Report on the Philosophy of Psychiatry Work in Progress Day, Lancaster University, 2nd of June 2017

The 2nd of June saw the annual Philosophy of Psychiatry Work in Progress Day. This has been going on for longer than I have been at Lancaster and is the fifth one I have presented at. There was good attendance and it went smoothly, an enjoyable day of seeing papers from multiple perspectives in the philosophy of psychiatry. I shall give a summery of the talks below.

Rachel Cooper (Lancaster) presented on “Intentional actions, symptom checklists, and problems with cross-cultural validity”. She discussed standardised tests for personality disorders and how they included intentional actions. She then discussed how intentional actions are often given different interpretations in different cultures, creating problems for such standardised personality tests.

Marcin Moskalewicz (Oxford) presented on “Ipseity, self-consciousness, and the problem of time in schizophrenia”. He outlined ways in which time is perceived and explained how altered self-consciousness in schizophrenia can lead to an altered sense of time.

Moujan Mirdamadi (Lancaster) presented on “Death-consciousness and Depression in Iran”. She discussed the Iranian focus upon death and described how she felt this influenced some of the descriptions she received from her qualitative study of depressed Iranian patients.

Ian Hare (UEA) presented on “Qualitative Methods: a Philosophical Toolkit for Cognitive Psychiatry”. He outlined how qualitative studies can be used to gain greater descriptive understanding of a diagnosis and this can be used to provide a firmer basis for constructing psychological and psychiatric theories.

Rachel Gunn (Birmingham) presented on “The Delusional Experience as a Breakdown in Affective Framing”. She described how experience of delusions was not just purely mental but also involved many physiological and experiential changes. She then suggested that this means non-cognitive therapy approaches could be of value.

Dan Degerman (Lancaster) presented on “If you’re not psychiatry, you’re antipsychiatry – Exploring how American psychiatrists perceive their critics”. He outlined how psychiatrists perceived anti-psychiatrists and how they often labeled critics with many divergent views as anti-psychiatrist. He then suggested this can unfairly devalue psychiatric patients, who often have valuable concerns over psychiatry, thereby reducing their political agency.

Anneli Jefferson (Birmingham) presented on “Mental disorders and brain disorders – an obsolete distinction?”. She looked popular and influential arguments against seeing mental disorders and brain disorders which employ a hardware-software analogy. She criticised this argument on causal grounds then looked at counter arguments to her claims.

Joel Kruger (Exeter) presented on “Unworlding and Affective Externalism in Schizophrenia”. He discussed notions of the external mind, how perception and cognition can involve parts of the external world, and used it to understand notions of breakdown of affective scaffolding in schizophrenia and the sense of unworlding it leads to.

Victoria Allison-Bolger presented on ” ‘A thing like the ocean’ – using metaphor in understanding psychoses”. She discussed how many psychiatric diagnosis did not fit typical notions of a good classifications and suggested this means we should modify notions of good classifications to fit the diagnosis rather than make diagnosis fit our preconceptions about what is a good classification.

Gloria Ayob (UCLan) presented on “Personal autonomy and serious psychopathology”. She discussed the difficulties and possibilities of attaining a value neutral notion of serious psychosis. She tried to see if the Liberal notion that everyone should be free to believe what they wish providing it does not harm anyone could fit the notion that some people have deluded views of the world.

Finally, I presented on “Causal Structures vs Causal Mechanisms: Implications for RDoC”. I will outline these ideas in the future.

Overall, an enjoyable day with a lot of paper presented on interesting and diverse areas. The workshop typically runs every year, usually in May, June or July, and it would be worth looking for the announcement of the 2018 workshop next year.

Philosophical analysis of Neurotribes

My article, ‘Putting the Present in the History of Autism’ has been published in Studies in the History and Philosophy of the Biological and Biomedical Sciences (a pdf of the uncorrected proofs can can be found here). Though the article title mentions history, there is much philosophical content in article.

