Conceptual psychiatry: the ground beneath our feet

… at a time when the very foundations of physics itself have become as problematic as they are now… when experience forces us to seek a newer and more solid foundation, the physicist cannot simply surrender to the philosopher the critical contemplation of theoretical foundations…

Albert Einstein (Einstein, 1956)

Conceptual and philosophical aspects of psychiatry have received increasing attention over the past three decades and the field of ‘philosophy of psychiatry’ has emerged as a flourishing academic discipline with active contributions of scholars from a wide variety of backgrounds. This special issue of International Review of Psychiatry is centred on the theme of ‘conceptual psychiatry’ and aims to provide a snapshot of some of the prominent developments in this arena. This collection of articles, while providing a professional survey, is also deeply personal to me: three articles in this issue are edited reprints of interviews from my interview series ‘Conversations in Critical Psychiatry’ for Psychiatric Times (Aftab, 2020a) which explores critical and philosophical perspectives in psychiatry and engages with prominent commentators who have made meaningful criticisms of the status quo. The interviews selected for inclusions in this issue are with three giants in the field of philosophy of psychiatry: Paul McHugh, Derek Bolton, and Peter Zachar. Furthermore, I contribute as a co-author in two of the articles in this collection.

As psychiatrists we integrate a diversity of perspectives to make sense of our patients and we straddle the mind-body divide every day in our work. We cannot afford to practice a version of psychiatry that is conceptually impoverished and divorced from its philosophical underpinnings. The conceptual work of psychiatrists such as Kenneth Kendler has demonstrated that a philosophical approach has a tremendous capacity to enrich our understanding of psychiatric conditions and to offer guidance for future development of the specialty (Kendler & Zachar, 2019). The philosophical view of psychiatry offered by Kendler and colleagues has provided a conceptual foundation for a new generation of psychiatrists. A philosophically-informed psychiatry as envisioned by Kendler requires recognition of multiple elements, such as: the role of non-empirical factors, social processes, and value judgments in psychiatric nosology (that psychiatric classification keeps ‘running into the limits of the scientific method’); anti-reductionism and scientific pluralism (multiple explanatory perspectives are available to us to understand psychiatric disorders and one perspective cannot be reduced to another); the ‘dappled’ nature of causality in psychiatry (causal risk factors are distributed across multiple levels of explanation); the pragmatic nature of psychiatric constructs (residing in between realism and constructivism); diagnostic anti-literalism (diagnostic criteria index a disorder but do not constitute the disorder); and the historically contingent nature of psychiatric nosology (psychiatric nosology sits in a historically contingent developmental arc). The articles in this special issue build on and intersect with these philosophical themes in productive ways.

The idea that we can be ‘atheoretical’ and purely empirical is a deceptive one, particularly so in the field of psychopathology. There are, for better or worse, no theory-free observations. We always approach human behaviour, and the world generally, with preconceived notions and theoretical constructs, whether these are recognised or unrecognised. The question therefore is not whether philosophical assumptions are inherent in our frameworks but whether we wish to examine them. The failure to give due importance to philosophical foundations of the field has resulted in widespread confusion and has negatively impacted the historical trajectory of the profession (Aftab & Waterman, 2020). The reification of DSM constructs, the tendency towards reductionism, and the debates surrounding medicalisation are all linked to inadequate conceptual appreciation of the nature of psychiatric diagnoses, the role of causal explanations, and the pragmatic functions served by diagnoses. It is not surprising that a recent survey of healthcare professionals and trainees at a US academic medical centre revealed a general lack of consensus regarding conceptual issues fundamental to psychiatry (Aftab et al., 2020).

As an educator, I have been involved in efforts to highlight the conceptual and philosophical aspects of psychiatry in psychiatric training (Aftab et al., 2018). In a recent Academic Psychiatry publication (Aftab & Waterman, 2020), my colleague Dr Waterman and I have argued for the development of ‘conceptual competence’ in psychiatric training. We define conceptual competence in the context of healthcare as the transformative awareness of the ways by which background conceptual assumptions held by clinicians, patients, and society influence and shape aspects of clinical care (such as pursuit of care, presentation of problems, assessment, diagnosis, treatment, and attitudes towards each of the foregoing). The elements of conceptual competence include making explicit the implicit conceptual assumptions (and corresponding conceptual questions) that influence diagnosis and clinical interactions; developing a philosophical vocabulary and acquiring familiarity with relevant arguments and frameworks with which to examine conceptual assumptions in a rigorous and systematic fashion (‘conceptual tools’); examining in an organised manner the merits of the various answers to conceptual questions relevant to the institution and practice of psychiatry (‘conceptual discourse’); and recognising the tentative nature of scientific and philosophical formulations and of the value of pluralism in assessments of them (‘conceptual humility’). I see this special issue as offering further resources which psychiatric educators, trainees, and clinicians can utilise in pursuit of conceptual competence.

