but these criticisms are often directed at
psychiatry <i>as a medical specialty</i>. By conflating the two, critics often ignore
or downplay the “market forces” and systemic influences in shaping contemporary
practice.</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">2) Many criticisms
that apply to psychiatry also apply to psychology, but psychiatry is typically
singled out in a way that psychology is not. While critics would admit that
criticisms also apply to psychology, this is typically admitted in the fine
print, while the rhetoric remains focused on psychiatry (which also partly
explains why such criticisms are often perceived as being ‘antipsychiatry’ or
reflective of interprofessional ‘guild’ conflict).</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">3) It is common
to see exchanges in which both sides stick to their talking points, when it is
clear that the talking points do not represent the messy reality. Sticking to
the talking points is an example of having the same arguments over and over,
because no progress is made. Progress is made when it is realized that talking
points fail to do justice to the reality, and we advance to more nuanced
positions. “Psychiatry is biomedical” and “psychiatry is biopsychosocial” are
examples of such talking points because psychiatry is biomedical in some
respects and biopsychosocial in others (vague as the terms are).</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">4) When it
comes to philosophical discussions, there is a continual tendency to confuse/conflate
“disorder” as an abstract category with specific disorders. Saying that “disorder”
as a category doesn’t exist out there in the world doesn’t mean that specific
conditions we characterize as disorders cannot be located out there in the
world or do not have biological contributions to etiology.</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">5) There is a
mistaken tendency to see psychiatric power as arising from a specific notion of
mental disorder. That in my opinion represents a profound misunderstanding of what
the exercise of psychiatric power (primarily involuntary commitment and
involuntary treatment) is really about. It is not about a philosophical
disagreement over how to define concepts. It is fundamentally about
considerations of risks (at least in the US), i.e. risk of harm to self (which
includes suicidality but also inability to care for self) and risk of harm to
others (severe agitation, violence, homicidality, or behavior that, to use the
legal language from Ohio Revised Code, “creates a grave and imminent risk to
substantial rights of others”). To exercise this power is a responsibility that
is enshrined in the law and is placed on the shoulders of the mental health
professionals.</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">I will
elaborate on these points further during the course of the commentary.</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p> </o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><b>Psychiatry
and the System<o:p></o:p></b></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">As I see it,
there are three different ways in which psychiatry is presented as a target of
criticisms:</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">1) Psychiatry
as a medical specialty, perceived to concern itself (rightly or wrongly) with
biological causes of psychiatric conditions and biological treatments, distinct
from clinical psychology and social work</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">2) Psychiatry
as representative of the current state of psy-professions as well as aspects of
primary care/general practice, representing scientific and technological
approaches to the human condition, and encompassing psychological approaches
such as CBT and psychoanalysis</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">3) Psychiatry
as representative of the systemic forces shaping mental health care and
discourse, including laws, funding organizations, health insurance agencies,
pharmaceutical companies, and social narratives, among other things.</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">It is my
impression that the target of the criticisms keeps shifting between the three
modes, yet the differences are not clearly acknowledged such that the target
always appears to be <i>psychiatry</i> as a medical profession. This is
important because it sets up psychiatry the medical specialty as the scapegoat
for all the systematic wrongs, even though psychiatry as a medical specialty is
also a victim of the systemic forces in many ways. Targeting psychiatry this
way serves a <i>rhetorical</i> function; it intentionally or unintentionally
plays into the rhetoric of guild conflict; and it ignores that even if psychology
possessed the power and prestige that psychiatry as a medical specialty enjoys
currently, a lot of the systemic problems would still exist, just in a
different form.</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">I think any
well-intentioned and fair critic should not scapegoat psychiatry (as a medical
specialty) and should make it clear wherever applicable that what is being
criticized is a larger system with many moving parts which also includes
psychology, social work, pharma, law, society, politics, capitalism, and
everything else that makes mental health care what it is right now.</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><br /></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><b>Biopsychosocial
Practice<o:p></o:p></b></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">It is important
to clarify that the biopsychosocial framework by itself doesn’t dictate which
treatments should be used: what it does is that it emphasizes the importance of
incorporating all the relevant variables across the bio-psycho-social spectrum
into a comprehensive explanation and of targeting those relevant variables by
appropriate means.</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">The
determination of what treatments to utilize comes from integrating empirical
evidence and in practice is often determined by various practice guidelines,
such as by NICE. It is the task of guidelines to synthesize existing evidence
for various biological and psychosocial interventions, and to guide clinicians
regarding what works best. Any bio/psycho/social treatment can be recommended
provided it has enough evidence to justify the recommendation. </p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">The difficulty
of implementing biopsychosocial treatment has to do a great deal with the
fractured nature of services: we have different professionals assigned
different roles within the system. Psychotherapy as a treatment, for instance, shows
up a consistent recommendation in guidelines. Why doesn’t it happen more often
in practice?</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">Let’s look at
some numbers. In 2010 <a href="https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2010.10040570">Olfson
and Marcus</a> reported that the percentage of Americans who use psychotherapy
each year has remained remarkably stable: 3.24% in 1987, 3.37% in 1998, and
3.19% in 2007. They also noted that among individuals receiving outpatient
mental health care, the percentage of individuals receiving psychotropic
medication only had increased, such that in 2007, 57.4% of individuals in
outpatient mental healthcare were on medication only, 32.1% were receiving both
medication and psychotherapy, and 10.5% were receiving only psychotherapy. Even
though majority were receiving medications, 43% of individuals receiving
psychotherapy, with or without medications, is not an insignificant number.</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">Olfson and
Marcus identified several factors that may have contributed to the shifting
distribution of treatment modalities.</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">1) The
pharmaceutical industry spends billions of dollars each year promoting
medications to physicians and the general public but there is no entity of
comparable influence or visibility to advocate psychotherapy. <o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">2) No federal
agency or prominent national organization certifies the effectiveness of individual
psychotherapies or psychotherapists, like FDA does for medications<o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">3) Reliable
information about medications is far more readily available to the public than
is information about psychotherapy. <o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">4) Ideological
disagreements among psychotherapists may have an effect on public acceptance of
psychotherapy. <o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">5) Primary care
physicians account for a great majority of psychotropic medication prescriptions
in the United States, but psychotherapy typically is restricted to mental
health specialists<o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">6) For some
practitioners, especially psychiatrists, there are financial disincentives to
providing psychotherapy. <o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">7) Unlike
pharmacotherapy, psychotherapy requires a considerable time commitment from
patients.<o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">How is all this
the fault of an individual psychiatrist, who may very much want to practice
psychotherapy or refer patients for psychotherapy, but is unable to because of
systemic forces? This system failure is as much a failure of psychology as it
is a failure of psychiatry. My intention is not to defend the current
practices; certainly a lot needs to be changed. But it is problematic to think
that the burden of biopsychosocial practice falls entirely on the shoulders of
the psychiatrists when clearly the psychologists are as much a part of this
system as anyone else.</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p> </o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><b>The Notion
of Disorder<o:p></o:p></b></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">Barnes writes
that the accepted, historical, common-sense notion of “disorder” is one that
defines “disorder” in terms of physical abnormalities. I think Barnes is
reacting to the notion of disorder that he perhaps grew up with and that he
sees prevalent in the society around him, but that is far from the overarching
historical reality. The adoption of “disorder” as a term in psychiatry itself
signified a break from older, more common terms such as “disease” and
“illness”. It was intended to be a category with less conceptual baggage, one
that was not inherently medical, and therefore also suitable for use in psychological
contexts. As I mentioned in the last post, DSM-III allowed for an understanding
of “disorder” in terms of psychological dysfunction. The usage of the term
disorder as way of implying <i>functional</i> rather than <i>structural</i>
abnormalities is also quite old. This has been the case since at least the late
1800s, when the <i>Lexicon of Medicine and Allied Sciences</i> stated that
disorder is “a term frequently used in medicine to imply functional
disturbance, in opposition to manifest structural change.” (<a href="https://amastyleinsider.com/2011/11/21/condition-disease-disorder/">source</a>)</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">I’m not here to
privilege dictionary definitions as truth, nor am I supporting the supporting the
functional/structural distinction per se. My point is that Barnes has a very
specific story in his mind. The story is along the lines of: it was <i>commonly
accepted</i> that disorder refers to a physical abnormality, therefore
psychiatry spent decades searching for physical abnormalities, and when it was
unable to find these abnormalities, psychiatry then sought for other creative
ways to interpret the notion of disorder to come up with one which doesn’t rely
on physical abnormalities.</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">As any good
historian can tell you, this story is extremely simplistic and misleading. Such
a story also fails to take into account various notions of psychopathology that
have existed in psychiatry over the years, such as Jasperian, Meyerian and
Freudian notions of psychopathology. The notion of disorder that Barnes sees as
common sense and widely accepted is, in its current iteration, a recent
historical development, heavily influenced by the contemporary rise of biological
psychiatry and pharmaceutical propaganda (“chemical imbalance”) that peaked in
the 1990s and 2000s</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">The only thing
I can say is: give it up, it is a rhetorical fiction, and grapple with the
complex reality of ways in which concepts of disease/disorder/illness/psychopathology
have evolved over the course of history. This lack of historical consciousness
wouldn’t be much of a problem if Barnes and associates were to admit that the
target of their criticism is a specific historical conception of mental
disorder that is prevalent in our societies, but that makes for a far less
appealing narrative.</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">Furthermore,
philosophical analysis of concepts is not necessarily bound to history.
Whatever the history of concepts, philosophy can challenge those histories,
reveal inconsistencies and problems, and force us to think differently. This is
a continuous, open-ended project. We are not wedded to our concepts. The
philosopher Lisa Bortolotti for instance has <a href="https://academic.oup.com/aristoteliansupp/article-abstract/94/1/163/5866048">recently
argued</a> against the idea that if there are no mental disorders then the
status of psychiatry as a medical field is challenged. I myself favor an
attitude of what I call “<a href="https://link.springer.com/article/10.1007/s40596-020-01183-3">conceptual
humility</a>”, the recognition that philosophical problems are open-ended
questions and rarely settled conclusively.</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">Whether
“disorder” can or cannot be meaningfully applied to individuals, or whether we
are forced to speak of individuals in relationship with their environments, or
some radical notion of Heideggerian “individual-world” entities, is an
interesting and important philosophical question, but one that has little to do
with legitimacy of psychiatry. I favor the enactive position at the moment but
what is clear to me is that a relational approach is consistent with many
different metaphysical views about the nature of experiences. There are many
different ways to take a relational approach, and I don’t think any profession
as a whole can really commit to a specific metaphysics of a relational
approach. Even PTMF, as far as I can tell, doesn’t commit to the sort of
metaphysics that Barnes has in mind.</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p> </o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><b>Mental
Disorder as Pragmatic Kind<o:p></o:p></b></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><i>Barnes: “From
what you personally are saying, however, it follows that the edifice of
psychiatry is based entirely on (inter)subjective constructions. It should also
then follow that we are all entirely welcome to reject the notion of ‘mental
disorders,’ and also therefore psychiatry as a medical discipline.”</i></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">What I am
saying is that not just psychiatry but also medicine is based on concepts of
health and disease that are essentially pragmatic and these concepts don’t
correspond to “anything out there”. I still think that Barnes continues to
confuse abstract (pragmatic) <i>categories</i> with specific <i>instances</i>
of those categories. For instance, frontotemporal dementia is a disease, but
the biological materiality of frontotemporal dementia does not by itself
contradict the pragmatic nature of the construct of disease or disorder.</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">We are welcome
to adopt different concepts, but in order to do so we have to grapple with the
functions these concepts serve. Concepts can be hard to change because we
collectively rely on them to perform certain functions, and it is only in the
presence of (better) alternatives that we exchange one concept for another.</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">Practical kind
approach has a lot of critical potential. As Robert Chapman recently commented
on <a href="https://twitter.com/R_J_Chapman/status/1322509054212739072">twitter</a>:
“I think critics of psychiatry should embrace the concept of pragmatic kinds.
It follows from the ontology of pragmatic kinds that they *should* change (even
be abandoned in some cases) if they aren't working well. So the concept can be
empowering and fruitful. It also legitimises questions such as "*who* is
this kind pragmatic for?" and "who *should* it be pragmatic
for?". Accepting it as a helpful ontology opens more space for
acknowledging the political elements of classification.” I completely agree
with him.</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">I lean towards
conceptualizing mental disorders as pragmatic kinds, but I certainly don’t
think that it is the only philosophical position of merit. I personally favor a
pluralism which welcomes multiple different philosophical perspectives. The
reason practical kind often comes up in discussion with the version of critical
psychiatry/psychology advocated by Barnes and associates is because the concept
of “disorder” that Barnes and associates still hold is one that has been almost
completely insulated from the developments in philosophy of psychiatry over the
last 2 decades. And this brings me back to a point I have made repeatedly. It
is one thing to criticize a specific biomedical notion of disorder that has
dominated societal thinking over the last three decades. If that was all what Barnes
and associates were saying, I wouldn’t have much of a problem with it. But
there seems to be pervasive reluctance to acknowledge that there are viable
notions other than the biomedical one, and the sense one gets is that the
critics think they have successfully criticized <i>any and all </i>notions of
disorder that psychiatry may employ. This latter attitude makes an unnecessary
enemy of various philosophical approaches such as enactivism/3E and practical
kinds.</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p> </o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><b>The Exercise
of Psychiatric Power<o:p></o:p></b></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><i>Barnes
writes: “Again, if this is the case, psychiatry has no right to diagnose, treat
or determine the fate of anyone except those who willfully request it to do so.
Psychiatry's status, power and responsibility are predicated on it treating
things “out there,” as in the rest of medicine.”</i></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">This is a
mistaken view. As I said, the pragmatic kinds analysis applies to all of
medicine, not just psychiatry. The concept of “disease” in rest of medicine is
no more “out there” than “mental disorder”. Saying that “disorder” as a category
doesn’t exist out there in the world doesn’t mean that specific conditions we
characterize as disorders cannot be located out there in the world.</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">Secondly, this
is a rather naïve view of social construction (pragmatic kinds are a special
instance of social construction). Our laws are socially constructed, is
everyone free to just reject them? The boundaries of nations are socially
constructed. Money is socially constructed. The rules governing exercise of
psychiatric power are complex socially constructed entities; recognizing them
as socially constructed is not enough to just wish them away. It requires
making sense of the complex collective functions they serve. Psychiatric power
is a function of legal responsibilities and societal expectations of
professional roles, and these fundamentally have to do more with considerations
of risk (risk to self, to others) than any particular philosophical notion of
mental disorder. This is again a reminder that psychiatry as a medical
profession exists as part of a larger societal system. The rules governing
exercise of psychiatric power can be changed, with great effort, but not merely
by philosophical analysis.</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">Furthermore,
the laws and practices regarding exercise of psychiatric power extend beyond
psychiatry as a medical discipline. For instance, in the US it is very common
for me to see cases where a social worker or a psychologist conducts an
evaluation in the emergency room and recommends/initiates the process for
involuntary psychiatric care. This is because the legal responsibilities of
clinical risk assessment don’t apply merely to psychiatrists but also to other
physicians as well as mental health professionals such as psychologists. It is
wishful thinking that these larger legal and professional responsibilities will
disappear if psychiatry as a medical profession were to be dismantled or if we
abandoned the idea of mental disorder.</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">A fundamental
consideration in practice is that involuntary holds and treatments are not a
matter of physician choice. In fact, these involuntary holds and treatments are
enshrined in law, and upheld by "standards of care", such that if
physicians don't follow them, they are putting themselves at tremendous
liability if a negative outcome happens (such as suicide or homicide or
psychotic violence). There is obviously some wiggle room in the interpretation
and application of these laws, hence there is variability in practice among
physicians, but the basic principles are pretty widely understood and accepted.</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">Many
psychiatric critics seem to have the simplistic idea that if we abolish
"psychiatric diagnosis", the issues of involuntary holds and
treatments will disappear. They think that because psychiatric diagnostic
constructs are invalid, any decisions based on these constructs cannot be
justified, and since involuntary holds/treatments are a consequence of
psychiatric diagnosis, then they also cannot be justified. But that is an
incorrect understanding. Involuntary holds/treatments are not about diagnosis
-- diagnosis is entirely peripheral -- they are instead about considerations of
risk, of harm to self and others.</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">My view on this
question is largely in agreement with the psychologist-philosopher Derek
Bolton, who writes: "[The issues of social control in psychiatry need] to
be interpreted in terms of human rights legislation and the other principles
and institutions of democracy. Democracies aim to protect freedom of expression
of belief and of action, provided they pose no demonstrable risk to others...
