Thursday 11 February 2016

Philosophy of Psychiatry Today: Interview with Dominic Murphy

In this post, Reinier Schuur, PhD student at the University of Birmingham, interviews Dominic Murphy (pictured below), Associate Professor at the University of Sydney, on current debates in the philosophy of psychiatry.

RS: Many people have said that over the last 20 years, philosophy of psychiatry has grown, as has the interaction between philosophers and psychiatrists. Do you agree? Do you think this interaction will increase, and what should the role of philosophers be in psychiatry, and vice versa?

DM: I suppose it has grown. When I started thinking about psychiatry in the mid-90’s (I started my PhD in 1994), back then there very few philosophers of psychiatry. Reznek had just written his book , Jennifer Radden and Stephen Braude had written, and Ian Hacking was about to start his writing. The field was very small and it has certainly grown. I think probably psychiatrists are interacting with philosophy. There has always been conceptual literature in psychiatry and there have always been some psychiatrists that have been interested in these sorts of issues.

So yes, I guess it’s been growing. I think it will probably continue, I think in some sense philosophy of psychiatry has started to become entrenched a little bit more now. I don’t think it really counts as a specialisation exactly, but I guess that more and more people are thinking of it as one of the things that they are interested in, and who knows maybe it will be like philosophy of biology in the 70’s and it will really take hold. I suppose the interaction will continue, I mean at the recent Copenhagen conference there were psychiatrists that had never been to a philosophy conference before. And it was very interesting and I hope more and more psychiatrists will get into it, though I don’t suppose it will be more than a very minor interest in psychiatry.

As far as the role of philosophy is psychiatry, I’m not sure. The way that I got into it was as a philosopher of mind and a philosopher of psychology. I was interested in psychiatry because people were talking about mental illness as evidence for certain hypotheses in the philosophy of mind. So people looked at Autism, or the contrast between Autism and Williams Syndrome, and they wondered if that meant that the theory of mind was modular in some way. Dennett and Humphrey found support for Dennett’s view of the self in the multiple personality literature. So I think there is always going to be an interest in looking at psychiatric diagnoses in the light of concerns that philosophers of psychology have, and there is always going to be an interest looking at philosophy of psychology in the light of some of the mental illnesses. Then I guess, you can also see a sort of philosophy of science wing in philosophy of psychiatry interested in much of the things philosophers of science have always cared about in explanation and so on and reduction. And I think as there’s been more nuanced philosophy of neuroscience the last 10 to 15 years, I think some of that has been lining up with the philosophy of psychiatry, such as the people looking at explanation and reduction. So I guess there will be these two sorts of tracks.

I also think there will be room, and maybe Miriam Soloman’s new book on medicine rather than specifically on psychiatry will be an example of this, but there is room for a sort of ‘science studies’ approach to psychiatry, but one that takes the field seriously. I think a lot of the science studies and sociology in previous intellectual generations has really been very skeptical of psychiatry, and has been very interested in medicalisation and labelling and social control.

Obviously those are all important questions, but unless you want to give up on the whole field, it does seem as though that, you know, people really do suffer and there really are mental illnesses. But the field itself obviously has all sorts of interesting properties and histories and politics and this big crisis of validation, so there’s all sorts of room for a critical study which takes the phenomena seriously. And the other side of that as well I suppose is the ethical and political stuff which I think a lot of philosophy of psychiatry, and a lot of philosophy of medicine more generally, hasn’t really gone into since the anti-psychiatry movement. The anti-psychiatry movement made some good points, but I think, as I just said, there’s room for I think a sort of applied philosophy of science that’s a bit less hostile to the whole enterprise.

RS: In your 2006 book, you argue for an integration of psychiatry into cognitive neuroscience. This has some people worried. But this integration can happen a number of ways. What do you think about such worries, and in what way do you think this integration should happen?

DM: Well, one of the things that bothered me I suppose is that I couldn't really see any reason for a split between psychiatry and neuropsychology if you took seriously the terms of the biomedical movement in psychiatry. It just seemed very odd and unprincipled to have a bunch of psychiatrists saying that what we are looking at are essentially brain problems but that we are not doing neuropsychology, and that always struck me as an odd thing to say.

