Wednesday, July 18, 2012

The Ontological Assumptions of Psychiatry

On the ontological assumptions of the medical model of psychiatry: philosophical considerations and pragmatic tasks

Tejas Patil, James Giordano

Philosophy, Ethics, and Humanities in Medicine 2010, 5:3

Full Text Available here.

A common theme in the contemporary medical model of psychiatry is that pathophysiological processes are centrally involved in the explanation, evaluation, and treatment of mental illnesses. Implied in this perspective is that clinical descriptors of these pathophysiological processes are sufficient to distinguish underlying etiologies. Psychiatric classification requires differentiation between what counts as normality (i.e.- order), and what counts as abnormality (i.e.- disorder). The distinction(s) between normality and pathology entail assumptions that are often deeply presupposed, manifesting themselves in statements about what mental disorders are.
In this paper, we explicate that realism, naturalism, reductionism, and essentialism are core ontological assumptions of the medical model of psychiatry. We argue that while naturalism, realism, and reductionism can be reconciled with advances in contemporary neuroscience, essentialism - as defined to date - may be conceptually problematic, and we pose an eidetic construct of bio-psychosocial order and disorder based upon complex systems’ dynamics. However we also caution against the overuse of any theory, and claim that practical distinctions are important to the establishment of clinical thresholds. We opine that as we move ahead toward both a new edition of the Diagnostic and Statistical Manual, and a proposed Decade of the Mind, the task at hand is to re-visit nosologic and ontologic assumptions pursuant to a re-formulation of diagnostic criteria and practice.

This is an interesting paper, especially their treatment of essentialism and the impressive way in which they associate epistemological demands with clinical realities(see the Conclusion). They also present a very good systems theory approach to understanding why psychiatric diagnosis will never have the precision we would like. Below I will address some of their statements but be warned, the paper should be read in full; and carefully. There are some difficult issues here, beware of what seems plausible. As the authors note:
In other words, naturalistic intuitions are not evidence of their content.

The key conceptual issues are:
In applying this framework to the medical model of psychiatry, we see a reliance upon four main ontological assumptions. These are 1) Realism: the claim that mental properties (such as desires, beliefs, and thoughts) are real phenomena and not merely artifacts of socio-cultural norms; 2) Naturalism: the concept that disturbances in neural structures are causally implicated in the formation and persistence of mental disorders; 3) Reductionism: the view that at some level, disturbances in neural structures are necessary to account for mental disorders, and 4) Essentialism: the assertion that mental disorders have underlying ‘essences” that allow distinction of one type from another.

Early in the paper they write ...
Simply, there is not an ontologically separate mental world, independent of its physical instantiation in the brain. The idea of an overriding mind, metaphysically independent of the brain, becomes untenable when we realize that lesions to various regions of the brain have profound consequences for subsequent subjective experience. 
Then they write ...
The brain and its potential representations are a primary focus of neuroscience
 What are these naturalistic intuitions called "representations". This comes back to the often expressed idea that brains move information around various regions. This is not possible because information does not exist. Even when we talk about the information potential of a thing we presume it holds that information. It doesn't, the "information potential" of a thing is very much contingent on what other things it interacts with. And if there is one things brains are designed to do, it is to make lots of things interact with lots of other things. The brain is the penultimate  interactive device.

Regarding the anti-psychiatry school.

Szasz was concerned about the validity of psychiatric concepts, and his critique raised questions about the evaluative nature of the psychiatric enterprise. To Szasz, psychiatry utilized terms (such as delusions, compulsions, and obsessions) that lacked the descriptive objectivity of other domains of medicine.
Szasz was right about this but only up to a point. I've met enough people diagnosed with various psychiatric disorders and I couldn't put a label on it but that didn't stop me realising that the person in question was going to have problems. The problem is not that mental illness does not exist, of course it does, that is trivially obvious, but rather that we have persistently failed to appreciate that so many things are inherently unpredictable so we should not be surprised that human beings are so unpredictable. It is in the nature of things generally. As the authors note:
Biological systems (including the embodied brain-mind) display complex network properties, and behavioral processes are often best characterized as non-linear interactions between physiological systems and the environment [29].
They write ...
A pressing question in naturalistic theories is how is it, exactly, that neurobiological disorders can be causally linked to certain behavioral outcomes?
 Perhaps this is the wrong question or reflects the limitations of language. The brain is an interactive device, we can only speak of its causative properties with respect to its interactions at any given time. To simply look at the brain without regard to its current interactions with the external environment is to engage in a doomed means of analysis. It is like trying to study aerodynamics on the moon.