Risk to public safety raises problems and require solutions that are quite
unlike those associated with medical care and healthcare generally: the control
of individuals for the safety of others is fundamentally an activity of the
state, not of the medical profession or any other healthcare profession."
(What is Mental Disorder? OUP. Page xxvii)</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">In other words,
whether involuntary holds/treatments should be allowed is not fundamentally a
matter for psychiatry to decide, but rather an ethical and legal decision to be
made by societies and their legislators. Are societies willing to allow deaths
from suicide and psychosis in order to preserve human autonomy? Societies can decide
how they wish to prioritize these competing values. Psychiatrists are certainly
a stakeholder in this discussion, but the decision is not really theirs.
Societies can also decide who will enforce involuntary holds/treatments.
Currently the law asks physicians to perform this role given their medical
knowledge and authority, but there is no reason it has to be physicians. The
law can just as well decide that it'll be social workers, or some other newly
created profession.</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">My point is
that decisions related to involuntary holds/treatments are issues of ethics,
human rights, and public safety, and they should be decided by the state and
legislators, using principles of ethics, human rights and public safety. This
is not an issue that directly relates to psychiatric diagnosis, although it
relates to psychiatric phenomena. These phenomena will remain there regardless
of whether they are conceptualized as psychiatric diagnoses or not.</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><i>Barnes
writes: “More to the point, if this is so, when are mandatory inpatients going
to be notified that they didn’t lack ‘insight’ after all — perhaps even had a
more sophisticated appreciation of the problem than did their psychiatrists —
and informed that they are free to go?”</i></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">This is also a
very naïve view of “insight”. Insight is not about a philosophical disagreement
of whether the condition one suffers from should be classified as a disorder or
not. If a patient is capable of making such a philosophical argument, in all likelihood
they possess insight. A typical dictionary definition of insight is: “Awareness
of the nature of one's own psychiatric symptoms with some appreciation of the
possible causes or precipitating factors.” Insight is not about disorder
status; it is about an appreciation of the condition in question. For instance,
an individual with delusions who is incapable of recognizing the nature of
his/her beliefs. An individual who thinks that the doctor is a CIA agent sent
to torture him lacks insight; this has nothing to do with the philosophical
question of whether that delusion should be characterized as a disorder or not.</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p> </o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><b>Critics and Common
Ground<o:p></o:p></b></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><i>Barnes: “The
common ground we can find, then, is that psychiatry needs to radically change.
This, for me, would involve a drastic shift away from medicine with all the
invokes and towards something that is centered on human and social concerns.”</i></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">There is indeed
a lot of critical ground. As I have said earlier, I see myself in the role of
the critic as well, and it is rather frustrating to me that I have to
continually defend psychiatry against criticisms that I perceive to be
misplaced instead of advancing the critical agenda that I think is much needed.</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">I suspect
Barnes and associates are not quite sure what to do with psychiatrists such as
myself and other psychiatric critics (such as neurodiversity philosopher Robert
Chapman), who are critical of the status quo but take different philosophical
approaches in response. The presence of such commentators is inconvenient for
the black and white narratives which some in critical psychiatry/psychology
circles seem to have nurtured. That either you are on the side of biomedical
reductionism or you are on the side of meaningful experience. That either you
are on the side of “dysfunction” or you are on the side of “understandable
reaction”. That either you believe in psychiatric diagnosis or you believe in
psychological formulation. Criticizing psychiatry is not black and white; the
philosophical options available to us are not exhausted by these dualities. Psychiatry
is not a monolith but a rich discipline with diverse traditions. Psychiatry is
also a profession that exists in relationship with other medical and psychological
professions, and in relationship with larger societal systems. The world we
inhabit, and the world we co-create is complex, and we need to approach it with
humility.</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">With this, I
want to give the final world to @apospodcast who <a href="https://twitter.com/apospodcast/status/1323402108960444418">said on
twitter</a>: “The problem of these debates, and why I think they're
unresolvable, is they presume the existence of an objective truth. We can't
determine the objective truth on how people should make sense of things (problem
of the person vs problem in society). Pain is intrinsically contradictory. We
can help people make sense of these conflicts, which will always be a
provisional sense for all of us, if we take a step back as professionals and
deprive our constructs, labels, procedures of power and create some space for
dialogue. Where multiple meanings of pain are accepted.”</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">Let us create
space for dialogue and let us accept the plurality of ways in which we make
sense of human suffering.</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><br /></p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><o:p></o:p></p>Awais Aftabhttp://www.blogger.com/profile/04718828055532728613noreply@blogger.comtag:blogger.com,1999:blog-8980517681041523849.post-14460833681934963542020-11-02T13:27:00.003-05:002020-11-06T15:44:07.594-05:00Critics and Their Psychiatry<p><i><span style="color: #444444; font-family: inherit;"><span style="font-size: 12pt;">This
is a guest post by </span><b style="font-size: 12pt;">James Barnes</b><span style="font-size: 12pt;">, who offers a response here to my earlier blog
post </span><span style="font-size: 12pt;"><a href="https://awaisaftab.blogspot.com/2020/10/psychiatry-and-its-critics.html">Psychiatry
and its Critics</a>.</span></span></i></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-size: 12pt;"><span style="color: #444444; font-family: inherit;"><br /></span></span></p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-size: 12pt;"><span style="color: #444444; font-family: inherit;">Your
response-blog was much appreciated and clarifying. I wanted to respond in kind
to some of what you said, partly to explore certain misunderstandings and
identify differences, but also to highlight degrees of agreement.</span></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="color: #444444; font-family: inherit;"><span style="font-size: 12pt;">I
do want to just say, though, that I disagree with your premise. I do not think
this should be characterized as a conversation that is being had “over and over
again.” The implication is that what is/has been missing is some sort of better
appreciation of a set of facts about what psychiatry actually is or</span><i style="font-size: 12pt;"> </i><span style="font-size: 12pt;">does.
I think that is a serious underestimation of what is going on.</span></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="color: #444444; font-family: inherit;"><span style="font-size: 12pt;">Ultimately,
this debate concerns a clash of ‘world views.’ Similar themes can of course be
traced back to the “antipsychiatrists” of the 1960’s — though they are not
simply regurgitations of those arguments — but that movement itself can and
should be located within the perennial clash between the reductive,
positivistic (and technological) approaches to the human condition and those
that vehemently reject such aspirations as dangerously flawed. This broader
clash goes back to the very beginnings of the Enlightenment, only arguably
having reached its climax in recent times — especially well illustrated in the
case of (the demise of) biomedical psychiatry.</span><span style="font-size: 12pt;"> </span></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="color: #444444; font-family: inherit;"><span style="font-size: 12pt;">Far
from this being a matter of clearing up technical distinctions, the dialectic
going on underneath this will only be ‘resolved’ when something genuinely new
and different emerges — from forces in all likelihood far outside the ‘academic
halls.’ That is my take anyway.</span><span style="font-size: 12pt;"> </span></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="color: #444444; font-family: inherit;"><span style="font-size: 12pt;">In
any event, to get to the technical distinctions:</span><span style="font-size: 12pt;"> </span></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="color: #444444; font-family: inherit;"><span style="font-size: 12pt;">You
say:</span><i><span style="font-size: 12pt;"><o:p> </o:p></span></i></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="color: #444444; font-family: inherit;"><i><span style="font-size: 12pt;">“Recognizing
that biopsychosocial model doesn't necessarily prevent biomedical reductionism
also doesn't imply that all biopsychosocial approaches in psychiatry are de
facto reductionist. The integration problem in philosophy of psychiatry is
complex. Lack of a satisfactory philosophical account of how this integration
happens doesn't indicate that there is a lack of commitment to the integrative
aspiration itself.” </span></i><span style="font-size: 12pt;"> </span></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="color: #444444; font-family: inherit;"><span style="font-size: 12pt;">Yes,
I am of course not saying that every psychiatrist is </span>reductionistic<span style="font-size: 12pt;">. The
‘critical psychiatrists’ are a case in point. I will put the point another way:
the vast majority of psychiatrists, biopsychosocial or otherwise (yourself
included, correct me if I am wrong) are in the day-to-day business of
prescribing psychiatric drugs as the first-line, primary intervention. This
suggest to me that the term ‘biopsychosocial’ is being used inappropriately,
irrespective of how one personally justifies it theoretically. An approach true
to the term’s equivalence of levels — and true to Engel's vision as I
understand it — should preclude the almost invariable priority that the
biological level is given in treatment.</span><span style="font-size: 12pt;"> </span></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="color: #444444; font-family: inherit;"><span style="font-size: 12pt;">Biopsychosocial
<i>should</i> mean that for a non-insignificant amount of the time
interventions at the biological level are <i>not </i>indicated and <i>only</i>
those at the psychological and/or social are. That clearly is not born out in
current practice. I acknowledge, of course, that psychiatrists make referrals
to psychologists and/or social workers, and some also provide psychotherapy
themselves. But if that only happens some of the time, whereas prescribing is
almost guaranteed, then it is clear that it is bio- first (and foremost) and
psychosocial as a secondary thought. It is clearly not integrated in practice
either, then. The fact that there is an “integration problem” in theory, serves
to strengthen the point here. If there is such indeterminacy and confusion at
the theoretical level, we should not generally find an inflexible assuredness
with intervening at the biological level.</span><span style="font-size: 12pt;"> </span></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="color: #444444; font-family: inherit;"><span style="font-size: 12pt;">So,
while I respect and appreciate the aspirations, I do not think it makes sense
or is right to justify current practice based on such things.</span><i><span style="font-size: 12pt;"><o:p> </o:p></span></i></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="color: #444444; font-family: inherit;"><i><span style="font-size: 12pt;">“I
see little antagonism among my psychiatric colleagues towards other
non-biological treatments. Most psychiatrists I know have a positive view of psychotherapy
and social interventions. Most psychiatrists I know want better access to
psychotherapy and social interventions for their patients. There is no
mainstream hostility towards psychotherapy or social interventions.”</span></i><span style="font-size: 12pt;"> </span></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-size: 12pt;"><span style="color: #444444; font-family: inherit;">It
is not about hostility as psychiatry is in the position of power; if it were
not, it is not hard to imagine that it might emerge. In any event, I certainly
acknowledge that the benefits of psychotherapy and social interventions are
recognized — not least because the evidence of their efficacy would be very
unwise to ignore. How their role is understood, however, is just as important.</span></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="color: #444444; font-family: inherit;"><span style="font-size: 12pt;">Following
what I wrote in the blog, interventions at these levels are generally
considered as having an effect on or mitigating the ‘triggers’ and ‘stressors’
of otherwise biologically determined process. This means that they are not
understood as addressing ‘the problem,’ but only ‘risk factors’ and such.
Helpful, yes, welcome even — but considered capable of taking the place of
psychiatric drugs (i.e., capable of equivalence with the bio- as
biopsychosocial implies)? Clearly not. Rather, it is a very impoverished
understanding of the role they actually play, and within the current power
structure it is no surprise that such interventions are viewed positively. When
understood in this way, they do not pose much of a threat to the dominant model
(whereas if understood correctly, they do). As such, the fact that there is
such an attitude has little bearing on the arguments.</span><span style="font-size: 12pt;"> </span></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-size: 12pt;"><span style="color: #444444; font-family: inherit;">“The
notion that biomarkers are essential for “legitimate” medical disorders is
simply one way to think about what constitutes a disorder. Critics such as
Barnes and associates seem to argue that because all <i>physical</i> disorders
have some identifiable <i>physical </i>component, therefore it demonstrates
that <i>all </i>disorders must have some identifiable physical component, in
the absence of which the condition cannot be considered to be a disorder. But
that is simply begging the question.”<o:p></o:p></span></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="color: #444444; font-family: inherit;"><span style="font-size: 12pt;">Well,
assuming that medical disorders need <i>not </i>involve identifiable physical
components, as the practical kind analysis does, is also begging the question,
which I think is instructive. I would argue that this is a natural result of
the term being emptied of specific content as a result of ‘mental disorders’
(that have no demonstrable physical components) being included in the category.</span><span style="font-size: 12pt;"> </span></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="color: #444444; font-family: inherit;"><span style="font-size: 12pt;">To
reiterate a point from the blog, the fact is that psychiatry as an institution
has done its level best to find such physical components. Evidently this path
was pursued precisely because verifying them as the physical disorders it fully
expected them to be was considered paramount — Kendler for example writes about
his own such dashed hopes. The fact that no ‘physical components’ were properly
identified consequently problematized a concept of disorder that was otherwise
unproblematic. Without ‘mental disorders’ that have no specific physical
components, there would be no problem of how we define the concept of disorder
(i.e., in terms of physical components). It is disingenuous, therefore, to
imply that this is an issue written into the concept of disorder.</span><span style="font-size: 12pt;"> </span></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="color: #444444; font-family: inherit;"><span style="font-size: 12pt;">Thus,
while we may well both be begging the question, it is psychiatry that has
deviated from the accepted, common sense notion of disease/disorder due to the
problems it encountered, creating a question to be begged in the process. In
truth the critical argument is begging the history of modern medicine. The
onus, as such, is on psychiatry.</span><i><span style="font-size: 12pt;"><o:p> </o:p></span></i></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><i><span style="font-size: 12pt;"><span style="color: #444444; font-family: inherit;">“I
would like to see a philosophical analysis of the notion of “disorder” that
doesn’t start with the assumption that disorders are physical. Why should
disorders be physical? What is it about the notion of “disorder” that makes it
so? “The idea that “meaningful, purposeful experiences” cannot be disordered
relies on a very narrow definition of disorder. I don’t think anyone really is
denying that phenomena under psychiatry fundamentally pertain to meaningful,
purposeful experience in the world. I mean, that’s pretty much a given. The
whole phenomenological tradition in psychiatry exists for that reason. The
question is how to best understand these distressing, impairing, problematic
experiences.”<o:p></o:p></span></span></i></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-size: 12pt;"><span style="color: #444444; font-family: inherit;">Firstly,
as above, there is only a problem with the term ‘disorder’ because
emotional/psychological distress has been included under it. If we removed that
domain then the problem evaporates, which is what some critics advocate for.</span></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-size: 12pt;"><span style="color: #444444; font-family: inherit;">Having
said that, I personally do not in principle have an issue with expanding the
term ‘disorder’ to include emotional/psychological distress <i>if </i>it
incorporates the world(s) that the emotional/psychological distress in question
is inextricably interwoven with. <o:p></o:p></span></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-size: 12pt;"><span style="color: #444444; font-family: inherit;">As
I alluded to in the blog (and went into our conversation <a href="https://awaisaftab.blogspot.com/2020/06/from-what-is-disorder-to-heidegger.html" target="_blank">here</a>), my
position — and I think, in one form or another, the position of many critics of
psychiatry — is that meaningful, purposeful experience necessarily implies the
world as constitutive of that experience. That is very different from reducing
the world to a causal object that somehow triggers biological processes somehow
distinct from it, which is positivistic (and dualistic) type of thinking that
does not and cannot incorporate meaningful experience of the world.</span></span></p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="color: #444444; font-family: inherit;"><span style="font-size: 12pt;">If