I focus upon Silberman’s extremely positive message about autism, discussing his portrayal of the past as being mistaken about the diagnostic criteria for autism and how the modern diagnostic criteria for autism has effectively got it right. I felt strangely conflicted about Silberman’s argument. One on hand, I thought he was unfair to many historical diagnostic criteria for autism. On the other hand, I still broadly agreed with his position. I agree with Silberman with that autism is getting something right about the world, being a worthy scientific concept and describing the world to at least a reasonably degree of accuracy. On this basis I significantly share Silberman’s positive message. However, as much as I believe in modern autism, I might believe even more in an alternative diagnostic approach to autism (whether it be one similar to one used in the past or something new), such as one with a greater number of subtypes or one with slightly altered boundaries. I felt Silberman’s positive message unfairly downplayed such alternatives. I think we need do research and consider our values to decide if the current diagnostic approach is superior to alternative diagnostic criteria and possible subtypes. We need study alternative approach and subtypes to see if we can make autism get even more right about the world or, alternatively, become more confident about modern autism by showing it works better than possible alternative views. So whilst I share Silberman’s positive views, I felt they risked reducing interest in scientifically investigating alternative approaches to autism, hence I both agreed with Silberman yet was critical of his position. I outline my views fully in the article.

Reviewing Psychiatry Disrupted

Psychiatry Disrupted was released in 2014, making it a relatively new book on the topic of anti-psychiatry. The editor’s introduction argues that anti-psychiatrists often do not focus enough on what an alternative to psychiatry would look like and this book is intended to fill this gap. Since most the well known classic anti-psychiatry texts are rather old and since they usually criticise psychiatry without sufficiently outlining an alternative I was interested in this book. Whilst I am far from being an anti-psychiatrist myself, I wanted to see what a modern alternative to psychiatry would look like. Unfortunately, I think this book fell quite far short of this objective.

Firstly, many articles often criticise psychiatry without actually explaining why psychiatry might be wrong. This does not occur on every issue but sometimes it is stated as a given that psychiatry is in error. For example, some authors simply criticise psychiatric classifications without explaining why they might be flawed. This is problematic because the problems with classifications are complicated. Generally, most psychiatric classifications are trade-offs, a committee having choices over how to formulate them and generally any advantages to a way of classifying will also involve disadvantages. For example, lumping vs splitting, or not otherwise specified being vague but allows more coverage, or having narrow but specific diagnosis vs broader ones which over-lap with each other. Now, it could be argued that psychiatrists are choosing a bad combination of advantages and disadvantages, or that any possible combination of advantages are always outweighed by disadvantages. I don’t think that myself but at least making that argument would be better than an outright dismissal without argument. This occurs too many times in the book.

Secondly, there was relatively little on what an alternative to psychiatry would look like. There is quite a lot of detail about how different groups with diverse interests could get together to oppose psychiatry. In a sense this moves the anti-psychiatry movement forward, in that we know anti-psychiatry objects to psychiatry and this book shows new ways to go about objecting. But I’m still uncertain what should replace psychiatry. I got the impression that an alternative would involve more psychotherapy, less drugs, more user involvement and more user choice. In principle, I could agree with all that, but doing this would not require an end to psychiatry. This would still leave room for psychiatrists to classify and proscribe drugs, just that psychiatrists would more often refer people for psychotherapy and involve the user more. So this is hardly a massive overhaul of psychiatry. If the anti-psychiatry movement has something more radical in mind then I want to see it explicitly outlined, a detailed alternative of what would replace psychiatry.

The book did have some good points. It went into quite a lot of detail about how various different interests groups might conflict and gave some reasoned arguments about how to resolve these conflicts or who should get priority. It also had some innovative ideas about how different groups could work together. Additionally, it did highlight, often with practical examples, various ways in which psychiatric patients can be oppressed, devalued or misinterpreted, primarily due to false assumptions on the part of psychiatrists and care workers. Some of these issues were subtle and worth reading about.

Thoughts on Brexit for British psychiatry

On the 23rd of June Britain voted to leave the EU. It will take many years before we ultimately know how things turn out. Here I will only discuss certain possible implications for psychiatry. Whilst issues surrounding funding of British research and collaboration with European research have been discussed in the media, there may also be an impact on the nature of mental illness itself.

The media is often calling Brexit the biggest decision in UK politics in the last fifty years. Philosophers of psychiatry rightly emphasise that people with mental illnesses are social beings living in a social environment. Even if there are set biological or psychological causes of many DSM diagnosis individuals with those diagnosis will still be affected by the social environment they are in. Consequently, different social environments could mean mental illnesses turn out differently. Now, exactly how much this is the case is difficult to judge, it is certainly very easy to focus too heavily on people as just being their abstract diagnosis disembodied from the environment but equally it is easy to just simply see mental illness as a social phenomena. Exactly how much weight we should place on each is difficult to say, and this may vary both for different diagnosis and for individuals with the same diagnosis. However, I do think it is credible to say social factors are important and can with some regularity make mental illness turn out differently. To the degree there are significant social changes then, for symptoms with social causes, there could be differences in which symptoms are expressed or in how they are expressed. For example, if there was an economic downturn then this could reduce the quality of life of many people, pushing many over the threshold for a diagnosis of anxiety or depression. Equally, it might mean people who are currently diagnosed now face new challenge and thus express symptoms in different ways. It may impact comparisons of studies taken from different decades, and impact ongoing longitudinal studies, if there are significant changes in the population of the UK. It could also impact comparisons with studies done in Europe.

It also raises more deeper philosophical questions. If mental illness can be influenced by social factors, should we have classificatory systems like the DSM and ICD which are typically treated as universal? I think this is a question which would need be informed by empirical research, studies of exactly how mental illness manifests in different settings, and even after that the decision would be influenced by difficult practical questions. If universal classificatory systems were rejected, then how broad should they be? Do we want to be part of the American classificatory system, the European one or have a unique British one? Of course, for better or for worse, the American and European systems are very similar, so in that reguard any detachment from Europe does not leave a binary choice between choosing between contrary American and European systems.

Reviewing Philosophical issues in Psychiatry III: Nature and Sources of Historical Changes

This is the third book in the series, started in 2008 and then the second volume in 2012. All three volumes have been edited by Kenneth Kendler and Joseph Parnas, bringing together contributions from psychiatrists, philosophers of psychiatry and historians of psychiatry. Each volume takes the same format, an overall introduction by one of the editors and then individual papers grouped by themes. Each paper is fronted by a brief introductory article by one author, then the main article by another author and then a commentary by a third author. This means each book contains an immense number of articles (43 in the case of this volume) despite only being 380 pages long. The introductions and commentaries are almost always worth reading, often making significant points in their own right which are not present in the main article they are discussing. This makes the book an excellent source for a multiplicity of viewpoints and, since sometimes the introductions and commentaries disagree with the main article, diverging points of view. If you wish to find an academic expressing a philosophical viewpoint on psychiatry, or multiple academics expressing contrary viewpoints, then turning to one of these volumes is a good idea.

Of the three volumes, this one is the most diverse in approach, mainly because it closely integrates philosophy and history. It has three sections. The first discusses ontological, epistemic and methodological issues relating to changes in psychiatry, relating to issues like why does psychiatry keep changing, are these changes for the better, what sort of changes should we aim for, etc. Secondly, what specific broad changes have occurred in psychiatry, such as development and decline of psychoanalysis, operationalism and genetic explanations. Thirdly, philosophically informed histories of specific diagnosis, such as schizophrenia, depression and autism. All three sections are worth reading, though how much you will get out of each section will likely vary considerably on your specific interests. As someone interested in questions of belief in psychiatric classifications, I primarily found the first section useful. I think psychiatric diagnosis can potentially merit belief even if there is not one fixed, eternal true set of psychiatric diagnosis – the causes of mental illness change, mental illnesses manifest differently as social settings change and our values which we use to interpret mental illness change. Though not all articles in this section addressed these specific issues, I found they gave much to think about on such question and offered some novel approaches and novel possible solutions to such issues.

Though I could comment on many articles (and may do so in future blog posts), the one which most interested me is by German Berrios. This articles challenges a long standing approach in philosophy of psychiatry. Generally, most mental illnesses are seen as separate from their environment. Internal biological and psychological causes (potentially set off by environmental causes) produce symptoms which express themselves in a social context. So on this model, the social context is not itself a cause of the symptoms but is a cause of how the symptoms are expressed, i.e. the symptoms interact with a social environment. However, Berrios challenges this, arguing the social context is itself part of the symptom, the social context cannot be separated out as something the symptoms interact with but are themselves part of the causal process. This makes causation in psychiatry much more complicated but I think much more realistic. It makes mental illness less static, less fixed, more embedded within the environment, rather than viewing mental illnesses as fixed and static yet malleable in how they are expressed. At a minimum, it raises important questions about how we should think about causation in psychiatry, where we should put the boundaries between things, their causes, and the environment in which they causally manifest in. At minimum, Berrios shows an alternative way of parsing up that equation and argument is needed to take the symptom manifesting in social context approach as superior to social context as part of symptoms.

Reviewing Peter Hobson’s The Cradle of Thought

Peter Hobson’s The Cradle of Thought is a philosophically and scientifically informed discussion of how thought develops in early life. Hobson’s main argument is that “interpersonal engagement contributes to the development of the mind – and [that] disordered interpersonal relations affect development of thinking” (p.143). He discusses many scientific studies which show how the level and nature of interpersonal relationships can impact the capacity for thought, suggesting deficient interpersonal relationships can lead to impoverished thinking.

Hobson highlights this through discussing individuals who are often not as capable of interpersonal interactions as most humans. He primarily discusses autism in detail, suggesting the usual thinking of autistic individuals (such as theory of mind differences) arise from lack of normal social and emotional interactions in early life. He heavily emphasizes that autism has a genetic component which results in biological differences (rejecting notions of poor mothering causing autism which some psychoanalysis used to believe) but argues the abnormal thinking itself is not primarily just due to biological difference. Rather, the biological differences result in difficultly interacting normally socially and emotionally, and this abnormal social and emotional experience results in abnormal thinking.

One might ask, why not just say the biological differences are responsible for both the abnormal interactions and for the abnormal thinking? Hobson uses a novel strategy to answer this question, primarily by looking at other types of individuals who also can face difficulties interacting normally. He considers individuals who are blind from birth and individuals who had very little social or emotional interaction in early life when raised in Romanian orphanges. These individuals often could not relate to other people in early life in the same way as most children. He then shows that these individuals sometimes develop some symptoms of autism, at substantially higher probabilities than would occur at random. Autistic individuals have biologically abnormal minds, blind individuals lack sight and Romanian orphans presumably have no major biological differences, yet all can exhibit some similar behaviour we associate with autism. Therefore, Hobson argues, some autistic behaviour is not directly the product of the biologically abnormal mind, but the biologically abnormal mind sets up abnormal interpersonal relationships and those interpersonal relationships result in symptoms associated with autism. Hobson also provides some evidence from how mothers with boarderline personality disorder interact with their children and how chimpanzees lack some parts of human socialising, suggesting both these cases can contribute to less than fully developed thinking.

Even though considered a developmental disorder, there is often a suggestion within scientific literature that the psychological development purely follow biological developments, rather than biological development resulting in psychological developments which then result in further psychological developments. I think a simple biological leading to psychological approach often present in modern science is far too simplistic, but I am unsure whether I think Hobson is correct or if I prefer a middle ground between Hobson and that modern science picture. Reguardless, the book is highly recommended for raising some important questions, presenting a solid evidence basis (often from very diverse sources which are not usually discussed in the context of autism) and for being highly accessible, being effectively popular philosophy and popular science.

Science and its use for philosophers

Really nice quote about the relationship between philosophy of science and philosophy more generally: “As long as there was no such subject as ‘philosophy of science’, all students of philosophy felt obligated to keep at least one eye part of the time on both the methodological and the substantive aspects of the scientific enterprise. And if the result was often a confusion of the task of philosophy with the task of science, and almost equally often a projection of the framework of the latest scientific speculations into the common sense picture of the world … at least it had the merit of ensuring that reflection on the nature and implications of scientific discourse was an integral and vital part of philosophical thinking generally. But now that philosophy of science has nominal as well as real existence, there has arisen the temptation to leave it to the specialists, and to confuse the sound idea that philosophy is not science with the mistaken idea that philosophy is independent of science” Wilfrid Sellars (quoted in an article from the book What is Philosophy?, C. P. Ragland, Sarah L. Heidt (editors)).