Since I wrote the book, and the more psychiatrists I talk to, I guess I am now more aware than I was that there is a sort of clinical basis to that concern. That psychiatry is not so much concerned with the metaphysics of disease that they think is distinctive of what they do but that there’s a kind of range of clinical concerns and clinical phenomena - the psychiatric symptoms, and that sort of thing is just different than the stuff that neuropsychologists have to deal with. In that sense I guess the clinical motivation for resisting full-on integration I have a little bit more sympathy for than I did, and you can certainly worry that if everything is just cognitive neuroscience that something will be lost in the way we deal with people and in the way we understand what they are going through. On the other hand if all we are going to do is give them pills, then it doesn’t seem that a great deal will in fact be lost, but I have some sympathy for that clinical concern.

I was always struck by some of the stuff that Nancy Andreasen had written in the late 90’s, saying that psychiatry sort of just is cognitive neuroscience in the sense that it is the applied wing of cognitive neuroscience that integrates a whole bunch of disciplines and tries to understand pathological mental phenomena on that basis. That was always the idea that I had, and I always thought that was a useful corrective to the kind of extremely reductionist biological psychiatry that you got sometimes in people like Kandel and Guze. Obviously figuring out the molecular mechanisms of our mental life is going to be very interesting, and obviously it’s going to be vitally important, but something will be missed if you just focus on those very small scale proximate explanations and you ignore a bunch of other stuff. So I always, I guess, thought that if this integration were to be done, the right way to do it would be something like Nancy Andreasen’s way that would be a sort of multi-level piece of cognitive neuroscience.

I’ve been persuaded by a bunch of people, John Campbell and others, that levels-talk is kind of, when you really get through it, very unappealing. It often just means discipline-talk. But if what you are worried about is the methodological stuff then thinking of it as multi-disciplinary rather than multi-level in a metaphysical sense, I think that’s okay. We need lots of models from different fields that will partly overlap and partly wont overlap, we need to understand the causal relations that we are interested in and that will cross these sorts of boundaries, the boundaries of the traditional disciplines.

You don’t know exactly how that will go, I guess the devil is always going to be in the details, but the basic idea that I had that psychiatry in some sense ought to become more closely aligned with the sort of computational wings of neuroscience and of the more ‘neurosciencey' ends of psychology, I think I still have that basic, well maybe it’s a prejudice, but I guess I still have that basic idea. So I wouldn’t want to retract that, but I am much more sympathetic than I was to idea that if psychiatrists just start thinking of themselves as straight up brain-doctors that we run the risk of ignoring a large amount of clinical experience and sort of putting clinical perspectives to one side in a way that will probably be a loss.

And as you know from the University of Sydney HPS winter school, what I am much more interested in now is, particularly but not exclusively under the influence of cultural studies, the dynamics of theories of cultural change. Whether the dynamics that you get in cognitive anthropology and historical sociology and fields like that, can explain some of the changes in symptomatology.

RS: In your 2006 book, you argued that the DSM as a framework for research was holding back findings from various sciences from properly informing psychiatry, and you called for having a ‘causal framework’ for research. In this regard, what do you think about the RDoC (Research Domain Criteria) project? Does it fit with your recommendation, and do you think it is promising and what psychiatry needs right now?

DM: Well yeah, both of the people who read my book would probably, looking at the RDoC, find it in the tradition of the book and find it sort of congenial, and certainly some of the stuff that Insel and his colleagues wrote looks like it was drawn from the same intellectual well as the stuff that I wrote. In that sense, I guess I’m kind of intellectually in tune with a lot of the bets that the RDoC people are making and a lot of the hunches that Insel and his colleagues at the NIMH (National Institute of Mental Health) were working through.

The initial RDoC manifesto though I think had a bunch of problems. Although they were officially ‘multi-level’ and able to take into account findings from all sorts of fields, they did also at the same time look very much ‘brain-centered' and ‘systems-neuroscience-centered', and there was always this worry that other relevant areas might be crowded out. I get a sense too among a lot of psychiatrists that there was a great deal of concern that it looked like a project that in some sense was suddenly sprung on the field by a bunch of people at the top of the NIMH without anything that looks like a proper consultation and without taking allowances of where we were.