the world is constitutive of the experiences, then any notion of ‘disorder’
applied to such experiences would have to necessarily include the world within
the explanation of what is disordered. If that is the case, then we would have
to be talking about ‘individual-world disorders,’ or some such thing, where the
person’s world is in principle as implicated and intervened in as the
individual. This, of course, is not on the table, as psychiatry and medicine at
large are in the business of pathologies of the individual organism a priori
(which is a central issue).</span><span style="font-size: 12pt;"> </span></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="color: #444444; font-family: inherit;"><span style="font-size: 12pt;">The
reason why the term ‘disorder’ or ‘disease’ is rejected as a
description/explanation of emotional/psychological suffering is that it currently
only applies (non-metaphorically) to the individual organism. If we can use
‘disorder’ to literally describe the persons world in tandem, then that is
personally fine with me. But if we did that then the phenomena of psychiatry
would be acknowledged to be inherently non-medical in the process — that is,
unless we consider the world/society to be under the remit of medicine too —
which is the reason why doing so is not on the table. Sometimes it seems like
this is an aspiration, but I’m imagining that is not a step you’d be willing to
make. So, I turn the question back on you: why must ‘disorder’ be something
limited to the individual? Now that disorder need not apply to physical
components, why must it only apply to the individual? So far as I can see, the
only reason is because you are/psychiatry is constrained by an a priori
commitment to individual pathology.</span><span style="font-size: 12pt;"> </span></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="color: #444444; font-family: inherit;"><span style="font-size: 12pt;">As
an aside, I take the basic idea of the world’s constitutive involvement to be
central to R.D Laing’s vision, who is much more of a forefather to modern
critical approaches than Szasz. Laing’s position itself was indebted to the
phenomenological-existential philosophical tradition, which, far from this
being a thing of the past, is now very much en vogue, as your interest in 4E
illustrates. Without being constrained by positivism as psychiatry (and much of
academic psychology) are one ends up with much more of a Laingian position than
a 4E position. I take the PTMF and Lucy Johnstone’s brilliantly argued position
across her papers/talks to be modern incarnations/variations of the Laingian
analysis in this sense, though of course not limited to it.</span><i><span style="font-size: 12pt;"><o:p> </o:p></span></i></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="color: #444444; font-family: inherit;"><i><span style="font-size: 12pt;">“The
idea that by calling an emotional/experiential/psychological condition as a
“disorder”, we are “pathologizing the individual in terms of their brain/body”
is incorrect. For instance, according to the DSM definition of mental disorder,
a mental disorder can simply reflect a “psychological dysfunction”. The
presence of a “biological dysfunction” is not necessary, and there is no
requirement by the DSM that “dysfunction” be understood solely in biological
terms. So even by the “official” definition, the integral link between
“disorder” and “brain pathology” is disputed.”</span></i><span style="font-size: 12pt;"> </span></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="color: #444444; font-family: inherit;"><span style="font-size: 12pt;">There
are clear assumptions in the DSM, none of which allow the disorder to be
anything but some sort of dysfunction of the individual. As a result, it
commits to a particular conception of what mind is that is reducible to the
individual (brain). Allowing disorders to be “psychological dysfunctions” is
therefore misleading if such dysfunctions are directly (or in a convoluted way)
reducible to biologically processes.</span><span style="font-size: 12pt;"> </span></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="color: #444444; font-family: inherit;"><span style="font-size: 12pt;">I
personally, as well as many critics, reject this kind of philosophy of mind,
taking a view that mind is relationally/socially generated and located. The
PTMF and Lucy Johnstone, for example, are patently not talking about ‘mind or
‘mental’ in a sense that can be reduced to the individual. As ‘power’ and
‘threat’ are integral to the experiences described, clearly we are talking
about a domain that has the events of the world inherent, not incidental, to
it. Claims that this debate is about the discipline of Psychology wrestling for
power are similarly confused, as like psychiatry, it is also a largely
positivistic, individual focused enterprise. This talk by Mary Boyle (PTMF
co-author along with Lucy Johnstone) I think illustrates this view well (</span><span style="font-size: 12pt;"><a href="https://www.youtube.com/watch?v=Kt4JcTDPUoc&ab_channel=TheBritishPsychologicalSociety">https://www.youtube.com/watch?v=Kt4JcTDPUoc&ab_channel=TheBritishPsychologicalSociety</a></span><span style="font-size: 12pt;">)<o:p></o:p></span></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-size: 12pt;"><span style="color: #444444; font-family: inherit;">This
matters, to reiterate the point, because under such a view minds cannot be
disordered/dysfunctional when these terms are limited to the individual. If we
call these experiences disordered, we are immediately and necessarily also
calling the (person’s) world disordered.</span></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><i><span style="font-size: 12pt;"><span style="color: #444444; font-family: inherit;">“The
fact that meaningful experiences in the world are embodied means that there is
in principle an opportunity to exert some sort of modulating influence on those
meaningful experiences by intervening on the biological phenomena, the limits
of which are to be determined empirically. If an individual is experiencing
severe anxiety, this anxiety can be lessened in the short term if the
individual, say, drinks some alcohol, or smokes some marijuana, or takes a
sedative medication. This will be so regardless of whether the severe anxiety
is a “disorder” or not, and regardless of whether the severe anxiety is a
“meaningful, purposeful experience” or not. The point is that meaningful,
purposeful experiences can nonetheless be influenced through biological means,
and the question is not whether we can do so, but whether it is a good thing to
do so, and how to balance the risks and benefits of such an intervention.
Meaningful, purposeful experiences do not preclude the possibility that
biological interventions can be beneficial or helpful.”</span></span></i></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-size: 12pt;"><span style="color: #444444; font-family: inherit;">Yes,
I agree with this. As I’ve said before, I am not against the use of psychiatric
drugs in principle. The key issue is the misleading narrative that has been
employed around them and how they are sold — metaphorically and literally — which
has led to disastrous consequences. I know you are in agreement about much of
this. The notion that such drugs are intervening in ‘the problem’ (i.e., the
biology of the individual) and therefore should be the primary intervention
continues to be at the basis of the psychiatry as practiced. I don’t think that
is debatable. If they were prescribed using a very different narrative, such as
Joanna Moncrieff's ‘Drug Centered Model’, then that would a different story. I
do not see that there has been much uptake of this narrative though. On the
contrary, I have largely seen antagonism to it, which is telling.</span></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-size: 12pt;"><span style="color: #444444; font-family: inherit;">Such
a narrative as Moncrieff's also involves a very different vision of psychiatry,
one in which psychiatric drugs are not routinely prescribed precisely because
their non-specific mode of action and highly particular role in relieving
distress are center stage, along with the harms of the drugs of course. I think
it is pretty clear that if people had proper informed consent in this regard
there would be a great reduction in their use. I think psychiatry would also
naturally have to become simply a specialty among many, to which referrals
would be made if deemed necessary by someone primarily trained in psycho-social
(spiritual) matters — not biology and positivistic science — as befits the
phenomena in question. It would, in other words, involve a significant
relinquishing of practical and ideological power, which is presumably why there
has been limited uptake of such a narrative. <o:p></o:p></span></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><i><span style="font-size: 12pt;"><span style="color: #444444; font-family: inherit;">“Barnes
writes: “the critical argument disputes the very reality of their being a
‘kind’ called ‘mental disorder’ in the first place, over and above the
phenomena described.” This is a really confused argument… what does it mean to
say that a “practical kind” category isn't real? Practical kind categories by
definition don’t correspond to anything “out there” in the structure of the
world. That is precisely why they are practical kinds and not natural kinds.”<o:p></o:p></span></span></i></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="color: #444444; font-family: inherit;"><span style="font-size: 12pt;">That
makes sense, though I don’t think the confusion is mine. It seems to me that
people who have used this term often use it in a sort of ‘perspectival realism’
way, i.e., as representing some partial reality that is not entirely a
construction. I did not understand it as ‘does not</span><i style="font-size: 12pt;">’</i><span style="font-size: 12pt;"> correspond to, as
you have said, but as ‘needn’t correspond’, thus leaving some room, at least,
for a degree of objective reality. If you are saying that a pragmatic kind
literally means that such things “don’t correspond to anything “out there,””</span><i style="font-size: 12pt;">
</i><span style="font-size: 12pt;">then I cannot but conclude that we are entirely in agreement: ‘mental
disorders’ are essentially the artifice of psychiatry. However, Kendler and
Pies clearly believe that psychiatry is about physical/brain abnormalities,
only ones that we cannot (yet) determine. So, there seems to be a disconnect.</span></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-size: 12pt;"><span style="color: #444444; font-family: inherit;">From
what you personally are saying, however, it follows that the edifice of
psychiatry is based entirely on (inter)subjective constructions. It should also
then follow that we are all entirely welcome to reject the notion of ‘mental
disorders,’ and also therefore psychiatry as a medical discipline. More to the
point, if this is so, when are mandatory inpatients going to be notified that
they didn’t lack ‘insight’ after all — perhaps even had a more sophisticated
appreciation of the problem than did their psychiatrists — and informed that
they are free to go? If ‘mental disorders’ do not correspond to anything in the
world, then it would seem impossible to justify the powers that psychiatry has.
It seems that this literal version of the practical kind analysis serves, as
such, to exactly undermine the taken-for-granted power structures that
psychiatry rests on. If this is the result, then I am also in agreement.</span></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-size: 12pt;"><span style="color: #444444; font-family: inherit;">The
confusion arises because no such radical conclusions are drawn by any of the
practical kind theorists, at least to my knowledge. The analyses are put
forward as theoretical justifications for psychiatry as currently practiced,
which the literal form of pragmatic kinds do not support. Given that it appears
as if they do not follow the consequences of their arguments, it feels very
relevant to address what they are doing with their arguments, rather than what
they may or may not be technically saying.</span></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><i><span style="font-size: 12pt;"><span style="color: #444444; font-family: inherit;">“Practical
kinds analysis is not there to settle the question of whether “the phenomena
are in fact ‘mental disorders’ in the first place”. Questions such as “is this
really a mental disorder?” reveal a certain misunderstanding of the practical
kinds analysis, because if by “really” we mean corresponding to some “natural
entity” then the answer is no. What the practical kinds analysis reveals is
that there is a coherent, pragmatic way of thinking about the category of
mental disorder, not that this way of thinking is “really” true, or that is the
only correct way of thinking about a particular phenomenon.”</span></span></i></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-size: 12pt;"><span style="color: #444444; font-family: inherit;">Again,
if this is the case, psychiatry has no right to diagnose, treat or determine
the fate of anyone except those who willfully request it to do so. Psychiatry's
status, power and responsibility are predicated on it treating things “out
there,” as in the rest of medicine. If it is not doing so, then by these
standards those roles should be relinquished.</span></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><i><span style="font-size: 12pt;"><span style="color: #444444; font-family: inherit;">“I
am also surprised at the claim that if the link to “hard sciences” is removed,
then one is left with little more than conjecture and biased consensus. The
approach to psychology that Barnes advocates, exemplified by the PTMF, has no
discernible link to “hard sciences”… does that make it “little more than conjecture
and biased consensus” by his own argument?”</span></span></i></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-size: 12pt;"><span style="color: #444444; font-family: inherit;">I’m
glad that you brought this up. The terms ‘arbitrary’ and ‘subjective’ here are
relative to psychiatry’s presumption of an objective, independent reality. If
there is an objective world, then the pragmatic analysis is ‘subjective’ and if
that world is ordered logically, then such an analysis is ‘arbitrary.’ I am, as
such, characterizing it from the point of view of its own philosophical mode.</span></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-size: 12pt;"><span style="color: #444444; font-family: inherit;">In
direct contrast, the PTMF — in my understanding at least — explicitly rejects
positivism’s reach in this domain, preferring a notion of truth and reality as
the product of shared meaning-making and co-constructed narrative. These terms
lose their meaning in this context, as from this perspective it is both true
that everything is subjective and arbitrary and also nothing is simply
subjective or arbitrary (this is very different from saying that there cannot
be empirical research – quantitative and qualitative — that validates the
PTMF). This indeterminacy is central, in other words. Indeed, it is the focus.
It is psychiatry that has pretentions to an ‘objective science’ and therefore
psychiatry that is falling foul of its own claims. The very fact of psychiatry
having ended up in a subjective and arbitrary place by its own admission, in
fact, should be evidence and good cause for dropping its pretentions to a
positivistic science. Instead, it might do well to embrace a conceptual
position such as the PTMF that centralizes the inherently qualitative nature of
the phenomena.</span></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-size: 12pt;"><span style="color: #444444; font-family: inherit;">In
conclusion, what you say seems largely very valid to me. The result, however,
is that we are left with a psychiatry that seems to bear little resemblance to
how the vast majority of psychiatrists currently practice and understand their
practice, including, so far as I can see, the authors I cited in my blog and
yourself. You said at the beginning of your blog that it was not a refutation
(of my blog), but I think what you have said does result in a refutation, only
a refutation of the current practice and status of psychiatry. The common
ground we can find, then, is that psychiatry needs to radically change. This,
for me, would involve a drastic shift away from medicine with all the invokes
and towards something that is centered on human and social concerns. I’m for
that version of psychiatry, though I am not sure it would be similar enough to
current the current version to preserve the name!</span></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-size: 12pt;"><span style="color: #444444; font-family: inherit;"> </span></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-size: 12pt;"><span style="color: #444444; font-family: inherit;"><i>[</i><b style="font-style: italic;">Awais
Aftab</b><i>: I am grateful to James Barnes for engaging with my post and for the
continued dialogue. You can read my response <a href="https://awaisaftab.blogspot.com/2020/11/the-users-and-abusers-of-psychiatric.html" target="_blank">here</a>.]</i></span><span face="Arial, sans-serif" style="color: black; font-style: italic;"><o:p></o:p></span></span></p>Awais Aftabhttp://www.blogger.com/profile/04718828055532728613noreply@blogger.comtag:blogger.com,1999:blog-8980517681041523849.post-29296359370629987382020-10-28T13:48:00.007-04:002020-11-12T13:11:19.086-05:00Psychiatry and its Critics<p><span style="color: #222222; font-family: inherit;"><span style="background-color: white;">This blogpost is in response to a
blogpost by James Barnes on </span><i style="background-color: white;">Mad in the UK</i><span style="background-color: white;">: </span><a href="https://www.madintheuk.com/2020/10/critics-psychiatry-stranded-jurassic-world/" style="background-color: white;">Are
critics of psychiatry stranded in a ‘Jurassic world?’</a></span></p>
<p class="MsoNormal" style="background: white; line-height: 12.65pt; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">I am not interested in framing my
response as a <i>refutation</i>. I am not interested in any claims of victory or
proclamations along the lines of “Hah! Arguments by critics of psychiatry have
been refuted!” That would be the wrong way to think about this. I think there
are many valid criticisms of psychiatry to be made, and it is important and essential
to engage with criticisms. As I explain below, any framing that frames this
discussion in terms of psychiatry vs its critics is problematic in my view. Refutations and counter-refutations are neither the best way to
advance a debate nor the best way to learn from each other. My hope, in
offering this as a response, is that we can move away from having <i>the same
arguments over and over again</i>.</span></p>
<p class="MsoNormal" style="background: white; line-height: 12.65pt; margin-bottom: 0in;"><b><span style="color: #222222; font-family: inherit;"><br /></span></b></p><p class="MsoNormal" style="background: white; line-height: 12.65pt; margin-bottom: 0in;"><b><span style="color: #222222; font-family: inherit;">1) Psychiatry and the Critics of
Psychiatry</span></b></p>
<p class="MsoNormal" style="background: white; line-height: 12.65pt; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">First thing I want to note is the
framing of debate, the way the title sets up the opposing parties as being
"psychiatry" vs "critics of psychiatry". Thinking in terms
of such a polarity actually sets us up for failure from the very beginning.
