Friday, November 14, 2008

What Should Be the Future of the Philosophy of Psychiatry?

This was a submission to a special journal issue that never happened. It was written in 1999.

What Should Be the Future of the Philosophy of Psychiatry?

I argue that philosophy of psychiatry has the potential to be a rewarding synthesis of philosophy and theoretical psychiatry. It can achieve a sophistication and richness that is lacking in most medical ethics. It can achieve a relevance to real life and policy that is lacking in most philosophy of psychology. Many of the most exciting areas in modern philosophy, such as philosophy of psychology, moral psychology, philosophy of science, personal identity, and moral theory are directly relevant to philosophy of psychiatry. There is a division in philosophy of psychiatry roughly corresponding to the divide between analytic and continental philosophy. A great deal of work that is done under the heading of “continental” is largely a waste of time, and needs to be improved. Nevertheless, this does not mean that all of the work in “continental” is worthless, and one of the most important tasks facing those who are in the position to shape the field is sorting out the wheat from the chaff. There are also problems with so-called “analytic” approaches to philosophy of psychiatry. In particular, it is difficult for philosophers to mold their concepts so that they fit the curves of clinical reality. Although dialog between philosophers and mental health professionals is often not easy, and is sometimes excruciating, it really needs to be fostered if we are to achieve a satisfactory subdiscipline of philosophy.

Keywords: interdisciplinary studies, methodology, content, analytic philosophy, continental philosophy, dangers, rewards, philosophy of psychology, cognitive science, moral psychology

Whom am I addressing? In considering the question of the future of the philosophy of psychiatry, it makes sense to address those who have some power and influence. That is, people in a position to hire and fire others, to award research grants, to decide topics for conferences, to referee journal articles, to influence which books get published, to themselves decide what to focus their research on, to teach philosophy of psychiatry, and to influence what topics graduate students write on.
It is hard to avoid glib or trite answers to the question. “The philosophy of psychiatry should be wonderful. Philosophers of psychiatry should be given awards for their work in the field of excellence.” “There should be a profusion of ideas in philosophy of psychiatry, and the best philosophers should be competing with each other to work in this exciting new area of research.” “Philosophers of psychiatry should be kind and polite to each other.” I will try to avoid being too glib.
I will discuss philosophy of psychiatry under three main headings: topics, practitioners, and methodology.

It is relatively simple to predict some of the topics that will continue to occupy Philosophy of Psychiatry in the future. For example, psychiatric ethics continue to face issues of when it is morally permissible to treat people against their will. It is highly likely that it will continue to be necessary to argue that mental health problems deserve a parity of treatment with other kinds of health problems. Psychotropic drugs will probably increase in their use, and some people will continue to criticize their widespread use as treating the symptoms of social problems rather than the root causes.
It is also likely that philosophers will continue to find psychopathology interesting when talking about the unity of mind, self, or consciousness. Extreme cases of psychopathology will continue to serve as exemplars or test cases for theories of personhood.
These are important directions for philosophy of psychiatry. It’s uncontroversial that these topics will be relevant. I want to move on to some more controversial issues.
First, multiple personality disorder or dissociative identity disorder. There has of course been interesting philosophical work done concerning the metaphysical understanding of this condition. Philosophers have extended the previous discussions of brain bisection and blindsight that occurred in philosophy of mind, to give serious consideration to the idea that there can be more than one person in a human body. Obviously one’s view on this depends greatly on what one takes to be the criteria of personhood, so there has been useful to and fro between the discussion of personhood and the discussion of MPD. One can easily imagine that the debate will continue as many others have in philosophy over personhood and correct definitions, such as the debate over the moral status of a fetus, anencephalic newborn babies, and imaginary fission cases in personal identity. It would be unfair to say that these debates don’t go anywhere: the discussion is increasingly sophisticated. However, it shows little sign of getting closer to consensus. Well mapped-out positions become increasingly well-entrenched.
So here I can make my first substantial claim. My claim is meant to be at the metalevel, rather than taking a position about personhood. Furthermore, I do not accept the view of Hacking (expressed in Rewriting the Soul, if not in his more recent work) that we should simply stop asking questions about personhood, and that the debate about personhood is somehow misconceived. They are important questions, and although we may have great difficulty answering them, we have no alternative language or set of concepts with which to address the questions that issues of personhood raise. But what I do want to say here is that there is a danger in placing such debates at the center of philosophy of psychiatry. My main reason for this is my observation is that the debates about personhood and multiple personality have ground to a halt, and that his has been largely due to the realization by philosophers that much of the debate about multiple personality has been psychiatrically naïve. While asking “how many people exist in a multiple personality” may be a philosophically important question, the phenomena surrounding multiplicity are so complex that much of the debate has not been very useful.
These comments of mine are, I have to admit, rather cryptic. But they are part of a larger point I want to make about how best to do philosophy of psychiatry which will emerge as a result of my discussion, so for now, I will move on.

