As I have stated before on this blog (and given examples) –
this is a standard philosophical approach to criticizing psychiatry while
ignoring what actually goes on in the field and how psychiatrists are trained. So,
I will start there.
Let me start with the concept of “social objectivity” since
the early claim by the author is:
“Further, insofar as the objectivity which psychiatry should
aspire to is a kind of “social objectivity” which requires incorporation of
various normative perspectives, this particular form of epistemic injustice
threatens to undermine its scientific objectivity.”
I am not completely sure of how philosophers use the term
normative here so I am assuming that it means – what other people approve of or
endorse. The other people here would be
the pathologized. He uses examples of
the pathologized in this paper as members of the Hearing Voices Movement and
the Autistic Self-Advocacy Network (ASAN).
He states that social objectivity is defined in two books by
Helen Longino but does not include an operational definition. Instead, he comments throughout the paper on
how various circumstances do not meet these criteria. He openly acknowledges that his argument is
deficient:
“Although I can provide only a limited argument
for embracing the social objectivity model in psychiatry here, my main goal is
to show fellow proponents of social objectivity that the particular kind of
hermeneutical ignorance I describe presents a significant obstacle to achieving
it in psychiatry.”
I agree that the argument presented is very limited. If that is the case, why should it be
achieved in psychiatry? Will it be
theoretically useful in some way?
His introduction to the need for social objectivity and
objectivity in general in psychiatry is based on the philosophy of
psychiatry. More to the point
non-empiricist philosophy. If that is considered, an empirically adequate model
is all that is required. Instead, he
introduces three models that all suggest that values play a role in psychiatric
diagnosis. He acknowledges that dysfunction is a value free criterion for
diagnosis but then goes on to separate out a category of mental disorder that
also contains judgements about dangerousness.
He lands on the DSM definition of dysfunction but explains it away as
“there is reason to believe that it is impossible (and undesirable) to uncover dysfunctions
in mental processes without reference to values.” He goes on to explain how “a scientific
process is more objective insofar as it engages a diverse array of points of
view with different normative background assumptions in a process of
“transformative criticism.”
There are multiple points of disagreement with this
viewpoint starting with a basic misunderstanding of what psychiatry is and how
psychiatrists work. The key element in the DSM that is ignored here are all of
the qualifications for subpopulations ranging from cultural differences to
gender differences that include a moving threshold for the diagnosis of
disorders and recognizing that in some cultures or subcultures varying degrees
of psychopathology are tolerated (or not) and that also includes a tendency to
stigmatize individuals with that psychopathology. Breaking that down –
psychiatry parses scientific objectivity and normative perspectives when it
comes to diagnosis and treatment planning. That not only occurs in psychiatry
but in all of medicine and it may actively include the outside input from
philosophers on ethics committees. Here
are a couple of clear examples.
Example 1:
Bob is a 65-year-old married man admitted for
hepatic encephalopathy from alcoholic cirrhosis. The Internal Medicine team
requests psychiatric consultation for further diagnosis and referral. The psychiatrist assesses the patient as
improved (less delirious) and competent.
No other psychopathology is noted. He discussed treatment options for
the alcohol use disorder and the patient is willing to listen. He has never attended an AA meeting or been
in treatment in the past. The family (wife and adult children) enter the room
and are all adamant about taking the patient home with no treatment. They are
angry and state several times “If he wants to drink himself to death it is none
of your business doctor. Let him drink himself to death.” The family and the patient are approached by
social workers and the Internal medicine team over the next two days but he is
discharged home with no treatment.
All of the people in this case were white 4th or
5th generation Americans. There are no assumed cultural differences,
but they are implicit. Patients and families affected by substance use disorders
have known patterns of adapting and some of them are not functional
adaptations. Was an attempt at involuntary treatment needed in this case? The
psychiatrist knew that hardly ever happens by local probate courts in substance use disorders unless
there was an actual suicide attempt or the family supported civil commitment. Should adult protection social workers have been involved? Referrals could have been made to county
social workers who might invoke a societal level value judgment on this
situation but instead dialogue was established with the family and they agreed
to call if problems occurred and take referral numbers for additional
assistance. They were also informed that the patient had a life threatening alcohol use disorder and severe complications (including death) could occur with any future episodes of drinking.
To the point of the article this example points out that
DSM diagnosis (alcohol use disorder, delirium plus dysfunction) were the
objective considerations. It also illustrates a point about social objectivity
and that is that it needs to be elaborated for every individual patient, family, and
culture/subculture specifically. Suggesting that physicians or psychiatrists don’t have
the capacity for recognizing these exceptions and planning according is not
accurate. Suggesting that the patient and family were ignored or that their
opinions were not considered is also inaccurate. The entire treatment and discharge plan was
based on those opinions - even after the recommended treatment was rejected and the high level of risk was explained.