This is because there are many different traditions of criticism, and many
different traditions within psychiatry, and the two overlap. In fact, depending
on the context, the same individual can be a defender of psychiatry or a critic
of psychiatry. A prominent example would be Allen Frances. I also see myself as
occupying a dual role in this regard, sometimes a critic, sometimes a defender,
depending on the issue at hand.</span></p>
<p class="MsoNormal" style="background: white; line-height: 12.65pt; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">So it is important to have some
conception of what is the object of one's criticism. Is it "biomedical
psychiatry"? Is it the down-and-dirty reality of how psychiatry is
currently being practiced in clinics and hospitals? Is it psychiatry how it
exists in academia and in professional guidelines? Is it about psychiatry as it
currently exists, as it has existed in the past, or is it also about any shape
and form that psychiatry can take in the future? Is it just
"psychiatry" or is it broadly the psy-professions? Is it the societal
understanding of psychiatric conditions? Some of these? All of these?</span></p>
<p class="MsoNormal" style="background: white; line-height: 12.65pt; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">These are not simply rhetorical
question. What we are criticizing is intimately connected to what we hope to
accomplish, the sort of change we want to see in the world.</span></p>
<p class="MsoNormal" style="background: white; line-height: 12.65pt; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">For instance, I criticize the many deficiencies
I see in contemporary psychiatric practices and the conceptual limitations of
existing ways of thinking, but this is because I have a different conception of
what psychiatry could be and should be. If I criticize reductionism in
psychiatry, it is because I can envision a psychiatry which is not
reductionist. I defend the ability of psychiatry to grow, to change, to learn
from its critics. I defend psychiatry's existence because I believe psychiatry
will continue to be relevant and continue to be essential, regardless of who
emerges as the “winner” in inter-professional politics and who enjoys greater
power and authority.</span></p>
<p class="MsoNormal" style="background: white; line-height: 12.65pt; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">That is a very different
relationship to psychiatric criticism compared to a hypothetical critic who
believes that "psychiatry" should effectively be abolished, that the
profession should no longer exist, that psychiatry is condemned to always be
reductionist, that psychiatry is condemned to always be biomedical, that it
will never be something other than what it is now.</span></p>
<p class="MsoNormal" style="background: white; line-height: 12.65pt; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">I am not saying there are actual
psychiatric critics who endorse this position; I wouldn't be surprised if
someone somewhere does, but I don't think this is a common position. I'm not using
this to attack a strawman. I am using this to illustrate the spectrum of
relationships one can have as a critic to psychiatry.</span></p>
<p class="MsoNormal" style="background: white; line-height: 12.65pt; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">This does, however, raise an
interesting point. I don’t quite know what James Barnes and his associates seek
from their critique of “biomedical” psychiatry. Do they wish to reform
psychiatry so that it is no longer “biomedical” but is something else,
something better? Do they seek better integration of multidisciplinary
perspectives? Are they okay with psychiatry “existing” as a profession but they
would rather see it deprived of its authority in the power hierarchy of psy-
professions? Or do they think that “psychiatry” is beyond hope? Is this a
project for reform or abolition? I think it would be helpful to know.</span></p>
<p class="MsoNormal" style="background: white; line-height: 12.65pt; margin-bottom: 0in;"><b><span style="color: #222222; font-family: inherit;"><br /></span></b></p><p class="MsoNormal" style="background: white; line-height: 12.65pt; margin-bottom: 0in;"><b><span style="color: #222222; font-family: inherit;">2) The Critical, Eliminative View
of Mental Disorder</span></b></p>
<p class="MsoNormal" style="background: white; line-height: 12.65pt; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">This also brings a related issue of
the critical, eliminative view of “mental disorder”. The view that “mental
disorder” doesn’t <i>exist</i>, that the very idea is incoherent and a
category error, that when it comes to the “meaningful, purposeful experience in
the world”, there can be no such thing as a “disorder”.</span></p>
<p class="MsoNormal" style="background: white; line-height: 12.65pt; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">There are obviously many different
ways of understanding “disorder” as well as more specifically “mental
disorder”. The critical position often begins with a certain view of disorder
as being an inextricably physical phenomena, and if the argument was that
“disorder”,<i> when understood in a certain way</i>, is incoherent, a
category error, doesn’t exist, etc. then there wouldn’t be much of a problem.
But the argument seems to assume the attitude that <i>all </i>philosophical
and conceptual notions of “disorder” are problematic and flawed, and that <i>all </i>of
them suffer from fatal errors when applied to the realm of the experiential. I
don’t know for sure if that is really the position that is being advanced, but
that is certainly the impression one gets at times. This latter attitude also
sets itself up for opposing <i>any and all </i>philosophical notions of “mental
disorder”.</span></p>
<p class="MsoNormal" style="background: white; line-height: 12.65pt; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">It would be one thing to
confidently oppose a “biomedical” understanding of “mental disorder” or to
oppose the popular societal understanding of mental disorders (say, in terms of
simple biological dysfunctions)… but to oppose the notion of “mental disorder”
in all its possible philosophical meanings is a very different undertaking.</span></p>
<p class="MsoNormal" style="background: white; line-height: 12.65pt; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">My stance is that there are views
of “mental disorder” that are highly problematic, and that many problematic
views of “mental disorder” are actually quite prevalent in our societies and in
psy-professions, and that it is our ethical and intellectual responsibility to
challenge such problematic views. But I also think that there are views of
“mental disorder” that are less problematic, that are more philosophically
robust, which cannot be easily dismissed. I also think that we are not wedded
to the category of “mental disorder” for eternity. I think the notion of
“mental disorder” will continue to evolve and change, just as the notions of
“madness” evolved into present day notions of “mental disorder”. I think each
specific notion of mental disorder has to be evaluated on its own merits.</span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><b><span style="color: #222222; font-family: inherit;"><br /></span></b></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><b><span style="color: #222222; font-family: inherit;">3) Biopsychosocial Psychiatry</span></b></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">In Barnes’s discussion of biomedical vs biopsychosocial psychiatry, the
charges against psychiatry seem to be:</span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">i) The practice of psychiatry remains biomedical in reality even though
it purports to be biopsychosocial.</span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">ii) The biopsychosocial model doesn't prevent biomedical reductionism</span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;"><br /></span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">Here's the more complex reality, the way I see it</span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">i) Psychiatry has and continues to aspire to be biopsychosocial in its
approach. This is fundamentally a pluralistic and integrative aspiration. This
is an <i>admirable</i> aspiration. At the very least this reflects psychiatry’s
ideological vision of what it wants to be, even if that is not what it is right
now.</span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">ii) The biopsychosocial approach is already reflective in many existing
practices of psychiatry. At the very minimum, I see little antagonism among my
psychiatric colleagues towards other non-biological treatments. Most psychiatrists
I know have a positive view of psychotherapy and social interventions. Most
psychiatrists I know want better access to psychotherapy and social
interventions for their patients. There is no mainstream hostility towards
psychotherapy or social interventions. As an illustrative example, the new
guidelines for the treatment of schizophrenia by American Psychiatric
Association explicitly recommend cognitive-behavioral therapy for psychosis,
psychoeducation and supported employment services, as well as coordinated
specialty care program for patients experiencing a first episode of psychosis.
If psychiatry as a profession were committed to a biomedical approach, it
certainly could be doing a much better job at it.</span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">iii) There are many practices of psychiatry that either fall short of
biopsychosocial aspiration or still reflect the on-going presence of biomedical
mindset and norms. I see no reason to deny that. This is in fact quite commonly
acknowledged by many within the professions. And why the practice of psychiatry
falls short of biopsychosocial is a complex question, involving many larger
system issues and limitations imposed by healthcare social structures. What I
find problematic is a common assumption that psychiatry falls short of
biopsychosocial approach because the biopsychosocial approach is really just
lip service while psychiatry as a profession remains committed to biomedical
model. I am not sure if Barnes believes this or alleges this, but that's the
charge which a lot of psychiatrists are trying to defend against. Psychiatrists
like myself don't deny the failings of the system or the failure of psychiatry
to live up to aspirations, but what we deny is a cynical interpretation of why
this is so. To acknowledge that there are unmet aspirations, as I do, means
that we can work towards them, get better, and we can work towards a realistic
assessment of the complex reasons for why this has proven so difficult. To
believe that these aspirations are simply convenient fabrications designed to
fend off critics is a very different thing.</span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">iv) The biopsychosocial model doesn't necessarily prevent biomedical
reductionism. I agree with that. In fact I made a very similar point in my
exchange with <a href="https://www.psychiatrictimes.com/view/sense-making-enactive-turn-psychiatry-sanneke-de-haan-phd">Sanneke
de Haan</a>. I have also been vocal about my <a href="https://www.psychiatrictimes.com/view/nine-lives-biopsychosocial-framework">dissatisfactions
with biopsychosocial model</a> as philosophical theory and I have advocated for
the need for better and more robust pluralistic approaches. Recognizing that
biopsychosocial model doesn't necessarily prevent biomedical reductionism also doesn't
imply that all biopsychosocial approaches in psychiatry are de facto
reductionist. The integration problem in philosophy of psychiatry is complex.
Lack of a satisfactory philosophical account of how this integration happens
doesn't indicate that there is a lack of commitment to the integrative
aspiration itself. Focusing only on biopsychosocial model also misses the point
that there are other pluralistic models being proposed and discussed, which
needs to be taken into account if one aims to be fair towards the ideological
commitments of psychiatry.</span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">v) Biopsychosocial thinking also enjoys support from the critical
community. A prominent example would be the psychiatrist Duncan Double of the
UK Critical Psychiatry Network, who has expressed his ideological support for
Engel's biopsychosocial model numerous times, and sees the critical psychiatry
position to be broadly consistent with that aspiration. Such overlaps suggest
the need for more nuanced dialogue and also again illustrates why talking about
"critics of psychiatry" as a monolith is simplistic and misleading.</span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">vi) The fact that many psychiatrists don't practice psychotherapy or
psychosocial interventions themselves by itself doesn't suggest a commitment
towards biomedical reductionism. This is akin to saying that internal medicine
physicians are anti-surgery or don't really believe in the value of surgery
because they don't do surgery themselves. First of all, many psychiatrists I
know actually do practice psychotherapy (including some who are trained
psychoanalysts), even though they are in minority. Secondly, even psychiatrists
who restrict their role to evaluations and psychopharmacological management can
nonetheless be biopsychosocial in their approach by working as part of
interdisciplinary teams, by referring patients to their psychology and social
work colleagues, and by recommending psychosocial interventions to their
patients.</span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><o:p><span style="color: #222222; font-family: inherit;"> </span></o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><b><span style="color: #222222; font-family: inherit;">4) Biomarkers and Mental Disorders<o:p></o:p></span></b></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">The charges against psychiatry here seem to be:</span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">i) The failure to find biomarkers leads to the inevitable conclusion that
the experiences in question are not legitimate medical disorders/diseases.</span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">ii) Phenomena under psychiatry fundamentally pertain to meaningful,
purposeful experience in the world, inextricably bound up with the world. The
disorders of general medicine, by contrast, are almost exclusively focused on
the functioning of the body, with only incidental or secondary allusion to the
person’s relationship with the world. Therefore, pathologizing the individual
in terms of their brain/body is wholly inappropriate in the case of
emotional/psychological distress</span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><o:p><span style="color: #222222; font-family: inherit;"> </span></o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">Here’s how I see this. <o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">i) The notion that biomarkers are essential for “legitimate” medical
disorders is simply one way to think about what constitutes a disorder. Critics
such as Barnes and associates seem to argue that because all <i>physical</i>
disorders have some identifiable <i>physical </i>component, therefore it
demonstrates that <i>all </i>disorders must have some identifiable physical component,
in the absence of which the condition cannot be considered to be a disorder.
But that is simply begging the question. If we have already restricted the
starting point of our analysis to <i>physical </i>disorders, it will be no
surprise that we conclude that <i>physical</i> markers are necessary. I would
like to see a philosophical analysis of the notion of “disorder” that doesn’t
start with the assumption that disorders are <i>physical</i>. Why should
disorders be physical? What is it about the notion of “disorder” that makes it
so? In fact, aside from insisting that real disorders have biomarkers, we have
not seen a proposed definition of what a disorder is.</span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">ii) There are many other ways to think about what constitutes a “legitimate”
medical condition, in particular ways that focus on the <i>methods</i> of the medical
approach when applied to a condition and not on the <i>nature</i> of the
condition. This is in fact a complex question in philosophy of medicine, and
the fact that Barnes and associates have decided that they are in possession of
a settled answer to this philosophical question is rather odd in my view.</span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">My own take on the issue is a broadly pragmatic one. I have written about
this a bit <a href="https://awaisaftab.blogspot.com/2020/05/medical-disorders-from-definition-to.html">on
my blog earlier</a>.</span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">iii) The idea that “meaningful, purposeful experiences” cannot be disordered
relies on a very narrow definition of disorder. I don’t think anyone really is
denying that phenomena under psychiatry fundamentally pertain to meaningful,
purposeful experience in the world. I mean, that’s pretty much a given. The
whole phenomenological tradition in psychiatry exists for that reason. The
question is how to best understand these distressing, impairing, problematic experiences.</span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">iv) The idea that by calling an emotional/experiential/psychological
condition as a “disorder”, we are “pathologizing the individual in terms of
their brain/body” is incorrect. I do not deny that such an attitude has been
expressed commonly, especially by those prone to biological reductionism, but
that does by no means exhaust the variety of attitudes that psychiatrists have
taken on this matter. For instance, according to the DSM definition of mental
disorder, a mental disorder can simply reflect a “psychological dysfunction”.
The presence of a “biological dysfunction” is not necessary, and there is no requirement
by the DSM that “dysfunction” be understood solely in biological terms. So even
by the “official” definition, the integral link between “disorder” and “brain
pathology” is disputed.</span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">v) The idea that “disorder” is intrinsically a medical concept is
incorrect. Peter Zachar, for instance, is a psychologist (not a medical
physician), and when he defends a particular view of “disorder”, he is not defining
a notion that he sees as intrinsically medical. Same with Derek Bolton, a psychologist
and another prominent commentator in philosophy of psychiatry. I also briefly
touched on this in my interview with <a href="https://www.psychiatrictimes.com/view/three-approach-psychopathology-kristopher-nielsen-phd">Kristopher
Nielsen</a>, who argues for a notion of “disorder” but does not see it as inherently
“medical”.</span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">vi) Barnes and associates also seem to ignore the tradition of “operationalism”
in psychiatry and psychology, which seeks to delineate operational entities for
the purposes of scientific study without making unnecessary assumptions about
the nature of the entities under question.</span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">vii) Just because phenomena fundamentally pertain to meaningful,
purposeful experience in the world does not mean that the biological processes
involved in the phenomena (and Barnes and associates are keen to admit that obviously
all experiences are accompanied by biological changes, because the mind is <i>embodied</i>
after all) cannot be identified or cannot be intervened on to make a
difference. This remains the case even if the biological phenomena under
question have no pathological changes. The fact that meaningful experiences in
the world are<i> embodied</i> means that there is in principle an opportunity
to exert some sort of modulating influence on those meaningful experiences by
intervening on the biological phenomena, the limits of which are to be
determined <i>empirically</i>. If an individual is experiencing severe anxiety,
this anxiety can be lessened in the short term if the individual, say, drinks
some alcohol, or smokes some marijuana, or takes a sedative medication. This
will be so regardless of whether the severe anxiety is a “disorder” or not, and
regardless of whether the severe anxiety is a “meaningful, purposeful
experience” or not. The point is that meaningful, purposeful experiences can nonetheless
be influenced through biological means, and the question is not whether we can
do so, but whether it is a good thing to do so, and how to balance the risks
and benefits of such an intervention. Meaningful, purposeful experiences do not
preclude the possibility that biological interventions can be beneficial or
helpful.</span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><o:p><span style="color: #222222; font-family: inherit;"> </span></o:p></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><b><span style="color: #222222; font-family: inherit;">5) Disorder as Practical Kind<o:p></o:p></span></b></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">i) I think Barnes misunderstands the application of Zachar’s practical
kinds analysis to mental disorders.</span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">Barnes writes: “As an illustration, Zachar (2000) writes, ‘Chairs are not
natural kinds [and] there are many reasons for refusing to believe that
syndromes, diseases, species, and personality traits are natural kinds as
well.’ This is a flawed analogy, as there is no doubt that there is a chair
over there that we are trying to define, however problematic that may be — the
fact of its existence as a chair is not doubted. We do not infer the existence
of a chair; its existence is demonstrably, empirically there. This is unlike ‘a
mental disorder.’”</span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">What is being discussed is the abstract category of “chair”… what is
demonstrably, empirically there is some kind of an object; the materiality of
the object is not under the question. What is under question is the characterization
of that object as a “chair”. Is the object a chair in some <i>real, fundamental
way</i>? This is a similar situation to
the psychological distress/impairment, where what is under the question is not
the existence of the psychological distress/impairment, but its
characterization as a “mental disorder”.</span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">The practical kinds analysis reveals the nature of the concept of “mental
disorder” but it doesn’t tell us if we should adopt the “mental disorder” concept
in the first place. That is, it is not inevitable that the concept be applied to
what we currently apply it to. (Just as the practical kinds analysis of “chair”
doesn’t tell us whether we should use the concept of “chair” or not… it
just tells us that if we do use the concept, it would be a practical kind.)</span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">Barnes writes: “the critical argument disputes the very reality of their
being a ‘kind’ called ‘mental disorder’ in the first place, over and above the
phenomena described.”</span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">This is a really confused argument… what does it mean to say that a “practical
kind” category isn't real? Practical kind categories <i>by definition</i> don’t
correspond to anything “out there” in the structure of the world. That is
precisely why they are practical kinds and not natural kinds.</span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">Perhaps what Barnes wants to say is that there is nothing forcing or
obliging critics such as him to talk about things in terms of the category of “mental
disorder”. That would be, I believe, correct. The category of “mental disorder”
is simply one of the many <i>practical</i> ways we can make sense of these phenomena.