Who should be working in philosophy of psychiatry? In order to address this, it is worth taking a look at the field of medical ethics. To be blunt, a great deal of the published work in medical ethics is philosophically unsophisticated. Furthermore, many people who classify themselves as “medical ethicists” do not pursue publishing, and have only a tenuous grasp of recent philosophical debates. Thus, medical ethics presents itself as a warning to philosophy of psychiatry. The urge to be inclusive is commendable, but it can lead to low standards for a discipline.
The converse error is to restrict philosophy of psychiatry to philosophers. It will of course be philosophers who have the most philosophical sophistication, and they will be best qualified to address the existing philosophical literature relevant to many debates in psychiatry. But philosophers generally lack any sustained and systematic training in clinical psychology, and there are very few Ph.D. philosophers who also have M.D.s. This causes practical problems. Philosophers and non-philosophers find it hard to find a shared language with which to discuss issues. Many implicit assumptions in specialized fields and not spelled out, and people foreign to those fields fail to understand such assumptions have been made. This is not only true of the empirical assumptions made by psychiatrists. Often psychiatrists who have some philosophical training make implicit philosophical assumptions not shared by all philosophers. Therefore, when philosophers talk to psychiatrists, and there is a mutual lack of shared language, the former can have a very difficult time working out where the empirical data end and the philosophical assumptions begin. Indeed, one of the problems that arise from philosophers’ lack of psychiatric expertise is that they can find it very difficult even finding a psychiatrist who is willing to talk to them for a prolonged period. Medicine generally is a field where qualifications count for a great deal, and if one does not have the right qualifications, one is excluded.
So far I have mentioned what are basically practical problems caused by the lack of shared language. But they soon lead to problems for the content of philosophy of psychiatry. While philosophers have philosophical sophistication, they generally lack psychiatric sophistication. (I should make clear that I speak as a philosopher with little psychiatric sophistication in the sense I am elaborating. My task here, to explain a kind of sophistication I lack, is not easy.) It is necessary to elaborate on what psychiatric sophistication consists in, in the context of philosophy of psychiatry. Philosophers can of course read psychiatric textbooks and journals on their own. They can learn about the latest theories and studies. However, I would argue that such learning provides only a partial understanding of psychiatry. In order to have a fuller understanding of psychiatry, and the different areas of the mental health professions more generally, one needs to spend time among these professionals. One needs to see their interaction with each other, and if possible, their interactions with clients and patients. (One can gain a little of this sort of knowledge through reading memoirs and first-hand accounts of clinical work by mental health professionals. There has been a profusion of “tales of psychotherapy” in the last decades, because, like detective stories, they often make gripping reading.)
This sort of “field experience” gives one all sorts of knowledge. There is sociological knowledge about the mental health profession, and the interaction between the different subgroups. Especially interesting and undocumented is the interaction between psychiatrists who visit patients in mental hospitals once or twice a day, and the nurses and aids who actually spend most of the day with patients. One sees a chain of command, with instructions generally coming from psychiatrists and occasionally other doctors, and being passed on down. Through this chain, one sees how theory is realized, or transformed, in practice. One also gets a greater understanding of the role of theory in psychiatric practice. It is quite possible for psychiatrists and others to pay lip service to a theory, but for their actions to be largely determined by other implicit assumptions or pragmatic considerations. Most obviously one sees this when financial constraints limit the treatment a patient is provided. But one also sees more subtle factors such as dynamics between professionals affecting the treatment of patients.
One example of how it can be important for philosophers to understand the role of theory in psychiatry comes from the case of classification and diagnosis. Many criticisms of psychiatry focus on its classification schemes, and especially the Diagnostic and Statistical Manual of Mental Disorders. When referred to in the popular press, it is regularly called “the psychiatrists’ Bible.” To be sure, it does play an important role in psychiatric life. Diagnosis is linked to careful observation of the patients, so good diagnosis requires better understanding of the patient. Psychiatrists in training are required to learn how to diagnose. A diagnosis provides some indication of what a patient’s problems are, how she is likely to behave, and what treatments might be most successful. Nevertheless, it is a mistake to suppose that diagnoses are written in stone and are the final word. Mental health professionals are well aware of the unreliability of diagnosis and the way patients can often drift from one diagnosis, such as bipolar mood disorder for example, to schizophrenia. Psychiatrists have to fill out insurance claims and other paperwork for patients, which generally requires a diagnosis, but they don’t in fact always believe what they write down in such forms, and they rarely believe that it captures the whole truth. So criticisms of the diagnostic system are often psychiatrically naïve, because they assume that the system is more important than it actually is.
An associated problem for “psychiatrically naïve” philosophy is that it can be too abstract and far removed from the realities of clinical experience. This problem used to be serious in medical ethics. Philosophers would bring in a grand moral theory, for instance, and apply it to medical ethics. However, because philosophers are so used to dealing in abstractions, they found it very difficult to bring their ideas to the real world. In the same way that physics finds it easier to deal with simplified and idealized cases, such as mechanics assuming objects that are perfectly spherical and uniform in density, and frictionless surfaces, so applied ethics often prefers idealized case histories lacking the messy complication of ordinary life. Philosophers are often bemused when confronted with the task of a real life problem, precisely because there are so many different factors to take into account. This is just as true for psychiatry as it is in the rest of medicine.
So philosophers of psychiatry need interaction with mental health professionals. They may also benefit from interaction with historians of mental illness and its treatment, sociologists of the mental health profession, and anthropologists of mental illness. This requires a great deal of patience and hard work. Such interdisciplinary interactions are fraught with incomprehension, misunderstandings and miscommunication. Often interdisciplinary conferences achieve little, because of these problems. I believe one of the main issues for philosophy of psychiatry is how to foster such interdisciplinary work. I will return to this issue in the next section.

