Wednesday, August 21, 2019

The implications for psychiatry of a processual philosophy of biology

René Descartes was the first to apply the natural scientific mechanistic approach to life (although excluding the soul) (see previous post). This perspective has remained the most pervasive view within biology. Nonetheless there have been challenges that recognise that living beings have a purposiveness that cannot be derived from mere physical-chemical processes. For example, Georg Ernst Stahl differentiated organic life from the inorganic, integrating the soul and the body in the organism. This led to his erroneous claim that living things possess a vital entity. 

With the origin of enlightenment thinking in the second half of the eighteenth century, Immanuel Kant’s critical philosophy was clear that it is absurd and futile to expect to be able to understand and explain life in terms of merely mechanical principles of nature (see previous post). A mechanistic conception of nature fails to provide a complete characterisation of living systems. Organisms, unlike machines, are self-organising and self-reproducing systems. Different modes of explanation are therefore required for teleological and mechanical points of views. Although we can never have theoretical knowledge that anything in nature is teleological, such judgment is nonetheless necessary and beneficial for us and we commonly embark on a ‘daring adventure of reason’ to understand life in mechanical terms. 

American pragmatic philosophers, such as William James and John Dewey, in the context of Darwin’s theory of evolution, attempted to dissolve such metaphysical disputes by focusing on nature and experience and the centrality of the organism-environment interaction. Following the development of quantum mechanics in physics, a group of organicist biologists promoted life’s dynamic, systemic and purposive character as a way of moving on from physico-chemical reductionism (see previous post). For example, John Scott Haldane recognised the distinctiveness and irreducibility of living beings because of the continuous dynamic preservation of the internal environment. One of the most important principles of biology for Ludwig von Bertalanffy was the stream of life conception, that living forms are the expression of a perpetual stream of matter and energy.

More recently, Dupré and Nicholson (2018) have proposed a manifesto for a processual philosophy of biology to move on from explanation in terms of static unchanging entities. Their project promotes the metaphysical thesis that the living world is made up of processes not substances. Alfred North Whitehead articulated a comprehensive metaphysical system for process thinking, but Dupré and Nicholson distance themselves from its details. There needs to be more discussion about the underlying philosophical worldview and limitations of the mechanistic approach to biology and such processual thinking provides a valuable framework to take this debate forward. 

This perspective has implications for medicine in general, in particular in relation to the concepts of illness and disease. Illness disturbs a person’s functional equilibrium. Disease, particularly since the development of anatomoclinical methods in the 19thcentury (see previous post), tends to be understood as structural biological pathology. Emphasising the disruption of dynamic processes as a way of understanding disease moves on from this simple contrast between organism as thing and its independent pathological process. 

This abstract focuses on the implication for psychiatry of processual thinking. The mind-body problem can be seen as a more specific form of the mechanistic-processual dilemma (see eg. previous post). Persons need to be understood as biological processes. There is a history in psychiatry of attempts to integrate somatic and psychosocial aspects, and this can be related to developments in processual thinking in biology (see previous post).

For example, George Engel proposed a new medical model, suggesting that the general systems theory of von Bertalanffy provided a suitable conceptual basis for his biopsychosocial model (see previous post). Perhaps in a similar way to Dupré and Nicholson, whose project does not specifically build on Whitehead’s overarching theory, an integrated biopsychosocial approach is not dependent on general systems theory as such. For example, Adolf Meyer’s Psychobiology was more related to American pragmatism. Meyer was clear that Psychobiology studies man as a person within the framework of biology (see previous post). 

Such integrated mind-brain understandings were also present in the origins of modern psychiatry. For example, Ernst von Feuchtersleben published his textbook influenced by Kantian critical philosophy in the same year, 1845, that saw the publication in German of the book in which Wilhelm Griesinger set the trend for understanding the pathology and therapy of mental diseases as a mechanical natural science. The argument of this abstract is that processual thinking in biology counters this dominant positivist tendency within current psychiatry. (see previous post).

(Abstract submitted to Peter Sowerby interdisciplinary workshop: Conceptual issues in biological psychiatry)

Wednesday, August 07, 2019

Advice to a young doctor considering a career in psychiatry

Dear trainee

Psychiatry needs doctors who are prepared to think critically. Unfortunately, it does not always make it easy for them to do so. Professor Sir Robin Murray, one of the most eminent UK psychiatrists over recent years, confessed to mistakes in an end of career mea culpa, wishing he had not adhered so “excessively to the prevailing orthodoxy" (see previous post) . As he says, there is an orthodoxy in psychiatry. You should, therefore, be prepared to be indoctrinated in your training (see previous post). This can be a confusing experience, and these comments are written to try and help you with that confusion.

Modern UK postgraduate psychiatry was developed at the Maudsley Hospital Medical School after Aubrey Lewis was appointed Professor of Psychiatry in 1948. He promoted the recruitment of high quality psychiatrists with "ardent, critical, lively, disputatious and reflective, eager minds" (see previous post). He encouraged a sceptical approach to psychiatry and had little patience for imprecision or poorly thought-out ideas. Building on these roots, it is still the case that doctors with open minds, who are sceptical of psychiatric quackery, need to be attracted into psychiatry.

The trouble is that you may have been encouraged to come into psychiatry because of clinical neuroscience (see previous post). There have been many exciting developments in basic neuroscience but what you may not have been told is that it is questionable whether these have any bearing on most of clinical psychiatry (see another previous post). The history of biological research in psychiatry is of speculations that have failed to be confirmed. Inconsistencies and confounders plague research studies, so that essentially it’s not been possible to say anything definitive about the neuroscientific basis of functional mental illness.

This may seem disappointing. But I wouldn’t want to encourage you to come into psychiatry if your only motivation is to uncover the biological basis of mental illness. You are bound to become disillusioned (see previous post). You may well have a successful career, like Robin Murray, but that may not be sufficient compensation for your personal scientific integrity (see another previous post).

However, maybe, after all, your primary attraction to psychiatry was more for philosophical and cultural reasons. You have trained as a doctor, so can appreciate how medical training is not always patient-centred (see previous post). However difficult it may be to have a whole-person approach to medical practice, this may well have been your initial motivation for choosing medicine. And, psychiatry, at least theoretically, should give you the opportunity to develop these interests further, although psychotherapy training is perhaps not always as readily available as part of psychiatric training as it used to be. Not that I am necessarily encouraging you to become a psychotherapist. Psychiatry itself has wider social concerns.

And, if you think about it, maybe you should not be so surprised that functional mental illness cannot be reduced to brain abnormalities. Biology itself raises philosophical issues about whether life can be understood as a machine. The fundamental issue of the relation of mind and body creates the context for stimulating conceptual debate and conflict in psychiatry. Despite Descartes, the soul and body are not separate but integrated in the organism. Psychiatry should take an organismic, processual, rather than mechanistic, perspective in the life and human sciences.

I would encourage you to take up the challenges of psychiatric practice. Clinical work is a privilege to share the traumas and sufferings of patients and help them understand and do something about their situation. Intellectual and academic rewards and fascinations are there for those that accept the limitations and uncertainty of practice. I wish you well in your application.

Let me know if I can do any more to help.