The interview with Paul McHugh (Aftab, 2020b) explores the Perspectives approach developed by McHugh and Slavney in their classic work The Perspectives of Psychiatry. This approach utilises four explanatory methods – disease, personality dimensions, motivated behaviours, and life encounters – to create a comprehensive and pluralistic psychiatric formulation. The perspectives approach overcomes some of the limitations of both the DSM and the biopsychosocial formulation by avoiding descriptive operationalism as well as sterile eclecticism. Furthermore, it offers a way of integrating idiographic and nomothetic perspectives in psychiatry, a division that has beguiled psychiatric nosology through much of its history.

Derek Bolton's work on the naturalism-normativism debate has been very influential, and the interview with him (Aftab, 2020d) explores these concepts further. He challenges the dichotomies between the medical and the psychological, between the scientific and the social, and argues for an understanding of disorder concepts in terms of harm and suffering. Peter Zachar, a frequent collaborator of Ken Kendler, has emerged as a leading figure advocating a pragmatist worldview in psychiatry and psychology, arguing for an understanding of psychiatric constructs as ‘practical kinds’ rather than ‘natural kinds’, and an understanding of psychiatric classification as an ‘imperfect community’. The interview with Zachar (Aftab, 2020c) fleshes out the implications of his pragmatist framework.

Ahmed Samei Huda (Huda, 2020) offers a philosophical defense of the medical model in psychiatry, while at the same time advocating for a view of ‘promiscuous realism’, the pluralistic co-existence of the medical model with non-medical perspectives, and viewing the current dominance of the medical model as a product of historical contingency. Sanneke de Haan (de Haan, 2020) discusses the limitations of current reductionistic and biopsychosocial approaches in psychiatry, both of which struggle to make sense of a wide assortment of causal risk factors for psychiatric disorders, ranging from genetic to economic factors. de Haan draws on insights from philosophy of enactivism, which focuses on the dynamic interactions between organisms and their environments, and views ‘sense-making’ as a central characteristic of life. Sense-making in humans acquires an existential dimension by virtue of our consciousness of our consciousness. Psychiatric disorders, in turn, are structurally disordered patterns of sense-making, and causal interactions of factors across various dimensions are understood through an organisational, rather than a linear, form of causality. de Haan demonstrates how an enactive approach to psychiatry provides a way to integrate the experiential, physiological, sociocultural, and existential dimensions of mental illness as a unified complex whole. Both de Haan’s enactivism and McHugh and Slavney’s Perspectives approach are examples of integrative, pluralistic frameworks with their unique strengths and emphases.

The two remaining articles explore the disorder-deviance dichotomy and the evolution of psychiatric nosology. ‘Mental disorder and social deviance’ (Aftab & Rashed, 2020) provides an overview of some of the major conceptual strategies that have been discussed as a means of discriminating between mental disorder and social deviance, and the extent to which these strategies can be said to be conceptually successful. Our review suggests that no single approach satisfactorily accounts for all possible cases and that a distinct dividing line between disorder and deviance remains elusive. However, these various philosophical strategies help illuminate the relevant considerations involved. The implication appears to be that the distinction between disorder and deviance is informed by empirical facts, but it is also a complex judgement requiring negotiation between competing values.

‘Conceptual and historical evolution of psychiatric nosology’ (Aftab & Ryznar, 2020) offers an overview of the development of psychiatric nosology with an emphasis on underlying conceptual frameworks and methodological assumptions. The inquiry ends with the recognition that the central philosophical questions of nosology (descriptive vs aetiological, symptoms vs course of illness, idiographic vs nomothetic, categorical vs dimensional, etc.) allow for no easy answers, and resultantly, there are multiple different ways we can classify the psychiatric landscape, each with its own distinct utility. Supplementing ideas explored in the interview with Zachar, we suggest that psychiatric classifications serve as pragmatic tools, and it is unreasonable for us to expect that one classification can fulfil all the different purposes that classification are required to serve.

Open-ended philosophical scrutiny is often uncomfortable. I suspect that the exposure to antipsychiatry literature has planted a nagging seed in the minds of many psychiatrists that unless we possess some natural, objective, fact-based way of determining the boundaries of our basic concepts and nosological constructs, the legitimacy of psychiatry as a profession would stand on precarious and perilous ground. The philosophical discussions in this special issue, however, should disabuse us of the notion that a simple reliance on naturalism is what is needed for psychiatry to be legitimate. Psychiatry may be value-laden through and through, and there may be no easy demarcations, but that is a problem only if we continue to naively insist that nature be carved at its joints when no such joints exist.

Disclosures statement

No potential conflict of interest was reported by the author(s).

Acknowledgements

I am grateful to Dr. Margaret Chisolm for her invaluable support in the creation of this special issue, as well as her mentorship and guidance over the course of my career. I would also like to thank the editorial staff of International Review of Psychiatry – Ian Blackford, Sadie Thrift, Susan Bigmore, and Rozanna Whitehead – for their assistance in the production of this issue.