Thursday, May 02, 2019

Anti-reductionism and critical psychiatry

Immanual Kant in the section on the ‘Critique of Teleological Judgement’ in his Critique of Judgement (1790) said:-
For it is quite certain that we can never adequately come to know the organized beings [living things] and their internal possibility in accordance with merely mechanical principles of nature, let alone explain them; and indeed this is so certain that we can boldly say that it would be absurd for humans even to make such an attempt or to hope that there may yet arise a Newton who could make comprehensible even the generation of a blade of grass according to natural laws that no intention has ordered; rather, we must absolutely deny this insight to human beings.   

What did Kant mean by this and what is its application to psychiatry? As a critical psychiatrist I think I am applying Kant’s critical philosophy to psychiatry.

What Kant was saying is that a mechanistic psychology is impossible. Not that people cannot be studied in a mechanical way, particularly parts of themselves - and as far as psychology is concerned this is the brain - nor that we cannot produce descriptions of thoughts, emotions and behaviour. But a mechanistic conception of nature fails to provide a complete characterisation of living systems.

Why is this? Living things are different from inanimate objects. They have functional and goal-directed characteristics. They have designed and designer-like aspects. They seem to be intended for a definite purpose and they have the ability to form their parts. Living things are purposiveness systems, or to use Kant’s words, teleological systems. A machine is different. It does not serve its own interests but the interests of its maker or user. Organisms, unlike machines, are self-organising and self-reproducing systems.

We therefore need different modes of explanation for teleological and mechanical points of views. For example, understanding the meaning of human action is a different kind of explanation from mechanical explanation. The mechanistic conception of causality fails to provide a complete understanding of human and living systems in general.

In fact, Kant goes further than this. What he says is that how living wholes cause their parts is unknowable to us. We just have to accept that our knowledge is limited because we conceptualise organic matter in a different way to inorganic matter. Life and human sciences are doomed to a kind of pre-scientific descriptivism rather than becoming a natural science.

We can never have theoretical knowledge that anything in nature is teleological, but such judgment is nonetheless necessary and beneficial for us. Which is why we attempt to understand human and living behaviour in mechanical terms. We may well wish we could explain life in mechanistic scientific terms and so-called science has often embarked on what Kant called a “daring adventure of reason”. Despite Kant recognising the wish to have a physical understanding of life and human behaviour, nonetheless he argued that it is absurd and futile to expect to be able to explain mental processes in physical terms.

I want to try and apply this kind of thinking to psychiatry. Mental illness is commonly perceived to be due to brain pathology. This is standard understanding. People may even be told by doctors that their mental health problems are due to a chemical imbalance in the brain or some other biological disease. You may even have heard or read something like this yourself. But critical psychiatry is saying you are being misled by perspectives like this.

Of course acute brain disorders can present as a toxic confusional state. More chronically they can lead to a dementia. But most mental health problems are functional in the sense that they are not structurally represented in the brain.

I don’t want to be misunderstood. Of course I’m not saying that mental health problems have nothing to do with the brain. The mind is clearly enabled by the brain. But what I’m saying is that mental health problems should not be reduced to the brain. And, like Kant, this is primarily a statement about how one explains mental health problems. I’m not saying that mind and brain are different substances. I’m not anti-materialist in this sense. Nor am I saying that it’s not important to use scientific methods. In fact, a lot of what passes for science, certainly in mental health, is more to do with speculation than the real world. Considering the amount of money that’s been spent on mental health research, one might hope that progress would have been made. But essentially results are so clouded by inconsistencies and confounders that it’s not been possible to say anything definitive about the biological basis of mental illness.

You may be surprised by me taking such a position as this. And, you may well not be alone. I am taking a minority view within psychiatry. In fact, psychiatry is more like a faith that doctors are expected to believe in rather than a science as such. If I don’t follow the faith of believing that mental illness is a brain disease, then I’m seen as unorthodox. I do, however, have a few other psychiatrists who agree with me. Twenty years ago we formed the Critical Psychiatry Network. If you’re interested in finding out more, there’s an editorial in February's British Journal of Psychiatry entitled ‘Twenty years of the Critical Psychiatry Network’.

(Adaptation of talk given to Cambridge University Psychology Society, 21 February 2019)


Richard Gipps said...

My comment concerns i) the difference between the characterisation of a phenomenon, and the causal explanation of an organism's proper function and breakdown; ii) the reason for the ineliminability of teleology in explanations of mental illness.

Agreed: a 'mechanistic conception of nature fails to provide a complete characterisation of living systems'. If we want to understand what it is to be a living organism then we'll have to refer to matters teleological. Similarly you can’t characterise what it is to be a fake or real bank note simply in terms of chemical composition, i.e. without looking to the social institution of money.