One of the most divisive splits within academic philosophy is between analytic and continental approaches. This split certainly threatens to divide philosophy of psychiatry too. But it is not a simple division. I will first discuss the division generally, before moving on to how it is relevant to philosophy of psychiatry and what can be done about it.
The very term “analytic philosophy” is not clear. Strictly speaking, it refers to a method of doing philosophy and an underlying view of what philosophy is. The method is conceptual analysis, in which the meanings of terms are analyzed. Thus to understand the nature of goodness, one should analyze the meaning of the word. The assumption behind this method is that this is all philosophy can achieve: it is futile to try to go beyond language and get at an underlying truth. Often there is a Wittgensteinian view of philosophy at play, which holds that philosophical problems arise because people misunderstand language. Careful analysis of language does not so much solve philosophical problems as dissolve them. Such an approach seems to assume that it makes sense to talk of the “meaning” of terms and that meanings of words can be clearly understood. More specifically, analytic philosophy seems to assume that we can divide truths into two sorts: analytic and synthetic.
Here we start to see one of the ironies of the term “analytic philosophy.” The preeminent American philosopher of the last fifty years is W.V.O. Quine, who many would identify as part of the establishment of analytic philosopher. Yet, Quine’s fame dates from his attack on the analytic/synthetic distinction, in “Two Dogmas of Empiricism.” Since at least 1952, a central tenet of analytic philosophy, i.e., that there is a clear and useful distinction between analytic and synthetic, has bee questioned by mainstream philosophy. There has never been any consensus, even amongst the most traditional of philosophers, that the method of philosophy should be conceptual analysis. In the last fifty years, there has been a profusion of different approaches to mainstream philosophy. Philosophy of psychology has thrived through its interdisciplinary alliance with cognitive psychology: in the journals of philosophical psychology, there is rarely any attempt to divide issues up into philosophical or psychological. All participants in their debates require a formidable command of scientific theories and data. It is clear that very little of their methodology depends upon conceptual analysis. Similar points can be made about philosophy of science, ethical theory, moral psychology, and political theory.
There are other terms that are also used to describe this area of philosophy, but these are no more adequate. For instance, sometimes people refer to it as “Anglo-American” philosophy. But the roots of this kind of philosophy are geographically diverse, including Ancient Greece, France, Germany, as well as England and the US. This kind of philosophy is also practiced all over the world, including Australia, Europe and northern America. It is certainly not restricted to the English-speaking world. Furthermore continental philosophy is also practiced all over the English-speaking world.
Even less adequate is the much overused epithet “positivist” philosophy. Positivism does refer to a movement deriving from August Compte, but only a small fraction of what is commonly called “analytic” or even “positivist” actually belongs to this tradition. Not much better is “empiricist,” since empiricism is only one branch of modern mainstream philosophy.
In short, there is no thematic or methodological unity to what is referred to analytic philosophy. (Nevertheless, despite the problematic nature of the label, I will continue to use it in a very broad sense. We may not be able to define analytic philosophy, but like pornography, we know it when we see it.)
We see a similar profusion of approaches within continental philosophy. There is historical work on Hegel, Fichte, Husserl, Heidegger, Sartre, de Beauvoir, and lesser figures. Some rather traditional religious philosophers are drawn to continental approaches, and at the same time, so are radical theorists of race and gender. Postmodernists, who are also classed as continental philosophers, disavow the whole project of traditional philosophy. There is no unity of assumption or approach under the umbrella of the label “continental philosophy.”
Furthermore, there are influential philosophers who do not fit easily within either the analytic or continental camps. Nietzsche and Wittgenstein come to mind first. Each is claimed by both camps, but each is so idiosyncratic that it is somewhat anachronistic to group either within a more general trend. Marx is also claimed by both camps.
Yet, despite the obvious silliness of the labels “analytic” and “continental” philosophy, they persist. There is plenty of name calling and stereotyping in the divide. Analytic philosophers accuse Continental philosophers of relying on the appeal to the authority of their major figures, and more generally, of lacking intellectual integrity. Continental philosophers accuse analytic philosophers of lacking an historical consciousness of their role approach, and indeed, of being boring due to the narrowness of their approach.
Academic philosophy has lived with this divide for decades now. Analytic philosophy remains the most influential and prestigious approach, yet continental philosophers are not ready to throw in the towel. There is no sign of the division diminishing, but both sides continue to exist. The division has left some casualties, though. Some quite well-known philosophy departments have disintegrated as a result of arguments largely or partly between analytic and continental sides.
How does all this apply to philosophy of psychiatry? I suggest that we should not be sanguine about it. This divide has the potential to be damaging for our newly blossoming but small field. This is especially true given the sociological mix of those who are interested in the field. At conferences and local meetings of the AAPP we see this mix; many of the philosophers and psychiatrists are primarily grounded in continental philosophy and especially psychoanalytic approaches, while many others are grounded in contemporary analytic philosophy such as philosophy of science, philosophy of psychology, or ethics.
The stereotypes about the different kinds of philosophy have some truth to them. I know that often philosophers and psychiatrists rely on the ideas of thinkers like Lacan and Derrida with little understanding of what they were really saying, and that when challenged to defend their claims, they simply use an appeal to authority, or reply that analytic philosophers cannot give any better justification of their claims. There is often a willful obscurantism to this work, combined with an apparent naiveté about the realities of modern psychiatry. Furthermore, sometimes authors assume that the simple interpretation of ideas of thinkers such as Lacan is interesting, without making a case for this assumption. However, while there is a place for the discussion of psychoanalysis, this field is under such a cloud of disrepute and tired dispute that any such discussion must be careful to explain why it is interesting and relevant to anyone other than historians of psychoanalysis.
Similarly, it is also true that analytic-style approaches can be mind-numbingly pedantic, making distinctions that do not matter and even relying on claims about ordinary language that have dubious universality and even less relevance to our understanding of psychiatry. Just as much as continental philosophy, analytic philosophers sometimes remain in a self-contained world of discourse recognizing little need to answer to a larger domain.
Combined with the mix of people who pursue philosophy of psychiatry is the strong emotional reactions that go with allegiance to one approach to philosophy. Speaking for myself, as someone trained in the analytic tradition, I confess that if I hear someone appeal to the French poststructuralist psychoanalytic theorist Jacques Lacan when making a point, my immediate inclination is to stop listening and get as far away as possible. I know that other people have equally strong reactions. I’m not generally inclined to read any journal articles that discuss Husserl or Heidegger. I will tend to avoid a conference if I know that it will be dominated by “continental types.” I am sure that my particular reactions and prejudices are not that unusual.
Of course it makes perfect sense for anyone in a field to concentrate on his or her own interests and specialties. It is impossible to be well informed about all areas in philosophy of psychiatry, read all relevant journal articles, and to attend all the conferences. However, at the same time we must be careful to avoid a possible deep split in the field. Thus, it is important to foster dialog between people with different approaches, and to make this dialog fruitful. This does not mean erasing differences between different approaches, but it does mean challenging individuals in each approach to consider the doubts that others express, and to do what they can to address those doubts. Furthermore, it may be possible for different approaches to cross-fertilize and enrich each other. For instance, there has been a recent trend in the philosophy of cognitive science, and especially the debate about the nature of consciousness and its reducibility to scientific terms, to draw on the phenomenological tradition stemming back to Husserl. Phenomenologists are starting to see that they have interesting contributions to cognitive science, and that cognitive science could also reinvigorate their research. This strikes me as a healthy development.
Book editors, conference organizers, and supervisors of graduate student work in philosophy of psychiatry have the power to encourage mutual understanding between “analytic” and “continental” approaches, and they should use this power. This may not only forestall a potentially destructive division, but it could also encourage some good research.

