that maturity…

Posted on Tuesday 2 September 2014

    We shall not cease from exploration
    And the end of all our exploring
    Will be to arrive where we started
    And know the place for the first time…
    Little Gidding  T.S. Eliot 1942

I hate being so repetitive with my quotes. This one has had many re-runs here. But I guess that’s the way it is with the good ones. Maybe next time I’ll use the story of the Holy Grail or the Wizard of Oz to say the same thing. Or maybe it’s just part of the experience of being an old man, to begin to see how cyclic human life can be. I came to psychiatry interested in psychotherapy at a time of transition. The psychiatry of the time was operating at its most "eclectic," or so I thought. There were models galore – psychodynamic, biological, medical, existential, social, behavioral, etc. Come one, come all. I thought that was great, myself. And then things changed dramatically and one was apparently supposed to choose – specifically choose biomedical. So those of us who didn’t moved to the side [because there was no place else to go]. At least that’s how it seemed. But that’s ancient history, albeit my own. I sure didn’t start writing well into retirement to rehash those days. I started writing because I woke up to the fact that a dominant paradigm in psychiatry throughout my career – psychopharmacology – had been invaded by industry and was more corrupt than I could’ve imagined. So I exhumed skills from a former career in hard-science-medicine and began to look at what I consider the carnage that resulted from an academic-pharmaceutical alliance that has afflicted a too-big sector of psychiatry.

It appears I came along at another time of transition. Now, there are real moves to clean up some of the side effects that came during the neoKraepelinian revolution that swept through the specialty of psychiatry in my early days. Industry had its day in the sun and seems for the moment moving on to greener pastures. The Clinical Trial world, seat of some of the major corruption is under a microscope and the target of a growing movement for Data Transparency. And people at least say "bio-psycho-social" model now frequently – a term that has long been only whispered. Then today, I look over the new American Journal of Psychiatry and read this:
by Kendler KS
American Journal of Psychiatry. 2014 May 16. [Epub ahead of print]

This essay addresses two interrelated questions: What is the structure of current psychiatric science and what should its goals be? The author analyzed all studies addressing the etiology of psychiatric disorders in the first four 2013 issues of 12 psychiatry and psychology journals. He classified the resulting 197 articles by the risk factors examined using five biological, four psychological, and three environmental levels. The risk factors were widely dispersed across levels, suggesting that our field is inherently multilevel and already practicing empirically based pluralism. However, over two-thirds of the studies had a within-level focus. Two cross-level patterns emerged between 1) systems neuroscience and neuropsychology and 2) molecular or latent genetic factors and environmental risks. The author suggests three fundamental goals for etiological psychiatric research. The first is an eclectic effort to clarify risk factors regardless of level, including those assessed using imaginative understanding, with careful attention to causal inference. An interventionist framework focusing on isolating causal effects is recommended for this effort. The second goal is to clarify mechanisms of illness that will require tracing causal pathways across levels downward to biological neuroscience and upward to social factors, thereby elucidating the important cross-level interactions. Here the philosophy of biology literature on mechanisms can be a useful guide. Third, we have to trace the effects of these causal pathways back up into the mental realm, moving from the Jasperian level of explanation to that of understanding. This final effort will help us expand our empathic abilities to better understand how symptoms are experienced in the minds of our patients.

Conclusion: …A vigorous debate between different scientific perspectives on psychiatric illness is to be valued. More problematic has been our tendency to develop “fervent monism.” This position, at times strongly advocated by psychoanalysis, early biological psychiatry, social psychiatry, and most recently, molecular psychiatry, is that their approach was the only valid one. Fervent monism, especially when applied to the field of human behavior, reflects epistemic hubris. It is helpful, in concluding, to revisit an old but central question: Is there a single “best” level at which to address the causes of psychiatric illness? Do we expect that over time one specific level of explanation for psychiatric illness will “win” the scientific competition and beat out all other kinds of explanations? I think that the mere posing of this question illustrates its implausibility. We are “stuck” with the dappled causal world for psychiatric disorders. In the introductory epigraph to this essay, Chang makes a point worth re-emphasizing. It is only the immature fields of science that advocate monism. Tolerance for diversity and humility come with scientific maturity.
Saying that "risk factors were widely dispersed across levels, suggesting that our field is inherently multilevel and already practicing empirically based pluralism" may well be a bit of an exaggeration, if he’s referring to psychiatric practice or research. As an aging pluralist, it has felt and still feels pretty monistic to me – even with a break in the clouds. My point is only that it has been a long time since I’ve seen an essay in the American Journal of Psychiatry that acknowledges the "dappled causal world for psychiatric disorders" and adds "It is only the immature fields of science that advocate monism. Tolerance for diversity and humility come with scientific maturity". We could use some of that maturity…
    September 2, 2014 | 8:41 PM