Much has changed since 1956 when Sellars wrote this but it raises an important issue. I’ve long believed we need closer merge science and philosophy, and whilst many philosophers do not integrate science in their work, plenty do. This is positive. However, I’m often concerned that when philosophers do use science to further their arguments, they often take scientific evidence too concretely, as something which either logically supports their argument or does not. Generally, however, scientific theories are models that describes idealised probabilities. They do not easily function as premises which entail logically valid arguments or function as clear counterarguments. Rather, they function more analogously to risk factors, scientific claims being individual sources of evidence which push an argument in one direction or another. Sellars claims general philosophers paid more attention to the methodology of science. I wonder if this is lacking today. Whilst it is great that philosophers not infrequently turn to science to support their arguments, those philosophers should realise how tentative, how heavily inferential and how probabilistic many scientific claims are. When philosophical claims rest upon such scientific claims then the strength of those philosophical claims is reduced. I think this is generally the case and philosophy would be better to recognise this. Just like scientists, philosophers employing science need both knowledge of science and knowledge of methodology of science.

Book Review of Alternative Perspectives on Psychiatric Validation: DSM, ICD, RDoC, and Beyond

The December issue of History of Psychiatry contains my book review of Alternative Perspectives on Psychiatric Validation: DSM, ICD, RDoC, and Beyond (edited by Peter Zachar, Drozdstoj St. Stoyanov, Massimiliano Aragona and Assen Jablensky).

Though the book review appears in History of Psychiatry, the book is primarily philosophical (plus a few history chapters). Some papers discuss what notions of validation can be legitimately applied to, some discuss under what conditions validation succeeds and others discuss exactly what validating something accomplishes. For its interesting and diverse discussion of validation it is recommended for both philosophers and psychiatrists.

When science goes wrong

I love science perhaps above and beyond all else yet I refuse to take a blind acceptance approach to science. When science gets something right then that is among the most important things we have, yet so often science gets things wrong. Here is a fantastic example. This is taken from an article by Emilie Bovet (from the book Philosophical Issues in Psychiatry III: the nature and source of historical change). She is discussing epigenetic research on violent behaviour and how some researchers combine evolutionary models and animals models (i.e. understanding how what evolutionary factors shaped psychology of modern animals) and sometimes draw parallels with humans. She points out just how far some researchers have taken this when she said “an internationally famous researcher in behavioral genetics claimed [at a conference] that beards in human males were related to the lion’s mane, which could explain a lot of similarities in way they both act” (Bovet 2015). She uses this as a good example of how specific methodologies (emphasis on evolution and animals) drives theoretical hypothesis and she provides some much more relevant alternative methodological approaches which would result in much better theoretical hypothesis. Anyway, I quote Bovet simply because she gives a clear example of when blind acceptance of scientific researchers is clearly unwarranted!

Realism vs… coherence? Relativism?

One of my philosophical interests is establishing if psychiatric classifications are real. This question has many, many dimensions and I feel it is often portrayed in untenable terms. A useful starting point is: what does it mean for a scientific thing (an electron, Newtons laws) to be real? (Note some interesting subquestions: are scientific things real in different ways to non-scientific things? Is there one overarching notion of real for all sciences or would psychiatry need a different notion of reality to physics). Here is an interesting and potentially useful diagram:

Realism Antirealism
[Note that I found this on Twitter [], I do not know who the author is but I did not create it].

It gives an interesting perspective on how various elements interrelate. I do not fully agree with it. Should correspondence and coherence be put at opposite ends of a scale? I wonder if coherence might be better put somewhere closer to the center, replacing the end of that arrow with relativism. Perhaps Psillos is correctly placed for his earlier works but I think his later writings place much greater emphasis on theoretical virtues, hence needs to go closer to coherence (but without moving too far from correspondence). Also, where would a neo-Kantian position in the style of Massimi and Kitcher go? The middle ground might seem the obvious place but I would not like to associate them with Constructive Empiricism or Instrumentalism. Anyway, the table has got me thinking and it certainly makes some interesting claims in a convenient visual form.