A Myth in Creation

Takeaway: The societal dominance of biomedical narratives requires physicians to practice medicine with epistemic humility and in a deeply collaborative manner.   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, testimonial and hermeneutic 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 th...

A twitter thread by Dr. Gipps prompted me to look at the use of the term "understandable" more closely in the document " Understanding Depression " 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.  1) "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 ar...

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 Beyond Definitional Disagreements  for additional background.) 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. ( link ) 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. ( link ) While characterization of distress/incapacity as “disease” is coherent and historically respect...

This blog post is derived from a twitter thread , in response to this blog by Mark Ruffalo . 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 ...

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.       Diagnostic constructs in psychiatry are typically ways of organizing observed behaviors and reported experiences into particular categories or dimensions. To emphasize, for instance, DSM categor...

Some common conceptual mistakes in psychiatry and psychology, in my opinion: 1. Thinking that scientific explanations must necessarily reside at a certain level of explanation [good scientific explanations are not constrained by reductionism or holism] 2. Thinking that the mental/psychological and the physical/biological are mutually exclusive [we need to avoid false binaries between mind and body] 3. Thinking of the mind in terms of entities and "mental stuff" rather than dynamic interactions and regulatory processes 4. Thinking that we can infer the nature of specific phenomena from definitions of disease concepts [ we cannot ] 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] 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] 7. Thinking that meaningful scientific pr...

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. 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. Tha...

This post continues the dialogue between James Barnes and me on the topic of criticisms of psychiatry. See last post by Barnes here . 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.  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 as a medical specialty . By conflating the two, critics often ignore or downplay the “market forces” and systemic influences in shaping contemporary practice. 2) Many criticisms that apply to psychiatry also apply to psychology, but psychiatry is typically si...

This is a guest post by James Barnes , who offers a response here to my earlier blog post Psychiatry and its Critics . 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. 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 does. I think that is a serious underestimation of what is going on. 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 p...