As noted in the abstract the authors take issue with essentialism and argue that it an erroneous assumption but one with clinical utility. I'm not sure, I remember one schizophrenic I knew who told me that he never encountered "Don't Walk" signs, had crows giving him guidance, and after seeing the Gandhi movie the very next morning was seen in Brisbane's busiest CBD street with only a towel draped around his waist, his head shaved, wearing Lennon style sunglasses, while playing his guitar and singing "Imagine". Oddly enough I could almost excuse these behaviors because my principal criterion for determining dangerous behavior is primarily about the ability of the individual to manage life. My old friend could never manage his life, his condition deteriorated over a number of years and he has spent most of his adult life under state supervised housing arrangements.

However, damn it, there are always too many "howevers" in this subject, even where people can be seen to adequately managing their lives there is always room for improvement and individuals can benefit from seeking to address certain behaviors with a view to enhancing their overall life satisfaction. I recall a strange example of this from many years ago. A friend of mine was telling me over the phone how a friend of hers, a psychiatric nurse, was feeling not right and sensed that something was wrong but she couldn't place it. So I told my friend to tell her friend to google "dysthymia". I have been repeatedly told since then it completely transformed her life. She went onto an antidepressant and quickly achieved remission. One guess in the middle of the night did her the world of good.

There is a sense in which we are all flawed, which might help explain why so many religious and ascetic traditions are about cleansing. Those traditions failed so don't be too critical of psychology and psychiatry. A long time ago there was a series of famous pop psychology books that were so warm and fuzzy you wanted to hug the world. "I'm OK, You're OK" was a big one. What did Wittgenstein once write:
The limits of my language mean the limits of my world.
Don't philosophers ever dream? Perhaps they should ...
"Analytical philosophy cannot survive in its present form. If it is to survive at all, it must begin to analyze its own dream. But the language of dream-analysis is not the same as that of set theory." ...
The positive task of the philosopher is to fecundate his analytical skills with dreams, and to discipline his dreams with analysis. ... There are no rules and regulations for being reasonable, and certainly no rules and regulations for dreaming reasonable dreams. In philosophy, as perhaps in everything else, one communicates best his deepest dreams by enacting them.
Stanley Rosen, The Limits of Analysis
It is a dream to think "I'm OK". I can only be OK with reference to specific events. It may happen that overall today most specific events left me feeling OK but that might change if it starts raining. I'm not always OK and sometimes the last thing I want to be is OK. As for you, I'm too busy wondering when I'll be OK to care about you're OKness. You could even be causing my unOKness. You bastard, you probably even killed Kenny.

The Clinic and The Logician

Consider my late night phone call example above. It may be the case that there was no dysthymia, that the anti-depressant did provide a boost to her because some anti-depressants can provide a boost to people irrespective of their Hamilton Scores. That boost may have instantiated behavioral changes that led to this or that change because our behavioral repertoire and flexibility is dazzling. This comes back to the authors' comments about the complexity issue. It is useful to assume that a given neurological insult will lead so a specific behavioral outcome and while that may often be true it is also true that that in such matters many things are "often true" but rarely "always true". It is humbling.  

The authors argue for a "spectrum" approach to psychiatric diagnosis. I'm not sure that solves anything. Most importantly they recognise that for clinical purposes we need some type of classification scheme ... .
At some point, the distinction between what is normal and abnormal, ordered and disordered will need to be made, and any such distinction must be practical in the sense of its viability to sustain the good of patient-centered clinical care.
I can't be sure but sometimes I get the  impression that too many people get their impression of modern psychiatry and psychology from the likes of Bookworld and the Oprah Effect. So people are inclined to think that when mental health professionals use words like "depression" and "schizophrenia" they are referring to distinct natural kinds of things. In my experience when I have pressed mental health professionals for elaborations on these issues they are well aware that these words are communication conveniences and they are painfully aware of the heterogeneity inherent in psychiatric disorders and human behavior as a whole. When what is regarded as normal behavior so often is lacking in any rational basis and is merely the long march of cultural entrenched habits why should we expect mental disorders to display some homogeneous set of characteristics? That would be irrational, you need a pill for that.

Take a hint from some modern neuroscience. We often create post hoc naturalistic intuitions to explain our behavior. Somehow we always manage to come up with a rational explanation. Sure ... .  

If you are interested in this subject matter then I strongly you suggest you read the paper. We do need to give serious re-consideration to our treatment of mental disorders but this isn't just about what happens in the clinic or the lab. It is raises and will to continue to raise a range of questions about how we manage our culture and its institutions because ultimately the rates of mental disorders will bear some relationship to the greater cultural and even global dynamics. Brains are interactive and we are obsessively so. That is our greatest strength.

No comments: