Thursday, June 26, 2008

Philosophy can offer insights into mental phenomena for psychiatry to objectively verify

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Notes on a Few Issues in the Philosophy of Psychiatry
Singh Ajai R 1, Singh Shakuntala A 21 M.D. Psychiatrist, Editor, Mens Sana Monographs, India2 Department of Philosophy, Joshi-Bedekar College, Thane, Maharashtra; Deputy Editor, Mens Sana Monographs, India
Correspondence Address: Singh Ajai R 14, Shiva Kripa, Trimurty Road, Nahur, Mulund (West), Mumbai 400080, Maharashtra India

Source of Support: None, Conflict of Interest: None

Abstract
The first part called the Preamble tackles: (a) the issues of silence and speech, and life and disease; (b) whether we need to know some or all of the truth, and how are exact science and philosophical reason related; (c) the phenomenon of Why, How, and What; (d) how are mind and brain related; (e) what is robust eclecticism, empirical/scientific enquiry, replicability/refutability, and the role of diagnosis and medical model in psychiatry; (f) bioethics and the four principles of beneficence, non-malfeasance, autonomy, and justice; (g) the four concepts of disease, illness, sickness, and disorder; how confusion is confounded by these concepts but clarity is imperative if we want to make sense of these concepts; and how psychiatry is an interim medical discipline.

The second part called The Issues deals with: (a) the concepts of nature and nurture; the biological and the psychosocial; and psychiatric disease and brain pathophysiology; (b) biology, Freud and the reinvention of psychiatry; (c) critics of psychiatry, mind-body problem and paradigm shifts in psychiatry; (d) the biological, the psychoanalytic, the psychosocial and the cognitive; (e) the issues of clarity, reductionism, and integration; (f) what are the fool-proof criteria, which are false leads, and what is the need for questioning assumptions in psychiatry.

The third part is called Psychiatric Disorder, Psychiatric Ethics, and Psychiatry Connected Disciplines. It includes topics like (a) psychiatric disorder, mental health, and mental phenomena; (b) issues in psychiatric ethics; (c) social psychiatry, liaison psychiatry, psychosomatic medicine, forensic psychiatry, and neuropsychiatry.

The fourth part is called Antipsychiatry, Blunting Creativity, etc. It includes topics like (a) antipsychiatry revisited; (b) basic arguments of antipsychiatry, Szasz, etc.; (c) psychiatric classification and value judgment; (d) conformity, labeling, and blunting creativity.

The fifth part is called The Role of Philosophy, Religion, and Spirituality in Psychiatry. It includes topics like (a) relevance of philosophy to psychiatry; (b) psychiatry, religion, spirituality, and culture; (c) ancient Indian concepts and contemporary psychiatry; (d) Indian holism and Western reductionism; (e) science, humanism, and the nomothetic-idiographic orientation.

The last part, called Final Goal , talks of the need for: a grand unified theory.he whole discussion is put in the form of refutable points...

VI. Final Goal
VI.A. A Grand Unified Theory VI.1. The ultimate aim of psychiatric theorizing and research is to find a grand unified theory that will explain all mental phenomena, in health and disease. VI.2. All piecemeal approaches are valid only as stop gaps to this destination, never as the only reality. Hence, statements like 'Our strongly held desires to find the explanation for individual psychiatric disorders are misplaced and counterproductive' (Kendler, 2005) need to be accepted as the reality of today, to be countered by systematic research to find exactly such an explanation. VI.3. No foreclosure, no giant leaps; just a string of evidences to a final resolution. VI.4. The present maze-like complex findings in most major psychiatric disorders only camouflage an essentially simple solution that awaits discovery. VI.5. Just as Einstein integrated a string of evidences/theories before him to give his essentially simple theory of relativity, we need the genius of a synthesizer to make sense of the burgeoning scientific research in psychiatry and extract the essential simple solution that lies within handshaking distance. VI.6. As we get to know it finally, we may be surprised at the naivetĪ¹ of it all.

Concluding Remarks
1. Disease cannot vanish. Diseases can. This is the very basis of medicine, it is very raison d'etre . It is equally applicable to psychiatry.

2. For psychiatry, we are in dire need of exact knowledge, and knowledge that is universally valid. Although the scientific approach may not be the only one, it is the only one that can be empirically validated, and refuted. Psychiatry, which claims to be a scientific discipline, should not lose sight of this. It either gives up the claim of being scientific, or learns to follow the cannons of science.

3. A scientist looks at the 'how' of phenomena. A philosopher looks at its 'why'. What is the nature of a question that combines both the 'how' and the 'why'? It will be an integrated question. A 'what'. What is the nature of an answer that answers both the 'how' and the 'why'? It will be an integrated answer. Again a 'what'. By integrated, or a 'what', we mean it involves the empirical knowledge of the scientist combined with the speculative reason of the philosopher.

4. Science is basically antiphilosophy, since its fundamental thrust is to reduce the need for speculation, and speculation is fundamental to philosophy. Philosophy is basically science nurturing, since it offers insights for science to objectively verify and accept/refute. It also plays the role of being the conscience of science, because it shows the path and often prevents it from getting waylaid. While playing this role, philosophy sometimes appears to be antiscience since it is critical of science's unbridled power. Actually it is science nurturing.

5. The mind is the functional correlate of the structure called the brain. It has no existence aside and apart from it.

6. Theology and philosophy of mind can supply many speculative insights, which will need scientific enquiry and validation to convert them into empirical knowledge.

7. Robust eclecticism is compatible with subscribing to any one strand of thought in psychiatry - biological or psychosocial. It remains robust only as long as it accepts the worth of evidence from any quarter, even adversarial. Eclecticism is an attitude. Empirical enquiry is a process. One cannot substitute for the other. But one can, and should, complement the other.

8. Diagnosis cannot replace individual and customized care. But the converse is equally applicable. In fact diagnosis complements individual and customized care. And the latter helps refine the diagnostic process.

9. Beneficence is essential, non-malfeasance obligatory; autonomy is relative and justice debatable. Beneficence is the bedrock of medicine, non-malfeasance its conscience. Justice its sentinel, autonomy its crowning glory.

10. Most psychiatric problems are illnesses, since they involve an inability to fulfill normal social roles. They are often also sicknesses, since there is subjective awareness of distress. But none are diseases as of yet, as there is no proven universally accepted objective pathology. This is the most important problem for psychiatry to tackle.

11. The major task of psychiatry, therefore, is to prove their illnesses and sicknesses are also diseases. Till this happens, psychiatry has the promise to become, but only approximates, a branch of medicine. It is at an interim stage of development as a medical discipline. This is an uncomfortable but necessary realization.

12. Genes determine, and regulate, behavior. And behavior alters gene expression. Both are interlinked through and through. The major task of modern psychiatry is to unravel which determines what, and to what extent.

13. Insights in psychiatric knowledge will come from many sources, especially the psychological, the psychoanalytic, the sociological, and the philosophical. Breakthroughs will come mainly, if not solely, from biology.

14. Psychiatric treatment will always require an empathetic grasp of the patients' inner feelings; and a working knowledge, if not an intimate grasp, of the sociocultural ethos in which they occur.

15. Biology is the engine and the fuel. Will psychoanalysis hold the steering, help change gears, and stop clamping on the brake?

16. The mind is the brain. And the brain, the mind. They are two sides of the same coin.

17. How do biological and psychosocial approaches gel? (i) Only under the overarch of ensuring comprehensivity of patient welfare; (ii) each supplies insights to the other while carrying out self-correction; and (iii) each accepts irrefutable evidence of its shortcomings, from whatever source it originates, internal or external.

18. Reductionism is a valid approach in the study of psychiatric phenomena. But integration of the finding of disparate approaches is equally valid. As is explanatory pluralism.

19. So, reductionism or integration? Both. Reductionism as an approach. Integration as an attitude.

20. All mental phenomena have a correlate in brain functioning, known or unknown. All brain activity gives rise to mental phenomena, known or unknown. The key is to find the links between brain activity and mental phenomena. The key is also to make the unknown mental phenomena and brain activity known.

21. In psychiatric therapy , beneficence and non-malfeasance are paramount, and must override autonomy and justice when they conflict. In psychiatric research , however, autonomy and justice are paramount, and must override beneficence and non-malfeasance when they conflict.

22. Social psychiatry must back up its insightful contentions with strong evidentials. Liaison psychiatry remains relevant only if appreciates the relevance of the medical model, but is prepared to transcend it. The same rule is applicable to psychosomatic medicine. Forensic psychiatry is necessary, but psychiatric ethics is mandatory. While the former ensures autonomy and justice, the latter ensures beneficence and non-malfeasance. Neuropsychiatry is promising but guild-driven.

23. What Szasz and his ilk have to realize is there is a moral judgment involved in any labeling, whether of a disorder in psychiatry or the rest of medicine. If it were good/proper to vomit blood, or fall unconscious, or live with broken bones, or develop heart attacks, no branch of medicine would be needed. Similarly, if it were good/proper to live with suicidal attempts/thoughts, to fear meeting people so, one remains confined to the house, to keep hand washing for hours, to believe one is the Almighty, or that the whole world is plotting/scheming against you, no psychiatry would be needed.

24. Psychiatric classification is capable of being both scientific and objective. Diagnostic categories do match real mental disorders. Hence, the medical model of psychiatry that many defend is legitimate, even if inadequate.

25. While psychiatry should beware it does not protect criminals, delinquents, etc., it must equally make people at large, and law enforcing agencies, aware that in certain mental conditions, a person may not realize the nature and consequences of his actions. A typical example is a schizophrenic who acts on his delusions and assaults someone, or a suicidal depressive who makes a suicidal attempt during a depressive phase. Treating helps them get rid of their delusion/suicidal impulse; putting them behind bars does not.

26. Often those who are creative are so not because of, but in spite of , mental illness. Moreover, often they continue to remain creative not because of, but in spite of, mental illness and treatment; and all the side effects and lifestyle modifications that ensue following a major mental illness.

27. Religion and spirituality hold an eternal fascination for some serious psychiatric thinkers. There are many concepts in both that intersect. But in so far as religion stresses the subjective at the expense of the objective, it cannot become a predominant force in psychiatric thinking. However, it can supply many insights into mental phenomena, which psychiatric research can explore with profit. But with its tools, its criteria, its methodology.

28. Unless the older concepts in the philosophy of mind, whether of the East or the West, get converted into empirically testable hypothesis, they are useless for modern psychiatry. Reverence and awe is one thing, proof and therapeutic validation quite another.

29. Indian psychiatrists' attempts to understand ancient Indian concepts and their relevance to contemporary psychiatry have been intensely patriotic/reverential but feebly scientific. As different from this, Western thinkers have not desisted from critical evaluation of their greatest predecessors. Only that which stands the critical scrutiny of peers is accepted, and that too provisionally. This necessary progression in mindset - from reverence to critical sifting and analysis - is essential if experimentally verifiable models of care have to evolve from the writings of the great masters of the past.

30. It is also mentioned, almost as a truism, that Indian thought is holistic, synthetic, as opposed to the Western, which is reductionist and analytic. The predominance of religion (and belief) in Indian thought, and of science (and verification) in the West has given rise to such predominance. Holism is necessary as an attitude ; reductionism is necessary as an approach . Holism is necessary to synthesize and integrate diverse strands of knowledge. But reductionism is needed to produce new knowledge, which is then synthesized and integrated.

31. The orientation necessarily has to be a blend of science and humanism. Where universally valid scientific knowledge serves individual patient welfare. And individual patient welfare serves to promote further universally valid scientific knowledge. Not as difficult as it seems, provided research integrity and patient welfare remain the watchwords. Holism at its best.

32. The ultimate aim of psychiatric theorizing and research is to find a grand unified theory that will explain all mental phenomena, in health and disease.[74]

Take Home Message
There are many areas of connect between philosophy and psychiatry. Philosophy can offer insights into mental phenomena for psychiatry to objectively verify. Psychiatry must progress from being an interim medical discipline to becoming a full one. It will do so only by finding biological determinants of behavior in health and illness. A grand unified theory to explain mental phenomena is the final goal.

Acknowledgment
The editors wish to thank the peer reviewers of this paper for their valuable contributions. The authors wish to thank Dr. Anirudh Kala who invited them to first write on this topic for the book Culture, Personality and Mental Illness: Perspective of Traditional Societies (Eds. V.K. Varma and A.K. Kala) to be published by Jaypee Brothers Medical Publishers. This is a substantially expanded version of the paper to be published there under the title, 'Notes on Some Philosophical Issues in Psychiatry'.Conflict of Interest Author and co-author are editor and deputy editor of MSM.

Questions That This Paper Raise

  • 'Science is basically antiphilosophy and philosophy is basically science nurturing.' Why can both not be nurturing of each other?
  • 'Disease cannot vanish. Diseases can.' When can disease vanish, and well-being flourish?
  • 'Eclecticism is an attitude. Empirical enquiry is a process.' What if their roles are interchanged?
  • 'The major task of psychiatry, therefore, is to prove their illnesses and sicknesses are also diseases.' Will only biology help here?
  • 'Insights in psychiatric knowledge will come from many sources, especially the psychological, the psychoanalytic, the sociological, and the philosophical. Breakthroughs will come mainly, if not solely, from biology.' What about breakthroughs from other sources and insights from biology?
  • 'Reductionism as an approach. Integration as an attitude.' What if their roles are also interchanged?
  • Unless the older concepts in the philosophy of mind, whether of the East or the West, get converted into empirically testable hypothesis, they are useless for modern psychiatry. How do we do that?
  • 'This necessary progression in mindset - from reverence to critical sifting and analysis - is essential if experimentally verifiable models of care have to evolve from the writings of the great masters of the past.' Is not reverence itself necessary to understand phenomena? Which areas of enquiry are most suited for a move from reverence to critical enquiry?
  • 'The orientation necessarily has to be a blend of science and humanism.' How much of each, what when they conflict, how can then blend seamlessly?
  • The ultimate aim of psychiatric theorizing and research is to find a grand unified theory. Is it at all possible? Such grand ideas are doomed to failure. Why at all attempt it?

[Authors' Postscript: A Parting Thought, and Some Explanatory Notes:
A paper such as this can arouse two extremes of reactions. There are some who may find this paper well worth the effort, others may want to forget all about it. While both reactions are understandable and legitimate, more relevant would be to tear apart and analyze which of its points are relevant, and which need rejection; and why.
The paper adopts a certain format of presentation because it best suits the assertion that it presents. This is no comment on the usual style in which academic papers are presented.
To those who may feel the writers think they are Wittgenstein, or it is an imitation, we wonder whether anyone, Wittgenstein included, enjoys sole proprietary rights to presenting papers in a certain format.
To those who find this paper poorly written, badly argued, and rather naive in its outlook, we plead guilty on all charges. It is not well written, if a typical academic paper format is what makes a paper well written, for it only presents points to be refuted, if possible. It is badly argued, for it mainly presents assertions and conclusions of arguments, and many actionable points, rather than pure arguments. It is rather naive in its outlook, for we believe a naivetĪ¹ that charts the course is preferable to arguments that enmesh and cause inaction. Of course the course should be worth charting, and well delineated. How this paper errs in so doing, would be worth knowing from our peers.
The charge can also be made that despite being a paper on philosophy and psychiatry, it seems to be ignorant of most recent philosophy. Being ignorant and not quoting, or commenting on, are not identical. The purpose of this essay is to raise certain foundational issues with regard to psychiatry and its sub-disciplines, and its relation to many other branches, especially philosophy. The purpose is not necessarily to enter into a polemic with recent writings in the philosophy of psychiatry. This is no comment on the need for, or preoccupations of, the latter.
Some may not be sure if this is a final version: this reads like an essay plan for several papers and does not offer a coherent argument and position. This is the final version, as of now, which of course can expand into several papers over a length of time. It does not offer a coherent position/argument, because it presents several assertions to be worked over, by the author and contemporaries, if psychiatry has to make solid ground as a rigorous empirical discipline in biomedicine. If it wishes to reject its empirical base, if it rejects the very need to establish itself as a branch of biomedicine, if it wishes to keep floundering, or if it wishes to continue with presenting arguments for the sake of arguments, then these assertions may be kindly forsaken.
Some of you may get irked at the sheer audacity of making such a grand project of a paper. Especially the sweeping generalizations, the dogmatic assertions, and the occasionally brusque comments. If you can stop getting irked, and can manage to give it a second read, things may not seem that bad after all. For you, as a reader/thinker, have at least sometimes realized the worth of an initially rejected idea.]

About the Authors Ajai R. Singh M.D. [Figure 1] is a Psychiatrist and Editor, Mens Sana Monographs (http://www.msmonographs.org). He has written extensively on issues related to psychiatry, philosophy, bioethical issues, medicine, and the pharmaceutical industry.

Shakuntala A. Singh, Ph.D., [Figure 2] is Principal, Reader and Head, Department of Philosophy, K.G. Joshi College of Arts and N.G. Bedekar College of Commerce. She is also Deputy Editor of MSM. Her areas of interest are Indian Philosophy, Bioethics, Logic and the Philosophy of Science.

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