However, what is problematic is treating the category of mental disorder as a
natural kind and dismissing it based on such criticisms, without grappling with
or without acknowledging that criticisms that apply to natural kinds don’t
necessarily apply to practical kinds.</span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">Practical kinds analysis is not there to settle the question of whether “the
phenomena are in fact ‘mental disorders’ in the first place”. Questions such as
“is this <i>really</i> a mental disorder?” reveal a certain misunderstanding of
the practical kinds analysis, because if by “<i>really</i>” we mean
corresponding to some “natural entity” then the answer is no. What the
practical kinds analysis reveals is that there is a coherent, pragmatic way of
thinking about the category of mental disorder, not that this way of thinking
is “really” true, or that is the only correct way of thinking about a
particular phenomenon.</span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">ii) Barnes writes that the practical kinds analysis untethers the concept
of mental disorder from its ties to biomedical disease processes, and relieves
it of its connection to an objective, hard science, and also of the authority
it claims in virtue of this link.</span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">This also shows a profound misunderstanding. Acknowledging that the category
of mental disorders is an abstract practical category doesn’t say anything
about the involvement of biological processes in individual conditions we call
mental disorders. The extent of the involvement of biological processes in any
particular condition we call mental disorder is an empirical matter; it doesn’t
spring automatically from the definition of mental disorder. Therefore, objective
science continues to have a role in the empirical investigation of the specific
phenomena classified as mental disorders, although it may not have any
necessary role when thinking about the abstract category of mental disorders.</span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">I also dispute that psychiatry claims its authority based on ties to
biomedical disease processes. Psychiatry claims its authority based on the
application of the medical model to psychiatric conditions. That is an
important difference.</span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">I am also surprised at the claim that if the link to “hard sciences” is removed,
then one is left with little more than conjecture and biased consensus. The approach
to psychology that Barnes advocates, exemplified by the PTMF, has no
discernible link to “hard sciences”… does that make it “little more than
conjecture and biased consensus” by his own argument?</span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">iii) Barnes points out: “Under this kind of definition, there is no
‘natural limit’ to what is and isn’t a disease/disorder, which Zachar himself
calls ‘a cause for concern.’” But the answer to this concern cannot be that we
just make up a “natural limit” if one doesn’t exist! That there is no “natural
limit” doesn’t mean we cannot have “practical limits” based on scientific, ethical,
and pragmatic considerations. An account of such considerations is beyond the
current discussion, but it would be a mistake to simply dismiss that such limitations
do not exist or do not have a meaningful role to play.</span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;">iv) Acknowledging that the notion of mental disorder cannot be fully
naturalized and that it remains inevitably practical and value-laden is not a
fault, it is not a shortcoming; it is a strength. It permits robust philosophical
and ethical discussions of how understandings of violations of psychological
norms and experiences of psychological distress/impairment are influenced by
social and cultural context, etc. Recognizing this is a sign of philosophical
maturity on part of the field, not a regression to something “subjective and
arbitrary”.</span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><span style="color: #222222; font-family: inherit;"><o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><o:p><span style="color: #222222; font-family: inherit;"><br /></span></o:p></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><o:p><span style="color: #222222; font-family: inherit;">[P.S. This exchange has continued in the following blog posts:</span></o:p></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><o:p><span style="color: #222222; font-family: inherit;">James Barnes: <a href="https://awaisaftab.blogspot.com/2020/11/critics-and-their-psychiatry.html" target="_blank">Critics and Their Psychiatry</a></span></o:p></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><o:p><span style="color: #222222; font-family: inherit;">Awais Aftab: <a href="https://awaisaftab.blogspot.com/2020/11/the-users-and-abusers-of-psychiatric.html" target="_blank">The Users and Abusers of Psychiatric Criticism</a>]</span></o:p></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in;"><o:p><span style="color: #222222; font-family: inherit;"><br /></span></o:p></p>Awais Aftabhttp://www.blogger.com/profile/04718828055532728613noreply@blogger.comtag:blogger.com,1999:blog-8980517681041523849.post-32697460066610899172020-08-27T11:45:00.000-04:002020-08-27T11:45:45.637-04:00The VICE story: Beyond Anti-psychiatry<p><span style="font-family: inherit;">VICE News published the article '<a href="https://www.vice.com/en_us/article/qj4mmb/the-movement-against-psychiatry">The Movement Against Psychiatry</a>' yesterday by Shayla Love.
The article examines the anti-psychiatry and critical psychiatry movements, and
also features several quotes from me. My communication with Shayla Love was
more than just the featured quotes, and it has become apparent to me after
conversations with several friends that I should offer more context and
background. So, this blogpost is an attempt to do that.</span></p>
<p class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;"><span style="font-family: inherit;">I occupy a
somewhat uncomfortable position on the critical spectrum. I do not identify as
a "critical psychiatrist" because I do not think "critical"
serves well as an identity function. The word also means different things in
different contexts, and has different nuances and connotations, ranging from fertile
and philosophically robust critiques to serving as a euphemism for views that
embody anything but critical virtues. I am wary of extreme criticisms of
psychiatry – of which there is no shortage – that rely on mischaracterizations,
vitriol, and propaganda, and seek to delegitimize psychiatry as a medical
specialty. Such views are typically characterized as
"anti-psychiatry" but that is an imperfect term, because the term is at
times applied rather liberally, the "classic" figures considered to
be anti-psychiatrists rejected the label, and very few these days self-identify
their views as being anti-psychiatry. As imperfect as the term is, there
doesn't seem to be a more suitable alternative for extreme views that rely on
dangerous disinformation. But denouncing such antipsychiatry views does not
detract from the many meaningful critiques of psychiatry and contemporary
practices that serve an important role; one can still recognize the tremendous
need for reform, and acknowledge the valid ways in which an exclusive emphasis
on medical conceptualization can be harmful. This is a delicate and qualified
position and navigating a dialogue from such a position is subject to the
constant pressure for the dialogue to collapse into one polar position or another.
I do not always succeed in that, but I try. That has precisely been the
function of my interview series for <i>Psychiatric Times</i>, "<a href="https://awaisaftab.blogspot.com/2019/12/conversations-in-critical-psychiatry.html">Conversations in Critical Psychiatry</a>", where I try to engage with various critical and
philosophical perspectives. This doesn’t mean that I am presenting myself as
neutral; I am not neutral. I have opinions which form the reference
points for my discussions. It’s just that these opinions don’t fit into the
usual </span>Procrustean<span style="font-family: inherit;"> traps.</span></p>
<p class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;"><span style="font-family: inherit;">Now, it so
happens that most of my featured quotes in the VICA article are related to
criticisms of "anti-psychiatry" views. As is the way with many news
stories, comments are quoted by journalists based on a judgment of where they best
fit in the story. It is important to note that my comments were made in the above-mentioned
context which recognizes that framing the issue as psychiatry vs
anti-psychiatry is not always the most helpful frame for critical discourse and
acknowledges the need to resist sterile polarization.</span></p>
<p class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;"><span style="font-family: inherit;">So, when I
say, "The vast majority of psychiatric critics have no realistic idea of
what it means to provide medical care to someone who is actively
psychotic...", my intended referent was the "anti-psychiatry"
critics – not critics per se – because I was talking about the sorts of critics
who view schizophrenia merely as a problem in living requiring no medical
interventions. My discomfort with polarization is also reflected in my
complicated relationship with Mad in America, which certainly earns me little
favor among many colleagues. It is conveyed in the article correctly that I do
not dismiss Mad in America entirely and that I think it does serve as a platform
for certain essential perspectives (full disclosure: I have been interviewed by Mad in America in the past, but otherwise have no organizational links with them). Because Mad in America has emerged as the
major platform in the US for critical and dissatisfied voices, it demonstrates the full
yin-yang messy complexity of the bad mixed in with the good and the good mixed
in with the bad. Some felt that my comments were targeted specifically at MIA’s
research news team, but that is not correct. When I said things like I “shake my
head with disappointment”, it is with regards to blogs and articles such as
<a href="https://www.madinamerica.com/2020/03/dangerous-thing-psychiatrist/">this one</a>.</span></p>
<p class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;"><span style="font-family: inherit;">That is the
background for my quotes which appear in the VICE story. And I believe
that is in spirit with the conclusions of the article itself, in which Shayla
Love recognizes the need to resist a polarizing discourse. She writes,
"It's nearly as useless to be steadfastly pro-psychiatry as it is to be
anti-psychiatry. Psychiatry is not a monolith..." and "the Cartesian
desire to separate mind from body, soul from biology, trauma from medical
symptom—may not prove to be useful to those who need help now". Our
ultimate obligation is to those who need our help and focusing on that is
perhaps our best way forward. One can recognize the need for meaningful
criticisms and structural reform without delegitimizing the medical basis of
psychiatry.</span></p><p class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;"><span style="font-family: inherit;"><br /></span></p>Awais Aftabhttp://www.blogger.com/profile/04718828055532728613noreply@blogger.comtag:blogger.com,1999:blog-8980517681041523849.post-16037701326185480862020-07-23T15:10:00.000-04:002020-07-23T15:10:42.017-04:00Virtue Ethics and Professional Success<div dir="ltr" style="text-align: left;" trbidi="on">
Some reflections in a piece for <a href="https://closler.org/lifelong-learning-in-clinical-excellence/virtue-ethics">CLOSLER</a> on looking at success in academic medicine through the lens of virtue ethics.<br />
<br /></div>
Awais Aftabhttp://www.blogger.com/profile/04718828055532728613noreply@blogger.comtag:blogger.com,1999:blog-8980517681041523849.post-26628563876817978662020-07-12T08:48:00.001-04:002020-11-14T12:30:06.204-05:00Primum non Nocere: A Psychiatrist’s Review of “Medicating Normal”<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify;">
I was lucky
to see a screening copy of the documentary <i>Medicating Normal</i> (2020, directors:
Lynn Cunningham & Wendy Ractliffe) earlier this weekend, and this post is
intended partly as a review and partly as a way of organizing my preliminary
thoughts and reactions to it.<o:p></o:p></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify;">
As described
by the <a href="https://medicatingnormal.com/">filmmakers</a>: “<i>Medicating
Normal</i> is the untold story of what can happen when profit-driven medicine
intersects with human beings in distress.” The film is well-made and
remarkable. It is engaging and rewards emotional investment.<o:p></o:p></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify;">
The focus of
the documentary is on the harms of psychiatric medications, the harms these
medications can do while one is taking them, and the harms these medications
can do when one tries to stop taking them or has stopped taking them. The
documentary primarily focuses on the stories and experiences of five
individuals who took psychiatric medications and experienced derailment of
their lives. There are also interviews with various
authors/commentators/experts (which include Allen Francis, David Cohen, Anna
Lembke, Robert Whitaker, Peter Gøtzsche, among others). In terms of
medications, the focus is mostly on benzodiazepines and stimulants, to a lesser
extent on antidepressants, and very little on antipsychotics and other
psychotropics. The documentary doesn’t make much of a differentiation between
these different medication groups in terms of their harms and risk of
dependence and withdrawal, and generally paints them with the same brush.<o:p></o:p></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify;">
The personal
narratives of the ex-patients/survivors are certainly the most powerful
component of the film. They are also the most persuasive: the tremendous
suffering of these individuals is indisputable and heart-wrenching. Common
threads among these various stories are: high “premorbid” psychosocial and
occupational functioning; experiences of anxiety/trauma/grief/stress/insomnia
which were diagnosed by various clinicians as specific mental disorders
(PTSD/GAD/MDD, etc.) with little to no exploration of the psychosocial context;
these diagnoses were offered with a generally implicit disease-based
understanding; psychotropic medications were prescribed, with little to no
informed consent, and the potential harms of these medications were either not
discussed or discussed in a manner that severely minimized them; there was
typically quick short-term relief, followed by onset of side-effects and
problematic experiences (emotional blunting, cognitive impairment, suicidality,
psychosis, worsening anxiety, etc.); these new experiences were attributed to
the progression of their disease with little to no consideration that these
might be due to the medications; this led to a cascade of multiple additional
diagnoses (ADHD, MDD, psychotic illness) with compounding polypharmacy such
that many of these individuals were on psychotropic cocktails which included
benzodiazepines, stimulants, antidepressants, and antipsychotics; this was
followed by a rapid decline in psychosocial and occupational functioning
leading to a disabled status; years of misery and disability in which their
disability continued to be attributed to their illness and not to their
medications; slow loss of trust in the system; decision to go off medications;
experiences of withdrawal; finally coming off medications and slow restoration
of psychosocial and occupational functioning.<o:p></o:p></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify;">
Supplementary
to these terrible experiences with psychotropic medications is another
background narrative that pops us repeatedly. That narrative challenges the
validity of psychiatric diagnoses – and the attribution of disorder/disease
status to the experiences of these individuals – which provided the
justification for the use of medications, with the subsequent iatrogenic
cascade. The sentiment is that: “We were experiencing stress, trauma, grief,
life issues. What we needed was reassurance, normalization, empathy, time, and
psychological support for healing. Instead we were offered quick diagnostic
labels, told we had a disease, and prescribed medications with no informed
consent, which made everything exponentially worse, and destroyed our lives.”<o:p></o:p></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify;">
This
narrative is sometimes accompanied by criticism of the DSM, in which the DSM is
described as having no scientific basis, in which the diagnoses are “all made
up” by committee votes and have no basis in reality. There is some discussion
of our culture in which we have become intolerant of any sort of distress and
suffering and see it as a medical problem. There is also much discussion of the
evils of pharmaceutical companies, their nefarious tactics, and their
corruption of science as an instrument of profit. <o:p></o:p></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify;">
On twitter
I’ve recently been talking about the relationship of <i>text</i> and <i>subtext</i>.
Arguments and evidence exist in a certain ideological and structural context.