One of the things I’ve always worried about is that I think it’s difficult when you look at a field in any kind of crisis, maybe this is an unkind way of putting things for psychiatry, but we can think of philosophy. So somebody comes along and has a plan for overhauling philosophy. They could point to the history of philosophy and say, ‘well it hasn’t exactly made a lot progress has it?,’ so we should sort of junk the whole thing and start again. I think I would have made a terrible revolutionary. Jaroslav HaĊĦek, the Czech novelist, started a political party in Prague in the 1920’s and it was called ‘the party of moderate progress within the bounds of the law’ [laughs] and that’s my temperament too. 

In some sense I always worry that if you have this big new reform program, you chuck out everything else, you’re kind of asking for trouble because you really have no good starting points. It’s not obvious where you start from, you need some way of keeping what’s good and what’s not good in the existing fields, you have to take all the old studies and sort of translate them into the new idiom. You have to get people to come along with you, and they might not want to come along with you. And so in many ways I think that RDoC looks like a problem because I suspect its support in American psychiatry is, you know, an inch deep and a centimetre wide, and it will be interesting to see how long it survives.

My other concern is that people will just do all the same things that they have always been doing but just translating their grant applications into ‘RDoC-language’ without really changing anything, and its not really clear how we’re going to stop that from happening. I think that intellectually and philosophically the RDoC, obviously if you’re a philosopher of mind or a philosopher of science it looks a bit crude, but I think it’s very much in the sort of ballpark that I was interested in. I think it is going to be a fascinating few years and if I was a young sociologist of science I would be clamouring to try and get into the RDoC stuff on the ground floor and see how it pans out. So I guess the RDoC is promising. I do think it has some of the same worries about ignoring clinical perspectives that I mentioned in response to the last question.

A lot of my reservations I guess are mostly worries about the politics, in the broader sense, and the sociology of the field. And in an important kinds of way the RDoC is underspecified. It’s very programmatic, so it’s difficult to judge exactly what we should be enthusiastic about and what we should be wary of. But the general set of prejudices running behind the RDoC I suppose are a lot of the same methodological prejudices that I’ve got.

RS: Conceptual analysis has dominated the concept of disease and mental disorder debate in the philosophy of medicine and philosophy of psychiatry. In your 2006 book you argued that we should give up on conceptual analysis. Since your book, more philosophers are following suit, with Lemoine (2013) the latest edition. If this criticism of conceptual analysis grows, and if conceptual analysis stops as a project, what should philosophers of medicine/psychiatry do instead?

DM: I am not sure if this trend will grow. I was never really sure that doing the 125th iteration on ‘Boorse studies’ struck me as something that I would really want to do, but there are people still really trying to push this line. I think though that there is a difference between some of the stuff that has been done more recently and the sort of traditional stuff that Boorse did. I mean Boorse was rigorous and important but he was quite happy in certain places to say that medics are just wrong, and this is the concept of disease and medicine has it wrong. And I think most people these days that are doing this sort of work would be much less keen to say that. So I do think there’s a sense in which people are interested in the role that concepts of disease play in medical thinking. And perhaps ways in which looking at different medical programmes might affect the way in which various psychiatric and general medical traditions might think about disease.

A specific example I think would be the work that my Sydney collogues, Paul Griffiths and John Matthewson, have done recently. Like a lot of people I have been reluctant to embrace an account of disease which is very closely tied to notions of dysfunction that reflect a teleological or evolutionary and adaptive understanding of dysfunction. Paul and John think that a lot of our arguments aren’t very good, but they also think that if you take these sorts of concerns and put them inside growing and increasingly popular perspectives on medicine which sees it in terms of ‘life history theory’ that you get something new. So, what evolves is life history, life history integrates a bunch of biological perspectives. And their view is that if you take a life historical perspective on human organisms, it gives you an interesting set of questions about these systems, the incentives natural selection faces in designing these sorts of systems, to survive long enough to get you to reproduce. It gives you a catalogue of ways in which the system can go wrong or the system could do badly in a certain kind of environment or it could be doing as well as is possible relative to an environment in which resources are very scarce, but the system will still come out looking sort of sub-optimal. So I guess there is an interesting set of questions. 