    Amen. Nuff said.

    September 2, 2014 | 10:47 PM

    I think that anyone reading Kandel has noticed he has been saying this for about 50 years. A scientific approach is by definition a dynamic one and a continuous and open ended process where there is no ultimate answer. (I am paraphrasing Pigliucci).

    September 3, 2014 | 4:49 AM

    “Monism” does not necessarily mean assuming superiority of one level of analysis over another, but may mean assuming “one undivided universe” including the physical and the psychological (or behavioral) world. Contextual Behavioral Science strategically takes this approach: 4.4 Monism:
    The situated action of contextualism is naturalistic and monistic: the word “behavior” refers to any and all actions of the whole organism, including those that are private. The monism of functional contextual science is not a matter of emphasizing the physical over the non-physical, but in the assumptive sense of starting with oneness. Behavior and its functions in context are not treated as proxies for inferred processes or hypothetical variables—they are viewed as legitimate levels of analysis in their own right. …monism is embraced in CBS, not as an ontological assumption, but instead as a strategic assumption. Disinterest in common-sense ontology allows the practical problems of dualism, including the ways that the mental and physical domains in dualism react or are related, to be left behind.

    This paragraph is from this article which describes the nature, scope, and purpose of Contextual Behavioral Science (CBS). (further from it) Clarifying assumptions of Contextual Behavioral Science: For scientists, the crucial aspect of philosophy of science is the process of explicating and taking responsibility for scientific assumptions. To ensure that theory, data, and methods comport over time, scientific assumptions need to be clear and coherent. If a research program wanders from its assumptions, the work becomes empty or unstable, and soon enough it is not a “program” at all.

    Kenneth Kendler (not Eric Kandel, btw) has been writing about philosophy of science issues for decades now, decrying dualism, but proposing an approach which cannot be seen as not dualistic. Problems with dualism were noted by CBS folks in 1986 and the overall strategy explicated in the first linked article were laid out in 1988

    The CBS approach accords with Ernst Mach’s strategy of science, which underlies modern physics. Mach wrote “There is no cause nor effect in nature; nature has but an individual existence; nature simply is.”

    Strategy (or philosophy) of science is fundamental. Psychiatry has ignored it, and here we are… There is another way of doing science other than the mainstream “elemental realism” aka mechanism. Hope the papers linked are of interest!

    September 3, 2014 | 1:29 PM

    Good to see you here, Dr. Purssey!

    Steve Lucas
    September 3, 2014 | 1:55 PM

    We are collectively of an age when polite discussion was the norm and challenging the status quo was expected. Never did nay of us in our respective fields expect to hear ‘the science is settled” in any serious discussion.

    That phrase is now being used to not only stop discussions, but to belittle the speaker. Those in authority no longer accept an ongoing debate of their positions, but in stopping this debate, prevent any further advancement of their field.

    Government, business and academia have all fallen for this term and the certainty that they know what they know. The older I get the less I know and the more I want to know. My hope is that I live long enough to know nothing and am interested in everything.

    Steve Lucas

    September 3, 2014 | 2:19 PM

    “Never did aay of us in our respective fields expect to hear ‘the science is settled” in any serious discussion.”

    By accepting this reality the rhetoricians would really have nothing to add. The attacks on psychiatry are generally predicated on some monolithic version of psychiatry that I have never seen. I have really never met a psychiatrist that clueless.

    And if I did – I doubt they would be dissuaded by a philosophical argument.


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