If we look only at the subtext, we risk losing the tether between our worldview
and reality. If we look only at the arguments, we risk ignoring the ways in
which arguments are tools to be wielded as means to an end.<o:p></o:p></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify;">
The way this
documentary is received by psychiatrists will depend heavily on the subtext as
well as some aspects of the text. The body of works and opinions of individuals
such as Robert Whitaker and Peter Gøtzsche with their long history of
controversy shapes that context; the active adoption and endorsement of this
documentary by various groups and platforms long felt to be unfairly critical
of psychiatry also shapes that context. Aspects of the narrative – which rather
simplistically see psychiatric diagnoses as unscientific – will also provoke
certain typical reactions. There are many legitimate criticisms to be made
along those lines. There is also the case that the clinical practice and
prescribing patterns that we get to see in the documentary fall <i>well below</i>
the standards of good psychiatric practice that I was taught as a resident as
well as standards that are enshrined in current practice guidelines. So many
psychiatrists can reasonably protest that what happened to the individuals in
the documentary <i>was not supposed to happen</i>. Yet it is also the case that
it did happen and that it has happened and continues to happen to a woefully
large number of individuals across the world. The question of good psychiatric
practice aside, it is the case – and I speak from my experience of psychiatric
training and from what I’ve observed in my psychiatric colleagues and teachers
across many institutions – that many psychiatrists severely underestimate considerations
of certain sorts of iatrogenic harm and withdrawal reactions.<o:p></o:p></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify;">
What we are
witnessing is a failure of pharma, a failure of regulatory agencies, a failure
of legislation, a failure of academic medicine, a failure of funding agencies,
a failure of psychiatric institutions, on such a massive scale that the
only thing left for ex-patients/survivors and other concerned citizens to do is
to take up the mantle themselves, armed with their personal experiences and the
tools and information at their disposal. They were sold a hollow understanding
of their distress, and they were offered cures which turned out to be poisons
for them, and now they are reclaiming their stories, and understanding and
interpreting them on their own terms.<o:p></o:p></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify;">
Just as the
disease-based understanding of psychiatric diagnoses is simplistic, misguided, not-the-whole-truth,
the notion that psychiatric diagnoses are “all made up” and unscientific is
also simplistic, misguided, not-the-whole-truth. Yet I say this from a position
of power and privilege; I say this with years of philosophical and scientific
reflection, which allows me to think of psychiatric diagnoses in a conceptual
manner that is different from that of the average clinician as well as the lay
individual. My ivory tower philosophical search for <i>truth</i> is far removed
from the experience of the harmed patient in the documentary, who cries out at
one point, “What have all these diagnoses ever done for me?” (I am somewhat
paraphrasing here based on my recall).<o:p></o:p></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify;">
I can
anticipate that many psychiatrists will react to this documentary in a very
defensive manner. They will bring up legitimate criticisms and will focus on
the subtext of the movie, some of which I’ve briefly touched on above. They
will focus on how this is not representative of all psychiatrists, how this is
not representative of good practice. They will also focus on how normalization
fails to do justice to the experiences of individuals with serious mental
illness who are genuinely impaired and suffering, and psychiatric medications,
for most of them, offer a realistic hope at some semblance of normalcy and
alleviation of suffering. I agree with all that. <o:p></o:p></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify;">
Yet to do so
<i>exclusively</i> will also miss the larger point of the documentary. Psychiatry
can continue to be aggrieved and defensive for good reasons, but in my view
that is a precarious strategy and may simply be a recipe for future
irrelevance. The conversation is no
longer in the hands of the psychiatrists. The conversation has moved into the
community. The pandora’s box is open. Many individuals have lost trust in the
medical system, they have lost trust in organized psychiatry, they have lost
faith in the ability of psychiatric diagnoses and medications to help them.
These individuals are taking ownership of their distress and making sense of it
in ways that speak to them with more authenticity. Organized psychiatry has a
choice to make here. It can continue to pretend that everything is hunky-dory,
and it can continue to dismiss the experiences of harmed patients as anecdotal
evidence. Or it can begin to acknowledge the reality of harmed patients, the myriad
ways in which we have ignored them and let them down, the ways in which we have
allowed the profit and greed of pharmaceutical companies to corrupt our science,
and the ways in which we as a profession are failing to offer narratives to our
patients that do not reduce their existence to disease and disability. <o:p></o:p></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify;">
<o:p><br /></o:p></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify;">
<i>Awais Aftab
is a psychiatrist in Cleveland, Ohio.<o:p></o:p></i></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify;">
See also: </div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify;">
* My
interview series for <i>Psychiatric Times</i> <a href="https://awaisaftab.blogspot.com/2019/12/conversations-in-critical-psychiatry.html">“Conversations in Critical Psychiatry”</a></div>
</div>
Awais Aftabhttp://www.blogger.com/profile/04718828055532728613noreply@blogger.comtag:blogger.com,1999:blog-8980517681041523849.post-25974053262265047432020-07-10T16:05:00.001-04:002020-07-11T16:12:35.215-04:00Sola Scriptura and the Scientific Reformation<div dir="ltr" style="text-align: left;" trbidi="on">
Recently I've been thinking about Reformation, the 16th century Christian movement in Europe led by Luther. As commonly understood, this movement "posed a religious and political challenge to the Catholic Church and in particular to papal authority, arising from what was perceived to be errors, abuses, and discrepancies by the Catholic Church" (<a href="https://en.wikipedia.org/wiki/Reformation">wikipedia</a>).<br />
<br />
Prior to Reformation, under the Catholic Church, scripture and tradition were seen as equal, and scriptural interpretation took into account former commentaries as well as Church doctrine and tradition. The Catholic Church had the authority to give authentic interpretation of the Word of God, as reflected in the notion of the Roman magisterium. The common people did not read the Bible or interpret it themselves; they relied on the Church to interpret it for them.<br />
<br />
Where others saw infallibility and divine authority, Luther saw corruption. He invoked the notion of <i>sola scriptura</i>, challenging the authority of the clergy to be the authoritative interpreters of the scripture, and proclaimed that scripture should be interpreted according to an individual's conscience, unbound by Catholic Church doctrine. The invention of the printing press made the Bible directly accessible to the educated, and facilitated the dismantling of Church's hegemony on Biblical interpretation.<br />
<br />
The reason this has been on my mind is because I am seeing some loose contemporary parallels with the public's relationship with scientific literature. Historically, much of scientific research published in peer-reviewed journals has been intended for an audience of other scientists and clinicians. Much of this research has been largely inaccessible for the general public, hidden behind a paywall or requiring academic affiliations for access. There was also little appetite for the public to read the research themselves; they were happy to let the experts do the talking or let the newspapers/media translate the message. Now, however, research is much more accessible. Thanks to venues such as Sci-Hub, almost anyone can access research articles with convenience. In addition, there are also websites that are devoted to communicating the results of new research to the public in a language that they can understand, although these websites typically have their own agendas. Suddenly, texts that were written for a technical readership of peers, are now open to scrutiny by anyone. People can look at the results of the studies themselves. More importantly, just as Luther saw Church as a corrupt institution, unworthy of having the authority of scriptural interpretation, the public is increasingly viewing scientists and researchers themselves as unreliable and untrustworthy interpreters of their own research; they are now fallible, corrupt, and conflicted by financial, institutional and intellectual conflicts of interest. This is particularly the case in areas which are subject to controversy, such as psychiatry. I see this on twitter a lot, individuals without a scientific or research background, are reading research articles, and openly challenging the validity of the results or the interpretation, and offering their own interpretation of the data. Sometimes they have the necessary intellectual skills and scientific knowledge to make sense of the study, other times they don't but this doesn't seem to hinder them from attributing more validity to their own interpretations.<br />
<br />
Maybe I am just biased given my own background and intellectual commitments, but I would like to think that there is a difference between having the authority and expertise to interpret scripture and having the authority and expertise to interpret scientific research. Academic credentials can be seen as an analogue of authority, but I don't think interpreting scientific research is a matter of authority primarily; I think it is more a matter of expertise. Interpreting research correctly and critically is <i>difficult</i>. It is a skill that needs to be learned, developed, and practiced. It also requires a certain background understanding of existing scientific literature, because research doesn't happen in a vacuum. So while I am a proponent of increased accessibility of scientific research, and while I don't think that interpretation of scientific literature should be (or can be) restricted to an exclusive group, I am concerned about the perception among many lay individuals that relevant expertise is unnecessary when it comes to interpretation of scientific research. The problem is compounded by active distrust of the medical and scientific community, sometimes resulting from negative experiences individuals have had. The distrust and charges of institutional corruption are not entirely without basis. Expertise has been abused and misused in very serious ways.<br />
<br />
Since public access to science, and public scrutiny and accountability of scientists are here to stay, increased scientific literacy in the general population is much more essential. The scientific process also needs to be more transparent, and experts need to do a much better job with regards to improving and restoring public's trust in them. These are, however, distant goals and distant remedies. I am not quite sure what can be done about it in the interim.<br />
<br />
I am sure someone somewhere has drawn such a parallel before. I haven't come across it yet, but I doubt these thoughts are particularly original. If you are aware of literature that has examined the public's relationship with science from the lens of Reformation, please feel free to send my way.<br />
<br /></div>
Awais Aftabhttp://www.blogger.com/profile/04718828055532728613noreply@blogger.comtag:blogger.com,1999:blog-8980517681041523849.post-3467010298493246132020-07-03T21:26:00.002-04:002020-07-03T21:26:42.799-04:00Bridging Critical and Conceptual Psychiatry: Interview with Mad in America<div dir="ltr" style="text-align: left;" trbidi="on">
I was interviewed by Mad in America. We talk about my intellectual development as a psychiatrist, the <a href="https://awaisaftab.blogspot.com/2019/12/conversations-in-critical-psychiatry.html">interview series for <i>Psychiatric Times</i></a>, my interest in philosophy of psychiatry, and work on “conceptual competence” in psychiatric education. You can listen to the audio as well as the transcript here: <a href="https://www.madinamerica.com/2020/07/bridging-critical-conceptual-psychiatry-interview-awais-aftab/">https://www.madinamerica.com/2020/07/bridging-critical-conceptual-psychiatry-interview-awais-aftab/</a><br />
<br /></div>
Awais Aftabhttp://www.blogger.com/profile/04718828055532728613noreply@blogger.comtag:blogger.com,1999:blog-8980517681041523849.post-11870707670664520422020-06-15T17:12:00.000-04:002020-06-15T17:12:30.454-04:00From “What is disorder?” to Heidegger & Explanatory Pluralism: A Discussion with James Barnes <div dir="ltr" style="text-align: left;" trbidi="on">
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<i>James Barnes is a psychotherapist, mental health advocate, and writer.
He lives in Exeter in the UK. He is on twitter: </i><a href="https://twitter.com/psychgeist52"><i>@psychgeist52</i></a><i> <o:p></o:p></i></div>
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<b>Discussion Background<o:p></o:p></b></div>
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This discussion started on Twitter in the context of the <a href="https://awaisaftab.blogspot.com/2020/06/an-exchange-with-ruffalo-pies-more-on.html">last
blogpost</a> in which Mark Ruffalo and Ron Pies discuss their views on
psychiatric diagnoses and on the definition of “disorder”.<o:p></o:p></div>
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James Barnes objected that a non-essentialist, pragmatic definition of
disorder misses the entire point of the term “disorder” or “disease”, which for
him is to discriminate an empirical object of/in the organism, as it does in
the vast majority of cases of unquestioned physical disorders.<o:p></o:p></div>
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I responded by saying it is possible to define disease/disorder is many
different ways, that each definition has its internal logic, and each has pros
and cons, and different implications. A common goal of most definitions is to
try to capture the everyday use of this term in general medicine, but other
definitions may not care for this goal. So, I don't find much value in trying
to argue for a specific definition since he can define it differently and may
value other goals. I stated that it will be far more fruitful and productive to
compare competing conceptualizations of disease/disorder with regards to
desired goals.<o:p></o:p></div>
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James responded to this by saying that he understands himself (and the
PTMF, for example) to be disputing the existence of such things in terms of
“disease” or “disorder”.<o:p></o:p></div>
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My response was that if he takes the stance that our psychological lives
should not be understood through the notion of disorder, then he already has an
implicit notion of disorder that he think excludes the psychological realm, and
so, it becomes important to clarify what that implicit notion is, on what
principle does it exclude the mental but not the physical, and how well does that
notion apply to rest of medicine.<o:p></o:p></div>
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James said this was fair, and at this point we moved our discussion to
email to conduct it more efficiently.<o:p></o:p></div>
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<b>Barnes:<o:p></o:p></b></div>
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The content of the issues described in physical disorders/diseases is
focused on, and primarily about, physical states of the organism. The content
of the issues described in 'mental disorders,' however, is focused on, and
primarily about, self, world and others — i.e. about meaningful,
socioculturally dependent phenomena — and in only some cases, and not
necessarily, physical states. As this type of meaningful content is not
reducible to/locatable in the organism, I reject the terms disorder or disease
for issues that have the stuff of this category for their content. I suggest
the terms are only appropriate for issues that are focused on, and primarily
about, physical states of the organism, i.e. locatable in it.<o:p></o:p></div>
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<b>Aftab:<o:p></o:p></b></div>
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Here's what I see as the problem.<br />
<br />
You haven't elaborated what a disorder is but you've articulated what it cannot
be. The argument seems to be something like this:<br />
<br />
Assumption 1: Physical disorders are about physical processes.<br />
Assumption 2: Mental problems are not about physical processes, they are about
mental processes.<br />
Assumption 3: Disorders can only involve physical processes.<br />
Therefore mental problems are not disorders.<br />
<br />
The whole argument relies on assumption #3, but that is precisely the point
that is being disputed by relevant parties. I don't accept assumption 3, for
instance. The philosophical question would be, what is it about the nature of
disorders that they can only be about physical processes?<br />
<br />
Another argument seems to be:<br />
Assumption 1: Mental processes are characterized by intentionality and
psychological meaning.<br />
Assumption 2: Physical processes and physical disorders lack intentionality and
psychological meaning<br />
Assumption 3: Disorders are incompatible with intentionality &
psychological meaning.<br />
Therefore mental processes cannot be disordered.<br />
<br />
Problems are with assumption #2 and assumption #3. I don't believe disorders
are incompatible with intentionality and meaning. Already in instances of
well-defined physical disorders and processes we can see the presence of
psychological phenomena. For example, personality changes, delusions,
hallucinations in dementia. Paranoia secondary to cocaine intoxication. Anger,
mood changes, personality changes due to brain tumors. So, assumption #3 is
clearly not valid.<o:p></o:p></div>
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<b>Barnes:<o:p></o:p></b></div>
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1. You have changed the terms here. I am saying the content of disorders
is <i>about</i> physical processes; they can and do <i>involve</i> mental
content. And, if you are saying that 'disorder' applies to content that is
about self, world and other, why then are we required to locate the disorder
inside the organism? It would seem that we are free to think that there are/should
be disorders of (and in) world/other — e.g. relational disorders,
sociopolitical disorders etc. If you permit those by definition, then I would
accept that, but that completely changes the nature of the situation. <o:p></o:p></div>
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2. This is true; the disorders you mention involve ‘intentionality
and psychological meaning.’ But, again, 'involving' is not enough — there
could be many reasons for this. It's possible, for example, that it is the
profoundly disturbing and radically disorienting experiences of, in, and
with, self, world and other that <i>follow</i> from such physical
events that come to constitute the content you describe. As such, the
physical events would only be the cause of contentless physiological change,
and the subsequent 'symptoms' you mention result from
events/experiences no longer issued from those changes.<o:p></o:p></div>
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Or, so long as we are not substance dualists, it also makes sense that
certain gross physical disturbances could mimic 'mental disorders.' You could
argue that if that is possible, then what is stopping us from concluding that
we have not just found the physical causes yet, as is often argued? I do
not accept that as an argument, as it excuses science from being scientific,
being that theoretically you can go on looking for something that is not there
for an infinite amount of time. Of course, one can make that
statement, but you can't then say that psychiatry is treating anything based on
science — the science is searching for the thing to do the science on, and until
it finds it, it is merely conjecture. Furthermore, the fact remains that such
causes have not been found after decades, several quantum leaps in
technology, and billions of dollars spent — and there is no reason to suggest
they will.<o:p></o:p></div>
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You seem to be arguing against a dualist straw man. 'Physical'
and 'mental' — imperfect, dualistic categories in the first place — of
course involve each other. The question, though, is what is the
appropriate level of explanation and where is the 'location' of the
content in question. I argue that physical explanations, located in the
organism, are entirely inappropriate for issues whose content is about self,
world and others. <o:p></o:p></div>
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<b>Aftab:<o:p></o:p></b></div>
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Thank you for the clarification. This certainly helps me understand your
view better.<o:p></o:p></div>
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It seems that you see "disorder" as a species of physical
explanation. That is, to call X a disorder is to, among other things, explain X
in terms of physical processes. In your view disorders are about physical
processes, concerned primarily with physical processes, and involve mental
content secondarily, but they are not primarily about mental content.<br />
<br />
You are right to guess that I do not restrict disorders to physical
explanations (and neither does the historical and “official” understanding of
disorder in psychiatry). I think that disorders can primarily deal with mental
content and mental explanations as well, that disorders can apply to content
that is primarily about the self, the world, and the others.<br />
<br />
Why are we required to locate the disorder inside the organism? The way this
concept is understood in medicine and psychology, disorder is a property of the
individual, not necessary <i>inside</i> the individual, but <i>about</i> the
individual, or <i>of</i> the individual. That arises from the fact
that disorder is applied to phenomena that are primarily individual, i.e.