Making Philosophy of Psychiatry Essential
So far I have discussed how to keep the work in philosophy of psychiatry at a high quality. But it is as important to make sure that workers in this area keep focused on doing work that is socially useful and that can be made accessible to a wide audience. There are both pragmatic and moral reasons for this. Pragmatically, philosophy of psychiatry will need to get funding and support from a variety of agencies, and it can only do this if it is seen to be worth doing. Addressing socially prominent cases and issues is essential if philosophy of psychiatry is to be relevant. But more importantly, these prominent cases are often the ones that cry out for philosophical analysis and consideration, so it makes perfect sense that they should receive attention.
This raises the question what kind of weight should be given to different kinds of topics, specifically, how much emphasis should be placed on ethical and social issues versus how much should be placed on metaphysical and non-moral conceptual issues. I should of course make the immediate proviso that there is no clean separation of the ethical from the non-ethical, and that metaphysical and conceptual issues often underlie contested moral issues (think of the abortion debate). We only have to look to medical ethics to see how easily normative issues can come to dominate such a field. One can argue that most medical ethics in fact involves many issues that are not directly moral ones, yet most of the time medical ethics is thought of as “applied ethics” (a misleading term with a derogatory ring to it). How often do undergraduates or medical students take classes in “philosophy of medicine”? It is instructive to note that very often when philosophy of medicine is taught, it often focuses on issues in psychiatry. It is tempting to conclude that psychiatry offers some of the most interesting issues and fertile ground for debate that exist in medicine. It is philosophy of psychiatry that is really the heir to philosophy of medicine. Medical ethics, having the limelight, has also been pressured to fit into a certain mold, with the result that many of its richest areas have been left relatively unmined. The more that philosophy of psychiatry gathers attention to itself, the more it will be under pressure to move towards hot button issues and away from more thorough critical reflection on the discipline as a whole.
So I have said that it is important for philosophy of psychiatry to address high profile issues, and also that doing so carries the danger of leaving no room for some more philosophically sophisticated and maybe arcane issues. Obviously, there is plenty of middle ground available between the two extremes. I hope that it will not be too difficult for those who have some influence over what issues get studied to keep people that middle ground occupied.