Now in some sense I think that a lot of the positions they end up with are taxonomies of ways in which systems can go wrong. These look kind of remote from traditional analysis of disease. So I think that conceptually, to the extent we have a clear cut notion of disease it is just not really tied to questions of fitness or of survival or reproduction. Nonetheless, I think Paul and John take the view that, well maybe that’s right, maybe we shouldn’t think of this as conceptual analysis in the traditional way, and they’re not really interested in trying to capture what you or I think pre- reflectively about the concept of disease. But their interested rather in: do these developments in medicine provide an illuminating set of distinctions in the way that systems might break down.

So, that’s a kind of conceptual analysis, right? If we start from a particular set of assumptions about how the human organism is put together historically and in the current environment then you get an interesting set of questions about a system like that could break down, and these might inform medical thinking and medical education. So I think that’s a project that philosophers who know a little bit about the science are likely to be quite good at, this job of spotting distinctions and spotting the commitments in all the various scientific projects and what leads to what and what’s assumed. And, I think there can be a bunch of different starting points that give rise to different families of distinctions. 

So that, I think, would be something that looks like conceptual analysis, but is less concerned about trying to capture some sort of everyday or even medical intuitions. It bears some ancestor-descendant relation to traditional forms of conceptual analysis, it’s not doing something totally remote, but the constraints are different, the evidence is different, it’s much less concerned about, you know, what would happen if we found a bunch of people on Mars who didn’t feel the same way that we feel about skin infections. At the same time I think there’s also a bunch of interesting questions which are as much sociological as philosophical, or more so, about the way in which things come to be seen as disease, or stop being seen as disease and get normalised. And I think that particularly historically informed philosophers could do sort of interesting genealogical work following that through.

I think this is a very general issue for philosophy, so I have been always suspicious of some of the intuition-mongering. I remember when I was a graduate student just starting out, hearing a couple of senior philosophers talking at a seminar, and you know it turned out in the course of the conversation that one of them had read Putnam on Twin Earth and believed every word, and one had read Putnam on Twin earth and was completely unmoved, and they just had different intuitions about meaning, and the conversation could make no progress. And it’s frustrating when that happens. 

I have always been sympathetic to the idea that we should be very distrustful of intuitions and in some sense like Jonathan Weinberg, you know, just get rid of them all and start philosophy from a different key. But there really is a question of, where the hell do we start from? What do philosophers have when we don't have intuitions anymore? So I think that if you are going to do something like conceptual analysis, if your starting point is not going to be intuitions, or at least it’s not going to be intuitions gathered by sitting in your office and wondering what you think about something and asking your friends, then I suppose one starting point is the way particular concepts have grown and changed over time within particular fields of human thought.

And the concern then is that if you look then there are no interesting lessons to be drawn, and the history of the shifting concepts over time just looks like a chapter of accidents. But even if it is just a chapter of accidents and even if it is just historically contingent, you end up in a place where you can still say, okay, given the state we are in, and this gets back to some of the things we talked about a minute ago about reform and where you start from and where you go, given the goals of medicine and making itself open to debate, social and political as well as scientific debate, you know, but given the goals of medicine, what sorts of concepts would serve us well. What might the concepts that serve those goals look like if we take a slightly different view of the science, and I think these are interesting conceptual questions that philosophers can help with.

RS: There has been a lot of discussion in recent literature in philosophy (such as Lisa Bortolotti’s work) on the nature of delusion. What are your thoughts on this debate? Is this a way that psychiatry can inform epistemology and philosophy of mind about our concepts of belief, or would this potentially be circular since psychiatry might presuppose epistemic assumptions about belief?

