Thursday, 25 February 2010
Values based practice in heaven?
And how many of your students are practising monotheists? It doesn’t concern you, Sister: that kind of absolutist view of the universe? Right and wrong determined solely by a single all knowing, all powerful being whose judgement cannot be questioned and in whose name the most horrendous of acts can be sanctioned without appeal?
It had not occurred to me to think that an argument for polytheism might be that in an ethics based on theology the moral value-determining judgement of a single god might be thought to be totalitarian. (This seems not quite to be the Euthyphro paradox: working out which way the determination works between being good and being loved by the gods.)
But my colleague Bill Fulford, who champions the idea of a rational ‘dissensus’ about values over what he sees as the potentially abusive absolute standards of quasi legal bioethics, would surely love this. In the skies above Caprica, the many gods try to sort out what is good through free debate in a heavenly ‘values based practice’.
For a more serious view of values based practice see this.
Monday, 22 February 2010
Review of Psychiatry as Cognitive Neuroscience
Psychological Medicine, 40 (2010). doi:10.1017/S0033291710000103 Psychiatry as Cognitive Neuroscience : Philosophical Perspectives. Edited by M. R. Broome and L. Bortolotti (Pp. 382; £34.95; ISBN 978-0-19-923-8033). Oxford University Press: Oxford. 2009.
Psychiatry as Cognitive Neuroscience is a collection of consistently high-quality chapters addressing a variety of conceptual issues regarding the role that the cognitive neurosciences can play in psychiatry. Best described as a work of interdisciplinary philosophy, the book has a broader appeal than it would were it primarily an attempt to construe scientific psychiatry as a type of cognitive neuroscience. One feature of the book that may be of special interest to psychiatrists and psychologists is that the individual chapters focus on specific psychiatric conditions. Psychotic and delusional states are prominent, but addiction, personality disorders and memory disturbances also receive attention.
As befitting a diverse collection, the chapters have a variety of goals. Philosophical analysis is used to better conceptualize psychiatric symptoms, but information about psychiatric conditions is also used to advance philosophical understanding. Lynn Stephens and George Graham’s chapter on what is ‘pathological ’ in compulsions exemplifies the former approach. Tim Thornton in particular uses psychiatry as a tool for making progress on philosophical problems.
Schizophrenia and/or delusions are addressed in chapters by Richard Samuels, John Campbell, Philip Gerrans, Dan Lloyd, Shaun Gallagher, Keith Frankish, Anne Aimola Davies and Martin Davies, as well as the editors themselves. One of the interesting themes running throughout the book involves the exploration of phenomenology and cognitive neuroscience – especially with respect to delusions. Many thinkers have criticized the DSM and ICD categories for being too heterogeneous to support the discovery of underlying biological mechanisms. A similar argument is given here, namely, that a more accurate phenomenological understanding of psychopathology might provide a better map for discovering underlying pathological processes. Alternatively, as noted by Matthew Ratcliffe, information about underlying mechanisms might also contribute to an improved phenomenological analysis. Over the course of several chapters, a good case is made for the proposition that a significant potential exists for jointly reformulating our understanding of both disturbed consciousness and the nature of biocognitive mechanisms.
The contributors support using information from the cognitive neurosciences to advance the psychiatric knowledge base, but they generally do not advocate making the cognitive neurosciences the sole paradigm for scientific psychiatry. Here is where careful philosophical analysis offers an important contribution. Focusing the philosophical lens on specific scientific theories makes it clear that there are crucial background assumptions and normative considerations that (a) cannot be reduced to cognitive neuroscience and (b) are essential to our understanding of psychiatric disorders. As might be expected, this viewpoint is consistent with the general perspective of the editors Broome and Bortoliti in their own work.
There are valuable ideas in the book for anyone with an interest in the conceptual problems of psychiatry. Some of the more engaging chapters actually deal less with neuroscience per se. These chapters include Rachel Cooper on the science versus pseudoscience distinction, and Hanna Pickard on personality disorders as both Szasian and ‘ valid. ’
The two chapters prior to the editors’ epilogue are ‘big idea’ chapters that address psychiatric disorders, moral theory and the cognitive neurosciences. Written by Iain Law and Jeanette Kennett and Steve Matthews, they explore whether major depressive disorder is associated with compromised virtue/character and the implications that dissociation and amnestic symptoms might have for moral responsibility. Both claim that psychiatric symptoms result in reduced moral capacities.
These final chapters underscore a conclusion that readers are likely to draw as a result of carefully working through the various contributions, specifically, that thoughtful analyses like those offered throughout the book helpfully challenge us to think more deeply about science and psychiatric disorders.
PETER ZACHAR (Email: firstname.lastname@example.org)
Monday, 15 February 2010
Living and Learning, Learning and Teaching: Mental health in higher education
Sunday, 7 February 2010
Presentation for Amsterdam
In my Essential Philosophy of Psychiatry I attempted to defend, in rather a breathless manner, three anti-reductionist theses. One such claim marks each of the three main sections of the book. The irreducibility of mind to brain; of moral judgements to principles; and of uncodified skilled epistemic judgement to codified evidentiary principles. In this paper I briefly reconsider the arguments for these claims. Whilst the targets differ in the three cases (reductionism in the philosophy of mind aims to discharge normative descriptions whereas principlism in the moral philosophy does not aim to derive normative judgement from norm-free principles), normativity nevertheless plays a key role in each case. In this paper, I aim to tease out the assumptions about the normativity that support anti-reductionism and the picture of both agents and subjects for psychiatry.
Friday, 5 February 2010
Since Christmas, she had lost too much of a happy, catty lifestyle and no longer seemed to have enough fun.
I am more upset than I can say and will miss her, the best cat in the world.
Thursday, 4 February 2010
On wishing for a paradigm shift
On wishing for a paradigm shift
One aspect of the recent discussion of the development of DSM V has been whether it should aim to express, or perhaps bring about, a paradigm shift. Allan Frances has described the initial optimism about the possibility of such a change as ‘absurdly premature’. He writes:
The DSM-V goal to effect a “paradigm shift” in psychiatric diagnosis is absurdly premature. Simply stated, descriptive psychiatric diagnosis does not now need and cannot support a paradigm shift. There can be no dramatic improvements in psychiatric diagnosis until we make a fundamental leap in our understanding of what causes mental disorders. The incredible recent advances in neuroscience, molecular biology, and brain imaging that have taught us so much about normal brain functioning are still not relevant to the clinical practicalities of everyday psychiatric diagnosis. The clearest evidence supporting this disappointing fact is that not even 1 biological test is ready for inclusion in the criteria sets for DSM-V. [Frances 2009: 2]
In the first half of this short note, I will draw out some of the consequences of this on a broadly Kuhnian picture of science. Central to this picture is the connection between paradigms and the meaning of theoretical terms and hence the connection between changing paradigms and the consequent incommensurability of the meanings of terms across time. It is this that helps to support Kuhn’s theoretical scepticism about whether sciences can be said to progress. And this in turn calls into question whether it can be rational to wish for a paradigm shift.
In the second half, I address a related but more substantial point. Whilst the wish for a paradigm shift typically reflects optimism about the developments of neuroscience (notwithstanding the connections just summarised), psychiatry aims to use its technical innovations to relieve human distress. An improved psychiatry should thus be better able to address issues of distress. But if so its understanding of distress - which guides diagnosis, treatment, management and shared plans for recovery - had better remain closely wedded to the self-understanding of those it is supposed to help. And if so, any plans for a paradigm shift threatens to disconnect technical psychiatry from the understanding of human agents which should guide it.
Paradigms incommensurability and progress
The widespread use of the word ‘paradigm’ in the description of scientific change is the fault of Thomas Kuhn’s Structure of Scientific Revolutions. Although he is said to have used it in at least 21 different ways, one basic idea is central [Masterson 1970].
Kuhn argues that scientific activity falls into two kinds. In the main, scientists are engaged in ‘normal science’. This comprises the articulation and application of stable dominant theories and meta-theoretical assumptions to new areas. Kuhn calls this background the dominant paradigm. During such periods, no serious attempt is made to refute or even defend the theoretical background which is instead simply presupposed. But these stable periods of normal science are punctuated by brief periods of revolutionary theory change. Sparked both by the accumulation of anomalous results and by the development of rival theories or even rival meta-theoretical assumptions, the dominant orthodoxy is cast aside and a new theory or set of theories put in its place. Only during these revolutionary periods is the truth of what will become the new scientific background called into question.
Thus whilst during periods of normal science, some measure of progress can be based on an increasing ability to solve recognised puzzles against the background of a stable paradigm, that measure does not apply over periods of revolutionary change since a change of paradigm changes what is regarded as a potentially soluble puzzle.
In fact, however, a broadly Kuhnian view makes the idea of progress across a paradigm shift even more difficult. This follows from his, at the time, influential view of the meaning of theoretical terms. Like other philosophers and historians of science, Kuhn reacted against an influential view of the meaning of theoretical terms taken from the Logical Empiricists of the 1930s [Feigl 1970]. On that older view, theories could be judged against the standard of theoretically neutral observations and that separation was supposedly maintained by the independence of observation from theoretical language. Although theoretical terms were grounded in the observational predictions they collectively inferentially warranted, observational terms were thought to be definable antecedently.
A group of arguments towards the end of the twentieth century undermined that distinction between theory and observation (establishing instead the ‘theory dependence of observation’). Kuhn concluded that the holism that had been thought to apply to theoretical terms - albeit a holism constrained from the outside by their implications for observations claims - must apply to theoretical and observational terms collectively. But without a stable set of neutral observation claims against which to judge them, the new holism seemed to imply that a change of overall theory would change the context and hence the meaning of all theory-observation terms. As a result this seemed to suggest that there was no standard by which to compare overall theories across a paradigm change since different paradigms defined different scientific languages leaving no resources for a translation manual. And thus paradigm change was incommensurable and there could, in principle, be no content to the idea that science progresses.
This is not the only way to view the meaning of theoretical terms and thus not the only view of possibility of comparing theories. But part of the force of the idea of a paradigm shift is that the change of world view is radical. Indeed Kuhn himself notoriously suggested that after such a shift, scientists inhabited a different world. Thus any less radical account of the consequences of theory change would undermine the point of the suggestive word ‘paradigm’.
This, however, suggests that, at the very least, there is something strange about wishing to usher in a new paradigm. Without a standard by which to judge progress across such a change, what rational motive is there to wish for such a change? That, however, is not my purpose in recalling the close connection between paradigms, meaning and incommensurability. The real issue concerns the application of these ideas to psychiatry in particular.
Neuroscience, human distress and the prospects of paradigm change
In order to develop my real concern I will return to (and re-quote) the passage from Frances I quoted at the start. The most obvious reason for thinking that psychiatry is awaiting a paradigm shift are developments at the hard science end of psychiatry. Even Frances mentions ‘incredible recent advances in neuroscience, molecular biology, and brain imaging’ when discussing others’ confidence in the possibility of a new paradigm. Frances himself argues that ‘descriptive psychiatric diagnosis does not now need and cannot support a paradigm shift’ but he goes on to say that there ‘can be no dramatic improvements in psychiatric diagnosis until we make a fundamental leap in our understanding of what causes mental disorders’ and that the absence of biological tests in diagnostic criteria suggests that this has not been reached. But that comment does not distance himself from what might seem a plausible aspiration for a bio-medical psychiatry. What is needed, on this assumption, is greater biological understanding of ‘what causes mental disorders’ and a sufficiently ‘fundamental leap’ in that might give us the hoped for paradigm shift.
But I think that there are two fundamental complexities that this view - a view Frances does not sufficiently distance himself from - ignores. The first is that, within psychiatry, the focus of neuroscientific, biological and brain imaging technology is mental pathology. Progress has been recently made in these areas and more progress is needed but, additionally, progress is also needed in determining not just what causes mental disorders but what they comprise. What is it, in other words, for something to be a mental disorder? There is no reason to think that an answer to this question can be provided by neuroscience, molecular biology, and brain imaging since, insofar as these can help shed light on psychopathology, one needs first to have decided the extension of that concept then to study its neurological and biological underpinnings. Given the conceptual complexity of the very idea of mental disorder, and that what is so classed is so contested, any leap forward in knowledge of brain mechanisms needs to go hand in hand with answers to that question.
The second complexity stems from the first. Suppose that innovations in neuroscience, molecular biology, and brain imaging were used to articulate a form of psychopathology on the basis of its neurological similarity to currently identified forms but which had no connection to any mental distress or suffering. That would not, I suggest, mark a triumph of neuroscientific psychiatry. Rather, it would amount to psychiatry losing its way by losing its connection to its particular subject matter.