It is possible to wax lyrical about what philosophy of psychiatry could achieve. It could become as important and productive both in the academy and in society as medical ethics and as philosophical work in cognitive psychology. It could also serve to reinvigorate large parts of philosophy. To make some sweeping generalizations, it strikes me that the field of moral psychology, covering the philosophical understanding of emotions, weakness of will, self-deception, irrationality, personal autonomy, and moral responsibility has become an area with such well staked out positions that it has come close to exhausting most of the interesting ideas it considers. However, by expanding its field of discussion to include psychopathology, it will also deepen its discussion, and will find new exciting issues. Philosophy of medicine has largely ground to a halt, so much has the discussion of medicine become dominated by ethical issues, so a new concentration on epistemological, metaphysical, and conceptual questions could reinvigorate a more general discussion of medicine. Philosophy of psychology would overlap with philosophy of psychiatry especially in its discussion of emotion, and a bridge could be formed between the two subfields over this issue. Finally, philosophy of psychiatry could do some real good, having an effect both on governmental and corporate policy, individual interactions between people, and the psychiatry profession.
I sincerely hope that philosophy of psychiatry accomplishes all this. Further, I hope that we will get closer to achieving all these fine aims through considering the strengths and weaknesses of philosophy of psychiatry as an emerging discipline.

American Psychiatric Press. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition. APP: Washington, DC; 1994.

Hacking, I. Rewriting the Soul. Princeton University Press: Princeton, NJ, 1995.

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