DM: Yes, I share that worry. But it is important to see that a lot of questions about belief are not really epistemic ones in the usual philosophers’ sense. So, for a start I think that it is obvious that one thing that psychiatry can do is provide a great repertoire of genuine well-attested phenomena that might run counter to what some philosophical account thinks is possible. So rather than thought experiments, you can use real cases. Kathleen Wilkes called her book on personal identity Real People, because the idea was that we don’t have to do a bunch of thought experiments. Now, imagine a book called something like Real Belief, in which someone looks at all the ways that belief forming mechanisms can go wrong, and in some be sensitive to things like class position, personal interest, and wishful thinking, and so on. So I can imagine an account of belief that is less focused on justification and more focused on, you know, how belief works. I know from experience that it is hard to get philosophers to see that you are talking about the causation of belief, that when you are pointing to a process that doesn’t justify belief and that doesn’t provide any warrant, it can be very hard for people to understand even what you are trying to convey.

Above all, I have a lingering sympathy, not for eliminativism about belief exactly, but for some of the ideas that Steve Stich put forward in his 1983 book, so it’s really not clear that there is something that we can call a unified phenomenon, belief, that covers everything that we use to refer to the term. So when the historian says, ‘Well, I have spent six months in the state archives in Vienna, and I don't think that the Hapsburg government really planned to get into a major war in 1914’, it’s the conclusion of that piece of intellectual effort that we call a belief. And so does, you know, what happens when you hear a door banging in a lonely house late at night and instantly think there’s an intruder. The second one of those is very very quick, and the first one of those is incredibly laborious, one depends on careful shifting of the evidence, one is immediately jumping to a conclusion, one’s part of a tradition of inquiry, one’s just an expression and in some sense an evolved reflex. We call them all belief, and I’m not suggesting that we give up on the word or anything, but I do think that it’s quite unlikely that a theory of what goes through a historians mind after six months of being in the archives, or a scientists mind on staring down an electron microscope, is going to admit of the same sort of treatment as what happens in my mind if I’m startled, or in a child’s mind thinking about their imaginary friends.

I think that psychiatry can provide all sorts of interesting information about a range of possible phenomena, and the ways in which people can be put into something like belief-like states. These are states that have content and a certain sort of connection to behavior. I’m skeptical there is a concept of belief that can cover all that ground, and so I suppose what I’d want to say is that if you look at psychotic episodes and other sorts of episodes, and a great range of other possible intellectual activity, and get less fixated on epistemic justificatory notions, then there are a lot of resources out there to build a much better naturalist theory of how it is that human beings come to affirm things and how it is that human behaviour is sensitive to all sorts of states of mind. Whether you want to call it all belief, or whether you think there should be a bunch of successor notions or whatever it is, those are further steps.

As far as your thought about circularity goes, if you are worried about circularity you always have the option of saying well it’s not really circularity, it’s just back and forth and co-articulation. Psychiatry does, if you look at the definitions of delusion (and in fact the DSM has two, and they are not consistent, but never mind), if you look at the definition of delusion that you get in the textbooks, they’ve clearly got epistemic notions built into them, notions of justification and evidence and truth. That’s something that could do possibly with some philosophical refinement or scrutiny.

At the same time I think that the range of psychiatric phenomena is something that can feed back into philosophy and lead us to think in slightly different ways about some of the stuff in the philosophical tradition. What is admirable about Lisa’s work is the way she’s been willing to do that. If you define belief in some of the ways that people have done in the Dennett and Davidson camp, very much tied to notions of rationality and consistency and so on, then not only do delusions not count as belief but most of the things that we probably believe would not count as belief, and maybe that’s fine, maybe we just need a different label for that stuff.

But what you don’t want to do is kind of shunt all of that to one side on the grounds that it’s therefore not belief and therefore not very interesting. Because probably the majority of human behaviour is driven by those things that don’t look like belief on that account, and psychiatry is one of those sciences of human behaviour.

So I guess my response to the circularity thing is to say that, no, maybe it’s not circular, maybe we can just have a back and forth deal rather than just circularity. So I guess it’s certainly isn’t the case that you should just uncritically say that psychiatrists say this so therefore p, but I do think that as is generally the case across the sciences of the mind, I think there’s an awful lot of room for a productive back and forth with traditional philosophical issues.

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