Category Archives: Realism

Perspectivism and psychiatric diagnoses

My article ‘Perspectivism and Psychiatric Diagnoses: Respecting History and Constraining Relativism’ has been published in the European Journal for the Philosophy of Science (click for the open access article). I aimed to use a philosophy of science named scientific perspectivism to position psychiatric diagnoses as being between realism and relativism, that is, between psychiatric diagnoses being mind-independent entities out there waiting to be found and them being arbitrary conventions. I will outline my motives for writing the article in this blog post.

Psychiatric diagnoses have been described as being arbitrary, inventions and made-up. My article aims to defend psychiatric diagnoses from such claims by responding to one issue which motivates such claims. Historians and sociologists often provide detailed studies of how various social conditions and theoretical position lead psychiatrists to conceptualise psychiatric diagnoses in particular ways. If one set of social conditions, theoretical assumptions or methodological practices is present then psychiatrists will conceptualise psychiatric diagnoses within a range of ways but if a different set of social, theoretical and methodological factors is present then psychiatrists will conceptualise psychiatric diagnoses within yet another different set of ways. These factors do not determine which diagnoses psychiatrists formulate but they do influence and constrain which psychiatric diagnoses are formulated. For example, views about what constitute good mothering or good health could influence psychiatrists, as could theoretical factors such as whether psychology is seen to largely stem from underlining biology or from social interactions with the environment, as could whether focus goes upon finding statistical commonalities across many individuals or qualitative studies of individual people. This leads to the concern that psychiatric diagnoses reflect the opinions of psychiatrists, which have been heavily shaped by these factors, rather than reflect reality. Psychiatric diagnoses would not be real and instead only be the product of the wider social, theoretical or methodological factors in fashion in a particular period.

As a philosopher, I feel such an understanding potentially misses out something important. As a philosopher, my natural inclination is to say, yes, such factors can influence psychiatrists but the question of whether a scientific claim reflects reality is separate to question to why scientists believe that particular claim. A philosopher might tell these historians and sociologists that they have successfully documented the views that psychiatrists hold upon what exist but that is different to what actually exists. As a simple example, historians can document changing views that people have held about whether the earth is the centre of the universe or not but the views that astronomers hold does not then determine if the earth actually is at the centre of the universe. It can certainly be argued that psychiatrists being influenced changing social, theoretical and methodological factors make it unlikely that the psychiatric diagnoses they formulate reflect reality, but strictly speaking that is a point about how likely it is that psychiatrists are describing reality (an epistemological point) rather than a question of what exists (an ontological point). 

However, as much as I am a philosopher, I also do historical research on psychiatry and I think philosophers need to take history seriously. I accept scientists are constrained by the historical context they work in but at the same time I also think that we should try to divide scientific claims into true, partly true and false. To do this I draw upon a philosophy of science named scientific perspectivism. This offers a more nuanced notion of truth and reality than either a common sense notion of ‘what things are really like’ or some form of essentialism. Following scientific perspectivism, I instead favour some sort of middle ground between ‘how things really are’ and the notion, seemingly favoured by some historians and sociologists, that all claims about truth (in psychiatry at least) are dependent upon wider social and historical factors. My motive for this is believing that some claims can be more truthful than others, some claims describe the external world better than others, yet no claim actually describes the external world as it is independent of our perspective.

One motive for my stance is that without it the legitimacy of science is potentially at threat. For example, if the beliefs of psychiatrists are constrained or heavily influenced in the era in which they work then their views seem to be the product of many subjective, rather than scientific, factors. Why should their beliefs have any higher legitimacy to the beliefs held by anyone else? Might psychiatry be literally on no better foundation than mere opinion and is no better established than the opinion of a random member of the public? Now, historians and sociologists typically do not endorse such a negative view of psychiatry but it is not clear to me what stops their position entailing such negative conclusions. As such, whilst I want to take seriously the influence of social factors on psychiatry, I think we need to still try and establish which claims are more truthful and which are less truthful. In the article I employ a philosophy of science to try and establish how philosophers can retain a non-trivial notion of truth whilst also respecting the influence of social, cultural, theoretical and methodological factors on psychiatry. 

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.

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.