This point suggests, however, a Winchian point [Winch 1958]. Psychiatry, unlike a more disinterested study of the brain, has an essential connection to human distress and suffering. But if so, it has an essential connection to the concepts with which we, as agents, make sense of ourselves. Whilst there seems no constraint imposed by the subject matter of much of natural science on the limits of conceptual innovation (as long as the concepts arrived at can still be understood by at least some scientists), the concepts of psychiatry need to retain some connection to those concepts in terms of which we ordinarily make sense of ourselves. Only so, can human experiences play at least some guiding role for psychiatric diagnosis, theorising and care .
If this is so, then the wish for a paradigm shift in psychiatry seems doubly misplaced. First, the connection to incommensurability undermines the rationality of the wish. Second, a change which did not sever the connection to the concepts we use to make sense of ourselves would not be a paradigm shift since the innovation would be merely partial leaving in place standards for rational assessment of the technical innovations. But a properly radical paradigm shift which rendered the pre- and the post- shift worldviews incommensurable would have to sever the connection to those grounding concepts and that could only be because psychiatry had lost its way.
Feigl, H. (1970) ‘The “orthodox” view of theories: Remarks in defense as well as critique’ in Radner, M. & Winokur, S. (eds.) Analyses of theories and methods of physics and psychology. Minnesota studies in the philosophy of science Vol. IV. Minneapolis: University of Minnesota Press: 3-16
Frances, A. (2009) ‘A Warning Sign on the Road to DSM-V: Beware of Its Unintended Consequences’ Psychiatric Times June 26
Masterson, M. (1970) ‘The Nature of a Paradigm’, in Lakatos, I. and Musgrave, A. (eds.) Criticism and the Growth of Knowledge, Cambridge: Cambridge University Press
Winch, P. ( 1990). The Idea of a Social Science and its Relation to Philosophy, London: Routledge
I’ve been invited to spend a bit of time at the University of Paris-Descartes by Pierre-Henri Castel to discuss anglo-american philosophy of psychiatry. I am frantically - but with minimal success so far - trying to revise my O level French.
After the summer, I’ve also been invited back to Paris to a workshop on social neuroscience in October.
Between the two there’s a workshop in Dortmund organised by Logi Gunnarsson on alienation (of whose book I owe a review on this blog).
My third and final paper on idiographic versus nomothetic versus narrative judgement has emerged from pre-production limbo with Psychopathology. I’ve seen a proof! I’ve also seen a proof of the Clinical judgement, expertise and skilled coping paper for the Journal of Evaluation in Clinical Practice. And the Szasz portmanteau paper is due out in March.
My co-authored chapter (below) in a substantial and expensive (£125) textbook on psychiatry came out in November but I’ve just had a copy. In the contents list I’m called Tom!
(2009) Fulford, K.W.M. (Bill) and Thornton, T. ‘The role of meanings and values in the history and philosophy of the science of psychiatry’ in Basant Puri, B. and Treasaden, I. Psychiatry – an evidence-based text for the MRCPsych, London: Hodder Arnold, Health Sciences
Perhaps more interesting and certainly more personally gratifying was finding this message on my little used Facebook page which I report (at the risk of sounding even more self-serving than a housekeeping entry already implies) partly to emphasise how pleasurable such one off comments are but also to say that there must be at least two people interested in McDowell in Iran.
I am really glad to see you in Facebook, and first of all, I apologize if my English is not good enough.
I am an Iranian student in philosophy; actually, I graduated with an M.A. in Philosophy-logic, from the university, Allameh Tabatabaie, which is the most prominent university, in Humanities. Your book on John McDowell was the most important resource for me to understand what McDowell’s view is about the Theory of Sense, which was the main theme of my thesis. My thesis had the title “John McDowell on Theory of Sense and Reference” which was the first text about John McDowell’s philosophy (and Dummett’s), in Persian (Farsi) language in Iran, and with lack of resources about new analytic philosophies and philosophers here, finding your book in a library (of an institute of philosophy which is the one among very finite [finest?] institutes in Iran) was a real miracle, because reading McDowell’s papers alone, with no complementary and illustrative texts, was really difficult. I could defend my thesis (last summer) with a really good grade and it was thanks to your book’s help.