bodily processes or individual psychological processes. That does not however
necessitate that the causes of the phenomena are also located inside the
individual; they could very well be spread out and extended beyond the organism
into the world.<br />
<br />
I want to focus a bit on the issues of<br />
A) what in the realm of the mental is about the self, world, and others, and
what is not<br />
B) what is the appropriate level of explanation for a phenomena<br />
<br />
A) Is everything in the realm of "mental" about the self, world, and
others? What is not and why is it excluded?<br />
<br />
Consider perception. How would you classify various modalities of perception
such as vision, hearing, olfaction? Are abnormalities in vision about the self,
world, and others? What sort of abnormalities of vision would be about the
self, world, and others, and what sort won't be? How would we know? <br />
<br />
What about sexual desire? Pain? Behaviors such as seizures? Language and
speech?<br />
<br />
B) You say that physical explanations are <i>entirely inappropriate</i> for
issues whose content is about self, world and others.<br />
<br />
They would very well be inappropriate as the only explanations, yet I do not
see why physical explanations cannot be a part of the larger explanation.<br />
<br />
We know very well that mental content, including content about the self, world,
and others, arises through a combination of many different sorts of phenomena
at many different levels of explanations. For example, personality traits are
partly genetic. Which means that if we are to scientifically understand
personality traits, genetic explanations would be involved in the larger
picture. It would be inappropriate to say they are the only explanation, or the
primary explanation, but I don't see how we can say that they are not a part of
the explanation at all.<o:p></o:p></div>
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<b>Barnes:<o:p></o:p></b></div>
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So, this is the point of contention, I think. <o:p></o:p></div>
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You say that disorder is not necessarily <i>in</i> the
individual but is a property of the individual. You make this claim on the
basis that even though the causes can be external to the individual, the
disorder is nevertheless <i>of</i> the individual. This relies on a
metaphysical position that we are under no pressure to accept, and I reject. It
is a symptom of dualistic, representationalist metaphysics, for which the
world (and by extension, others) is effectively contentless (i.e.
qualitiless) and it is the individual mind/brain that embellishes or 'fills
out' the neutral data of the world internally. If you start from this
metaphysical position, then what you say probably follows, but I do not and
there is no reason why we must. <o:p></o:p></div>
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By contrast, when I talk about the content being about self, world and
others, I am not referring to any kind of internal <i>representations</i> of
self, world and other, 'triggered' by 'stressors' from the outside— a picture I
entirely reject. I am referring, following Heidegger for example, to a
trans-individual ontological 'location' — the three of them, together, as the
site, so to speak, of the issues in question. Following this, I understand
this type of content (unlike content that is about physical states/processes)
as being 'a property' of world and others in principle equally (i.e. not in
terms of world and others <i>qua</i> self). This being so, I am
arguing against psychiatry, and any approaches to 'mental disorder'
that assume the same metaphysical picture, for limiting their
explanation and interventions to the individual in this sense. The appropriate
level of explanation, I suggest, is therefore where the issue is
considered in principle as an ontological property of all three.<o:p></o:p></div>
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This is why, for example, I put CBT/cognitivist accounts, and classical
psychoanalysis for that matter, into the same category, as all of them presume
this same starting point, which I reject. Thus, while the "official understanding
of disorder in psychiatry" may not limit itself to physical explanation,
it is — by its very nature (i.e. there are no other/world disorders in the DSM)
— limited to a dualistic, representational metaphysics of the mental and
social, which is what I meant by "inside the individual." While
socially derived causes (i.e. 'triggers') form part of the explanation in
psychiatry they, as inherently contentless (i.e. 'stressors'), are only
'social' in the capacity of triggering an otherwise internally determined
process. To me this ends in effectively the same result, i.e. an
inappropriate focus on what is going on 'inside the individual' to the relative
exclusion of the actual role of others and the world. <o:p></o:p></div>
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Finally, I don't think I am able to address your examples and would
have to defer to how they are understood from the point of view of such a
metaphysical starting point.<o:p></o:p></div>
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<b>Aftab:<o:p></o:p></b></div>
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A Heideggerian worldview is fascinating and from my own limited studies
of Heidegger, I am sympathetic to this perspective, and find this very
worthwhile.<o:p></o:p></div>
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However, from your discussion, some things are not clear to me that I’d
like you to clarify:<o:p></o:p></div>
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How does your understanding of the Heideggerian metaphysics tackle the
mental-physical divide? Is there a suggestion that mental phenomena require a
different sort of explanation, an explanation couched within a Heideggerian
worldview, but physical phenomena require a different sort of explanation, an
explanation in terms of science and physical processes? <o:p></o:p></div>
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That would be an odd distinction to make for a metaphysic that otherwise
prides itself on overcoming Cartesian distinctions.<o:p></o:p></div>
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Secondly, how would the Heideggerian worldview explain something like
“sexual desire”? What would be the ontological location of sexual desire? How
would this metaphysic account for the idea that differences and disturbances in
sexual desire can result from a combination of factors which may include
changes in levels of various hormones, changes in levels of neurotransmitter,
as well as various psychological processes?<o:p></o:p></div>
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<b>Barnes:<o:p></o:p></b></div>
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Yes, very true. Glad to hear you are sympathetic to the
Heideggerian starting point. <o:p></o:p></div>
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Clearly, the distinction 'mental and 'physical' is itself a
dualistic hangover. It has been fashionable, in one way or another, to collapse
the mental to the physical. But this ironically remains dualistic — we are then
left with distinct physical substances that have dualistic relationships with
each other. I have no definitive answer, but my thought is that if we take an
essentially non-dualistic stance, as Heidegger does, then we have to think of
it in terms of a continuum from physical to mental; or, in
other words, from concrete events in the ecology of the body (such as
lesions in the anatomy of the body) to the intangible, pervasive and
unlocatable events of the domain of self, world, others (such as our cultural
disconnection from nature). Monism remains dualistic, whereas non-dualism
involves some sort of paradoxical continuum, I think. <o:p></o:p></div>
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I would say, positively, that there would necessarily be a
subjective/indeterminate element as to the level of explanation, but to me
this is no non-problem, as it follows from the non-categorical nature of
metaphysics. Although, it also follows form this that there can be no science
of this order per se (being some version of the German g<i>eisteswissenschaft),</i> I
would say that even though there is a ideal of objectivity in the sciences
of psychiatry as it stands, clearly it is in the same position anyway given the
lack of physical markers, etc. by means of which to eliminate the dualism
still invoked — something which I suggest will be a permanent issue due to the
error of the metaphysics. <o:p></o:p></div>
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Having said that, aside from some anomalies (i.e. 'conversion
disorders'), it seems to me to be fairly clear what is most appropriately
explained in the terms of self, world and others and what in terms of the
physical body, i.e. in terms of what the content of the issue is about,
as I have said. As such, what I am practically proposing is to invert the
basic assumption we have at the moment: those issues whose content is
about self, world and others are presumed to be a property, in principle, of
all three, and explained as such, whereas those whose content is about the
physical body are to be explained in terms of properties of the individual,
bodily processes, etc.— until discovered otherwise. <o:p></o:p></div>
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I don't think taking an abstract case such as 'sexual desire' is
helpful, for me at least. If we are talking about a specific issue
related to sexual desire then we'd have to look at it in its complexity
and make a decision as to what it is about.<o:p></o:p></div>
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<b>Aftab:<o:p></o:p></b></div>
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I largely agree with you that there is an explanatory continuum from
"physical" to the "mental", as you describe "from
concrete events in the ecology of the body to the intangible, pervasive and
unlocatable events of the domain of self, world, others".<br />
<br />
However, I think we have to resist reification of these modes of explanation.
Another way to see this continuum is in terms of "local" to
"global". Sanneke de Haan describes it very well in a <a href="https://muse.jhu.edu/article/751748" target="_blank">recent article on
enactivism</a>. She writes:<br />
<br />
"The important, dualism-defeating move here is to resist thinking about
causality in linear terms and instead regard both the physiological and the
life-world causes as mereological or organizational forms of causality: the one
local to global, the other global to local. The causality involved is rather of
a mereological, organizational, or constitutional type. That is: within a
specific organizational structure the relation between its local and global
processes is reciprocally influential, but without the one working on the other
as if they were separate."<br />
<br />
The local and global processes are reciprocally influential. To the degree to
which local and global processes can correspond to physical and mental
processes, the physical and mental are reciprocally influential. We can trace
causal relations from local-to-global and global-to-local without resorting to
dualism.<br />
<br />
Secondly, you write "it seems to me to be fairly clear what is most
appropriately explained in the terms of self, world and others and what in
terms of the physical body"<br />
<br />
There are two issues here:<br style="mso-special-character: line-break;" />
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1) It may be fairly clear to you, but it may not be fairly clear to
another. Obviously we have clear-cut cases on which there would be large
agreement, but the gray zones in the middle are where much of disagreement and
conflict lies in psychiatry, and we have to acknowledge that things are not
fairly clear to a lot of people.<br />
<br />
2) There is nothing in the Heiddeggerian worldview that necessitates that there
be only a single appropriate mode of explanation for a given phenomenon. For
phenomena that are in the middle of the physical-mental, local-global
continuum, they can be viewed through multiple modes of explanation, and each
mode of explanation provides a different sort of insight, a different part of
the overall picture. Why would we want to restrict ourselves by insisting that
there is always only one appropriate mode of explanation?<br />
<br />
Here my question about sexual desire becomes pertinent. Sexual desire belongs
to the domain of self, world, others; it is characterized by phenomenology, by
intentionality, by interaction with others, with affectivity... and yet, any
account of sexual desire that ignores and excludes the physiology of sexual
desire will fail to attain a complete explanation of the phenomena. Sexual
desire is in the middle of the physical-mental continuum, the local-global
continuum. You can look at sexual desire from a local-to-global perspective, or
you can look at it from global-to-local, and depending on what we are
interested in, either or both perspectives may be relevant to us. This
indicates that physical-to-mental and mental-to-physical explanations are not
mutually exclusive but rather complementary.<br />
<br />
Hence, I see no reason to accept the explanatory dualism being proposed, that
"those issues whose content is about self, world and others are presumed
to be a property, in principle, of all three, and explained as such, whereas
those whose content is about the physical body are to be explained in terms of
properties of the individual, bodily processes". In fact, this explanatory
dualism is inconsistent with your own view of a continuum from physical to
mental, as explained above. If there is a continuum, there is a gray zone, and
gray zone is what the debate is all about. Instead of explanatory dualism, we
need explanatory <i>pluralism</i>.<o:p></o:p></div>
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<b>Barnes:<o:p></o:p></b></div>
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Great. Love it. I am aware of the article you mention, and so far as I
understand it, global, for de Haan, is describing the 'global organism,' i.e.
the mental order as a property of the organism. I liked that article, but it is
not Heideggerian, in the sense of rejecting the human organism (Dasein)-world
divide. Heideggarian 'global,' or at least my 'global,' actually includes, in
principle, the world-globe:<o:p></o:p></div>
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<i>“self and world belong together in the single entity, the Dasein. Self
and world are not two</i><o:p></o:p></div>
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<i>beings, like subject and object, or like I and thou, but self and
world are the basic determination<br />
of the Dasein itself in the unity of the structure of being-in-the-world.”
(Heidegger 1989: 422)</i><o:p></o:p></div>
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Thus, I would accept the argument, but again on this basis: that we
include processes of world/others under the term 'disorders.' Insofar as we do
not, then we are only talking about the properties of the individual and not
others and the world, which as I am saying is a dualistic hangover. As such, I
agree with what you say about the 'middle,' but only when it is the middle of
an organism-world continuum and not a continuum of the organism. The difference
here is what is meant by 'mental'. Again, mental is taken to be self, world and
other <i>qua </i>organism; I am using mental to refer to something
like <i>Dasein</i>, which is trans-organism and has the actual world and others
'equiprimordial,' to use Heidegger’s term, with the self 'in' it. <o:p></o:p></div>
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So, I agree with a pluralism, but a pluralism of explanation of the
organism-world entity, something which radically decenters biology,
and indeed psychology (of the variety that presumes the dualism mentioned
above), and opens the door to ontological importance of the actual content of
world and others <i>per se </i>(i.e. not as contentless 'triggers and
stressors').<o:p></o:p></div>
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(Just to be clear, I do not agree with De Hann's statement that her
position is 'dualism-defeating' at all. It defeats the dualism of mind and
body, but not mind and world, which is by far the more important problem with
dualism.)<o:p></o:p></div>
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<b>Aftab:<o:p></o:p></b></div>
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From a Heideggerian perspective, I agree with you that
"disorder" would not be a property of an individual or an organism,
but rather something that relates to the organism-world entity, the <i>Dasein</i>,
and I agree with you that such a perspective radically decenters biology
and individualistic psychology, but I would maintain that while it decenters
biology and individualistic psychology, it does not render them <i>irrelevant, </i>it
does not exclude them from explanations. The Heideggerian perspective opens up
richer ways of seeing the local-to-global and global-to-local causal relations
with the full realization that doing so does not and cannot <i>reduce</i> Dasein
to local explanations.<o:p></o:p></div>
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<b>Barnes:<o:p></o:p></b></div>
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I agree, yes. It certainly does not render them irrelevant; it reduces
the focus from roughly 100% to 30% in principle, if you'll allow the
simplification. We would not then subsume the social into the medical in this
context, but the medical into the social — or, at least we would have a proper
democracy. This might look like referrals to psychiatry, by an institution
that was oriented around the psycho-social, if the physical/medical side
of the issues was deemed obvious or pressing. Or it would look like a radical
revisioning of the institution of psychiatry from biologically focused to
psychosocially focused. <o:p></o:p></div>
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<b>Aftab:<o:p></o:p></b></div>
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I am less clear about specific practical implications, since adopting a
Heideggerian perspective would require a radical revision not just of
psychiatry, but medicine, neuroscience, and many other professions and
activities of life. How to implement those in a world where many or most may
never adopt the Heideggerian perspective poses complex challenges, even if the
practical implications of a philosophical theory could be worked out. But I do
know that as long as we keep talking about biological vs psychosocial, we would
remain under the shadows of old dualisms. I do agree that generally speaking it
would require a substantial de-emphasis of biological explanations in favor of
more holistic, pluralistic, integrated explanations. Such explanations can’t be
given a generic template since each condition is different and we approach
conditions with specific goals seeking certain sorts of outcomes. So,
explanations in this sense have a pragmatic function as well, and what
explanation works best for our purposes will depend on the question asked and
would need to be guided by the best available empirical evidence.<o:p></o:p></div>
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<b>Barnes:<o:p></o:p></b></div>
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Fair enough. I really do respect the kind of pluralism you are
pushing for, and appreciate you entertaining my thoughts. I'm actually not sure
that we disagree too much at all. I do recognize that the kind of
approach I am advocating for is specific or radical or both, but I don't
think it is limited to Heidegger. Alfred North Whitehead — that other great
early 20th century 'metaphysician' — has a totally different scheme based
on the same rejection of the scientific ontology as explaining life, which
would also work but in a very different way. I honestly think momentum is and
will take us further in that direction. For me, we are on the brink of a shift
in paradigm, which the new process philosophy in biology and 4E in cognitive
science are signs of. Anyway, good to have this conversation with you. It was
helpful for me to clarify it all!<o:p></o:p></div>
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<b>Aftab:<o:p></o:p></b></div>
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We do admire many of the same philosophers! A.N. Whitehead has left a
mark on me as well but primarily from a theological/mystical perspective with
process theology ideas that are derived from his process philosophy. I agree
with you that the conversations are shifting, we are witnessing a great
synchronicity as individuals with very diverse backgrounds are beginning to
grapple with the challenges of pluralism and integrative thinking in psychiatry.
Biological reductionism, in any case, is dead, and to quote Nietzsche's madman:
"This tremendous event is still on its way, still wandering; it has not
yet reached the ears of men. Lightning and thunder require time; the light of
the stars requires time; deeds, though done, still require time to be seen and
heard." This has been a great conversation, thank you.<o:p></o:p></div>
<br /></div>
Awais Aftabhttp://www.blogger.com/profile/04718828055532728613noreply@blogger.comtag:blogger.com,1999:blog-8980517681041523849.post-90828801686840991682020-06-12T12:19:00.000-04:002020-06-12T13:37:12.554-04:00An Exchange with Ruffalo & Pies: More on Diagnosis & Diagnostic Explanation<div dir="ltr" style="text-align: left;" trbidi="on">
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The following are comments from Mark L. Ruffalo, D.Psa., L.C.S.W
and Ronald W. Pies, M.D. in response to my previous blogpost: "<a href="https://awaisaftab.blogspot.com/2020/06/can-symptoms-be-caused-by-descriptive.html">Can
Symptoms Be Caused by Descriptive Syndromes? An Analysis</a>".<o:p></o:p></div>
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As a reminder, my blogpost was written in the context of an article by
Ruffalo and Pies ("<a href="https://www.psychologytoday.com/us/blog/freud-fluoxetine/202006/what-is-meant-psychiatric-diagnosis">What
Is Meant by a Psychiatric Diagnosis?</a>") that had been written in
response to an article by Jonathan Shedler, Ph.D ("<a href="https://www.psychologytoday.com/us/blog/psychologically-minded/201907/psychiatric-diagnosis-is-not-disease">A
Psychiatric Diagnosis Is Not a Disease</a>"). Both these article were
in <i>Psychology Today</i>.<o:p></o:p></div>
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I will post the comments from Ruffalo and Pies, followed by brief
comments from me.<o:p></o:p></div>
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<b>COMMENTS FROM MARK RUFFALO AND RONALD PIES</b><o:p></o:p></div>
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Dear Awais,<o:p></o:p></div>
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Thank you for the opportunity to respond to your thoughtful comments on
our article in <i>Psychology Today,</i> and on the broader—and very
complex—issues we are all raising.<o:p></o:p></div>
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Our position, roughly speaking, could be summed up in three basic
principles:<o:p></o:p></div>
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1) Avoid definitional essentialism<o:p></o:p></div>
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2) Embrace clinical pragmatism; and<o:p></o:p></div>
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3) Respect ordinary language.<o:p></o:p></div>
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In turn, these principles lead us to three fundamental conclusions, which
we flesh out in our article:<o:p></o:p></div>
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1) There is no “essential definition” (i.e., one specifying necessary and
sufficient conditions) for terms like “disease”, though entities called by this
name typically possess “family resemblances.”<o:p></o:p></div>
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(2) The most clinically relevant family resemblance among members of the
class called “disease entities” is the presence of <i>prolonged or
substantial suffering (or distress)</i> and <i>incapacity (or
impairment); </i>and these issues constitute the central focus of clinical
care and treatment.<o:p></o:p></div>
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(3) While the concept of “cause” and “causality” is complex—and, like
“disease”, admits of no essential definition—it is quite consistent with <i>ordinary
language</i> to say that at least <i>some</i> DSM diagnostic
categories represent <i>causes</i> of a patient’s suffering and
incapacity in the mental, psychological and behavioral realm. [<a href="https://www.iep.utm.edu/ord-lang/#H5">https://www.iep.utm.edu/ord-lang/#H5</a> ] <o:p></o:p></div>
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Any one of these principles or conclusions would merit a long paper,
which would be far outside the bounds of a blog. Nevertheless, we can “unpack”
our three principle conclusions and elaborate on some additional points that
you raise in your own comments.<o:p></o:p></div>
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1) The concept of “disease”—its meaning, scope, definition, diagnosis and
treatment—has been a source of controversy since the ancient Greek academies of
Knidos and Kos competed with one another [<a href="https://link.springer.com/article/10.1007/s00381-010-1271-2">https://link.springer.com/article/10.1007/s00381-010-1271-2</a> ].
We are not surprised the controversy continues to this day! Although some
scholars proffer definitional distinctions among terms like “disease”,
“disorder”, “illness”, “malady”, “morbus,” etc., these terms are actually used
very loosely—if not promiscuously—in the medical literature, and in everyday
medical practice.
[https://www.psychiatrictimes.com/dsm-5/what-should-count-mental-disorder-dsm-v].
The commonly made binary distinction between “disease” (known pathophysiology)
and “disorder” (unknown cause or pathophysiology) is of very limited clinical
utility<i>. </i>Example: <i>Kawasaki Disease</i> is an
inflammatory condition affecting children, whose cause/etiology remains
unknown. [<a href="https://kidshealth.org/en/parents/kawasaki.html">https://kidshealth.org/en/parents/kawasaki.html</a> ].
But it is not called “Kawasaki disorder” on that basis. More importantly, many
medical conditions do not lend themselves to the binary distinction between
disease and disorder, given that knowledge of etiology and pathophysiology
exists on a broad continuum.<o:p></o:p></div>
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2) Very few physicians contemplate their overcrowded waiting room and
think to themselves, “Hmmm…I wonder which of these patients has a disease, and
which has a syndrome, a disorder, a malady, or an illness?” The physician’s
chief concern is with determining <i>who is experiencing suffering and
incapacity (in varying proportions); identifying a likely cause, whenever
possible (it often isn’t!); and relieving the patient’s misery safely and
effectively.</i><o:p></o:p></div>
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3) As you suggest in your comments, Awais, the term “cause” is used in
various ways, depending on the context. And, as Ludwig Wittgenstein would
remind us, the “meaning” of a word depends critically on how it is used, and
for what purpose. [<a href="https://plato.stanford.edu/entries/wittgenstein/">https://plato.stanford.edu/entries/wittgenstein/</a> ] <o:p></o:p></div>
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We would distinguish at least three senses and contexts for the term
“cause”:<o:p></o:p></div>
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<i>a) etiopathological causation</i>: this refers, ultimately, to the
physical and physico-chemical mechanisms through which a disease process
develops; e.g., the causal role of the tuberculosis bacillus in causing
tuberculosis. In many ways, this is the “gold standard” to which medical
science aspires, but which is often unrealized, particularly in psychiatric
(and several neurological) disease entities.<o:p></o:p></div>
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(b) <i>clinical causation</i>: this refers to the clinician’s
identification of a “good fit” between the patient’s presenting signs and
symptoms, and a recognized clinical entity; i.e., the patient’s signs and
symptoms “map onto” a particular syndrome, disease, disorder, etc. and <i>not
to some alternative condition </i>(a critical point you make in your
discussion). This condition <i>may or may not be understood
etiopathologically.^^ </i>For example,<i> </i>the patient presents
with severe, unilateral head pain accompanied by nausea and extreme sensitivity
to light. The patient asks the physician, “What’s causing my problem, Doc?” The
physician—having ruled out, e.g., a brain tumor—replies, “I believe you are
having migraine headaches.” Interestingly, the word “migraine” is probably a
corruption of the Latin, <i>hemicranium</i>, meaning, “half the skull”.
The etiopathology of migraine—though clearer now than 100 years ago—is still
not well or completely understood; i.e., <b>“</b>The exact cause of
migraines is unknown…” [<a href="https://www.nhs.uk/conditions/migraine/causes/">https://www.nhs.uk/conditions/migraine/causes/</a>]<o:p></o:p></div>
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So, a “wiseass” (or very clever) patient might retort, “So all you’re
telling me, Doc, is that my one-sided headaches are caused by pain on one side
of my head!” Of course, there is much more to the neurologist’s understanding
of migraine—e.g., what triggers it, its course and prognosis; genetic factors
that make it more likely, how it responds to treatment, etc. <i>These
factors represent some of the “external validators” that help define disease
categories</i>.** The same type of validation applies to most of the major DSM
diagnoses; e.g., schizophrenia, bipolar disorder, major depression, and
yes—even generalized anxiety disorder [see, e.g., <a href="https://anxietyinstitute.com/what-we-treat/anxiety-disorders/generalized-anxiety/">https://anxietyinstitute.com/what-we-treat/anxiety-disorders/generalized-anxiety/</a>]<o:p></o:p></div>
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<i>c) causation in ordinary language</i>. Awais, you explicitly take this
up in your discussion; i.e., you rightly note that, “In ordinary language, we
sometimes use “cause”…as [meaning] something along the lines of “this is how to
best make sense of it.” So: when we ask, “What was the cause of Smith’s panic
attack?” it is perfectly understandable to reply, in ordinary language, “It
turns out Smith has Panic Disorder.” This, of course, doesn’t mean that <i>other</i>,
perhaps subsidiary or contributing causes can’t be posited or discerned; e.g.,
“Smith was under a lot of pressure at work,” or “Smith had just been evicted
from his apartment.” We may even go so far as to posit <i>unconscious
causes</i> that would lend themselves to psychoanalysis! But none of these
additional causes impugns-- or renders in any sense tautological—our “ordinary
language” claim that Smith’s problem is due to, caused by, or a consequence of
his having Panic Disorder. That is, to use your formulation: his problem is
“best made sense of” by this diagnosis.<o:p></o:p></div>
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<b>Conclusion</b><o:p></o:p></div>
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Meanings (b) and (c) coalesce in this statement from the Anxiety
Institute, which also happens to summarize our concept of
“disease”: <o:p></o:p></div>
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“Generalized Anxiety Disorder <i>causes its sufferers great distress
and trouble functioning</i><b> </b>in several different areas, such as
school, work, at home with family, or in social contexts with friends.”
[italics added] <a href="https://www.blogger.com/null" name="_Hlk42695450"></a><a href="https://anxietyinstitute.com/what-we-treat/anxiety-disorders/generalized-anxiety/">https://anxietyinstitute.com/what-we-treat/anxiety-disorders/generalized-anxiety/</a><o:p></o:p></div>
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Much more could be said, Awais, but we do not want to overstay our
welcome on your blog site, or anesthetize our readers! We hope we have provided
sufficient context here to render our article at least a bit more convincing.
Thank you again for this opportunity.<o:p></o:p></div>
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<i>Footnotes:</i><o:p></o:p></div>
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^^While etiopathologic diagnosis is usually the goal in medical diagnosis,
there remain many conditions called “idiopathic” in general medicine; i.e., “We
don’t know what causes this.” A good example is <i>idiopathic facial
paralysis</i> [IFP] sometimes called Bell Palsy, for which there are many
possible explanations, but <i>no clear etiology</i>. Nevertheless,
physicians routinely cite IFP as “the most common <i>cause</i> of
unilateral facial paralysis.” [emphasis added; see: <a href="https://emedicine.medscape.com/article/1146903-overview#a1">https://emedicine.medscape.com/article/1146903-overview#a1</a>]<o:p></o:p></div>
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**Many psychiatric diagnoses also embody <i>predictive validity</i>.
Contrary to some claims, this does <i>not</i> entail tautological
confirmation, such as when someone with schizophrenia—for which hallucinations
are one of the diagnostic criteria—is found to have hallucinations two or three
years after diagnosis. A diagnosis of schizophrenia also predicts, for example,
a higher than expected likelihood of a <i>dementia</i> diagnosis, up to
ten years later, even though dementia is <i>not</i> part of the
diagnostic criteria for schizophrenia. See, e.g., <a href="https://ps.psychiatryonline.org/doi/10.1176/appi.ps.201900325">https://ps.psychiatryonline.org/doi/10.1176/appi.ps.201900325</a><o:p></o:p></div>
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<b><br />
COMMENTS FROM AWAIS AFTAB</b><o:p></o:p></div>
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I would like to thank Mark and Ron for taking the time to respond to my
blogpost and to further elaborate their point of view. I will keep these
comments brief, largely because I don't have major disagreements with what they
have outlined above. I do have some clarifications and something to add about
why this debate is important. <o:p></o:p></div>
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Mark and Ron talk about external validators and predictive validity of
psychiatric diagnoses. I don't disagree with that. Major psychiatric diagnoses
are more than mere labels. They contain explanatory content; they are not
vacuous. Psychiatric diagnosis gives us important information about clinical
features, clinical course, and response to treatments, even though this
information may be general and not specific to the individual in front of
us. <o:p></o:p></div>
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They write: "at least <i>some</i> DSM diagnostic
categories represent <i>causes</i> of a patient’s suffering and
incapacity in the mental, psychological and behavioral realm". I don't
have any disagreement with that, but I don't think seeing the diagnosis as a
cause of patient's <i>suffering and incapacity</i> was ever the point
of contention, either on my end or Dr Shedler's.<o:p></o:p></div>
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The issue that I was specifically looking at was whether symptoms that
constitute the description of a descriptive syndrome can be said to be caused
by that syndrome. My conclusion was that we can say so in instances where the
diagnosis can also meaningfully refer to some underlying causal structure. This
doesn't necessarily mean that we have to know the exact etiology of the
syndrome; I think the more specific, the more distinct, the more fleshed out a
construct is, the more meaningfully it refers to some underlying causal
structure, even if that causal structure is unknown. <o:p></o:p></div>
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Mark and Ron describe three senses and contexts for the term
"cause": etiopathological, clinical, and ordinary language. What they
refer to as "clinical causation" might also be described as a <i>diagnostic
explanation</i>. In the context of my above discussion, I would say that the
diagnosis can offer an explanation to the extent that the diagnostic construct
is fleshed out.<o:p></o:p></div>
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Ken Kendler states that diagnostic criteria <i>index</i> the
disorder, they do not <i>constitute</i> the disorder, i.e. a disorder
is <i>more than</i> just the criteria.<o:p></o:p></div>
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Imagine that the information that constitutes the disorder construct is X<o:p></o:p></div>
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Imagine that the information that constitutes the diagnostic criteria is
Y<o:p></o:p></div>
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Imagine that the information that constitutes the description of a single
sign/symptom is Z<o:p></o:p></div>
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X is always greater than Y, and Y is always greater than Z, however, for
a lot of diagnoses, X is <i>not that much greater</i> than Y, and Y
is <i>not that much greater</i> than Z. For me, this is the situation
for diagnoses such as obesity, essential hypertension, and generalized anxiety
disorder (GAD). Essential hypertension is not that much greater than its
diagnostic criteria, and the diagnostic criteria are not that much greater than
the sign of high blood pressure. <o:p></o:p></div>
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For some diagnoses, X is <i>substantially greater</i> than Y,
and Y is <i>substantially greater</i> than Z. For me, this is the
situation for diagnoses such as migraine, diabetes mellitus, schizophrenia, and
bipolar I disorder, Migraine is a lot more than just a headache, schizophrenia
is a lot more than just hallucinations. Is GAD a lot more than anxiety in the
same way? I personally don't think so. I think it is comparatively more
meaningful to say that headache is caused by migraine, or hallucinations by
schizophrenia, because these constructs are more fleshed out, and thereby they
offer more of an explanation.<o:p></o:p></div>
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Readers may reasonably ask: what's the point of this discussion? The
reason I think it is important is because the clinical and ordinary language
sense of causation can easily give us the illusion of scientific explanation.
It seems to us as if we have explained something, the language we use gives us
that impression, when in fact we have done little of the sort in the scientific
sense.<o:p></o:p></div>
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When we say that Mr. Smith's anxiety is caused by GAD, yes, we have
diagnosed Mr. Smith, and yes, by virtue of that diagnosis we have non-trivial
information at our disposal regarding Mr. Smith's anxiety, yet we have not
explained Mr. Smith's anxiety in any scientifically meaningful sense, any more
than we have explained high blood pressure by diagnosing it as essential
hypertension. That is why our language of causation is important: if we are not
careful, our diagnoses can easily obfuscate more than they clarify, and end up
as a way of hiding our ignorance.<o:p></o:p></div>
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Awais Aftabhttp://www.blogger.com/profile/04718828055532728613noreply@blogger.com