You write that 'it is absurd and futile to expect to be able to explain mental processes in physical terms.' Iit's surely right that we can't explain what it is to (e.g.) hear in physical terms: no amount of knowledge of neurological structure and neural activity will add up to a reflective account of how perceptual verbs are properly used. Yet this doesn't entail that we can't explain how hearing comes about, what causes it, in physical terms. Someone who asks how hearing comes about may be interested in how it is that someone blowing into a tuba over there can have such a startling effect on me standing over here. The answer may contain descriptions of physical processes: vibrations of the tuba, transmission of these in the air, ear drum doing what-have-you, auditory cortex doing what-have-you, etc. But yet, and of course, we can agree that none of that tells us what it is to hear. Hearing is a particular kind of ability of an organism, not an activation of part of an organism (auditory cortex).

Suppose someone asked 'How is Geoffrey able to understand higher maths?' One answer refers to the teaching required. Another more recherché one refers to the brain regions required. Whether or not either is a good answer will depend in part on what the questioner was after. If the question was being asked in a neurology class, then perhaps they were after the latter. (What counts as a good explanation is always relative to the context of inquiry; the notion of a 'complete explanation' is, then, perhaps somewhat obscure.)

Turning to mental illness, it’s surely true that we can't say what it is to possess a healthy mind in physical terms, and equally that we can't say what it is for someone to become mentally ill in physical terms. But by itself this doesn't rule out physical answers to questions about what causes mental illness. We can't explain what money is in merely physical terms, but we might explain why production of it stopped in purely physical terms (cog snapped in the printing press). In other words, just because we can never say what it is to think or feel or be in touch with reality in merely physical terms, this doesn't mean that we can't say how someone became mentally ill in merely physical terms.

I'm not saying that somebody could become mentally ill without there being a teleological ('final') cause in play. My own (controversial) suggestion is that whilst we can explain those mental disorders (e.g. Alzheimers) which are not mental illnesses in physical terms, mental illnesses proper must be understood psychologically. This is not because I think we can move from 'the mind can't be characterised physically' to 'mental illness can't be causally explained in physical terms', but because I think that in mental illness proper the will is not merely compromised but is compromising. Mental illness involves, I reckon, a motivated (but not consciously contrived) avoidance of reality; not merely a disturbance to an intrinsically teleological system but an in-part teleologically-explicable disturbance. Without a diathesis itself perhaps explicable in physical terms the individual might not need to make such motivated retreat; even so this motivated element, I suggest, is part of any genuine mental illness.

F68.10 said...

"Mental illness involves, I reckon, a motivated (but not consciously contrived) avoidance of reality"

Yes and no. While it may be true of most cases of mental illness, there are situations where avoidance of reality is not exactly the problem.

I'm thinking of the trauma induced by child battery, severe physical accidents, war, rape, child sexual abuse, Munchausen by proxy.

All these are problems where "reality" has absolutely not been "avoided".

I'm having real issues with the trope "mental illness" = "denial of reality". It's factually untrue in some important psychiatric cases, and has damaging consequences in terms of conceptualisation of mental illness on many fronts.

DBDouble said...

Thanks, Richard. I don’t think we’re far away from agreeing. I suppose brain localisation may be more specific for sensory functions such as hearing rather than human meaning, including mental illness

Richard Gipps said...

On F68.10's comment:

I can understand the reason why someone who got PTSD from being blown up or violently raped, say, would be keen to say 'the problem isn't me avoiding things; the problem is that I was blown up / raped!'. There would be a point to saying that if, say, someone asked, out of the blue 'What caused his/her current problems?' We would be completely remiss if we didn't answer with 'being blown up / raped'.

I also now understand, thanks to F68.10, the reason why it's unhelpful to think of (what I take to be) the motivational element of mental illness always in terms of avoidance of reality. One way to 'save' my claim would be to say that avoidance of inner reality is also necessarily part of the deal with PTSD. Is it just that someone cannot retrospectively master those traumatic experiences that, by definition, they couldn't master at the time? Or is it that their mind also reflexively veers away from the attempt to master them? But now I'm not completely convinced by my own suggestion. After all, there's good reason to think that the motivational element in such PTSD as is true mental illness (rather than simply having one's nerves shot to bits, so to speak) is manifest also in the very having of flashbacks (failed attempts, but nevertheless attempts, to retrospectively master traumatic situations?).

So I've learned something here, and will now restrict the scope of the 'essentially motivation referencing' claim about true mental illness to include not just avoidance.

F68.10 said...

"One way to 'save' my claim would be to say that avoidance of inner reality is also necessarily part of the deal with PTSD."

There is indeed a case to be made to salvage your claim, and I agree with you (to some extent).

It's just that we shouldn't hide from looking at the problem as it is, in its entirety, rather as looking at it how we would want it to be for various reasons. We should avoid motivated reasoning when selecting aspects of reality that we consider when talking about "mental illness".