Example 2:
Tony is a 28-year-old man seen in hospital
following a suicide attempt. He shot himself through the shoulder and is on the
trauma surgery service. When interviewed by psychiatry he says” “I did not
shoot myself. Sure, I had the gun pointed at myself but it just went off. I am not suicidal and I want to leave.” He
gives the additional explanation that he was using large quantities of alcohol
even though he has been hospitalized for alcohol poisoning in the past. When
the psychiatrist points out the dangers of alcohol poisoning including death he
says “Look I already said I was not suicidal.
I was just trying to get high. I
get to the point where I don’t care if I live or die but I am not trying to
kill myself.” He has had multiple
admissions for depression and suicide attempts in the past. He is currently on a 72-hour hold pending a
court hearing at that time. The psychiatrist requests a review from the Ethics
Committee composed of a number of local philosophy professors. They decide that the
patient should be released despite the recommendation to the court for extended
treatment of the substance use disorder and depression. During the hearing the psychiatrist testifies
that he has seen this type of treatment work and that he considers the patient
to be at very high risk. The court
releases the patient. A week later he is found dead from acute alcohol
poisoning.
Again, there are no major cultural differences in this case
but clear subcultural differences based on the patient’s family and social
history. The psychiatric diagnoses are
clear and indisputable. The clinical
judgment of the psychiatrist based on risk factors was also clear. The value
judgments introduced here are the probate court and Ethics Committee as a proxies for society’s charge
to balance a persons need for autonomy against their need for protection. Those decisions were spread over multiple people and agencies outside of the
field of psychiatry.
These basic case examples (I say basic because they are
encountered in acute care psychiatry every day and multiple times a day) illustrate
a few facets of social objectivity. First, it is poorly defined. Second, it is impossible to achieve primarily
because is consists of an infinite number of subsets that cannot be averaged if
the expected result is to achieve active input into the field of psychiatry.
Third, for social objectivity to be useful it needs to be recorded as unique
for every person that comes into treatment and handled as it was in the above
vignettes. That way the relevant
considerations of every unique history and constellation of signs and symptoms
can be evaluated in the proper context. It turns out that technique has been
around in clinical psychiatry for as long as I have been a psychiatrist and it
is called cross cultural psychiatry.
For 22 years, I practiced on an acute care unit where we
had access to professional interpreters who were fluent in both the language
and cultures of several countries as well as the hearing-impaired population
who used American Sign Language to communicate.
There were 15 language interpreters who spoke a number of African and
Asian languages in addition to Spanish. Professional interpreters do a lot more than translate languages - they also interpret cultural and subcultural variations as well as normative behaviors. We had access to telephone
interpreters in any language if we encountered a patient outside of the
hospital staff expertise. The interviews were lengthy and often incorporated
family members, community members, and in some cases local shaman. Without this
intensive intervention attempting to assess and treat these problems would be a
set up for the epistemic and hermeneutical injustices the author refers to. In
fact, treatment would have been impossible. In completing these assessments
there was not only an elaboration of the stated problem, how the relevant
community conceptualized that problem, a discussion of how it may be treated
psychiatrically and the rationale for that treatment, as well as whether the
family wanted the patient treated in general or more specifically in the
hospital and whether their shaman or medicine man would be involved.
These are just a few examples of how social objectivity is
approached in clinical psychiatry. The
result is that values are incorporated that are important to the patient and
their family even if they affect diagnostic thresholds and treatment planning. That is also clearly stated in the DSM. It is
a much more practical and personalized approach than trying to incorporate all
of those opinions into the DSM diagnosis and it gives a voice to many more people
than would be involved in that process. It also considers a multitude of local
factors (budgets and attitudes of social service agencies, budgets and
attitudes of local courts, community resources, etc.) that all factor prominently
in values-based decision making.
The other important aspect of an all-inclusive process for
social objectivity is that the normative thinking of some - may result in
exclusion rather than inclusion. Normative thinking based on beliefs can be
political thinking and in the past two years we have seen that lead to fewer
rights for women, the banning of books, a widening scope of gun permissiveness
in a society rocked by gun violence, gross misinformation about the pandemic, and an attempt to overthrow the elected
government of the United States. These are all good examples of how including
normative thinking outside the scope of medical practice could lead to
disruption of the entire field. The author suggests that the opinions expressed
do not need agreement - they only need to be aired. That strikes me as the basis for a very bad
meeting. Unless there is basic agreement on the values and rationale for a
diagnostic system – I think Spitzer has a point that opinions for the sake of
stating an opinion is a futile exercise especially if it is not in basic
agreement with medical and psychiatric values and ethics.
The author defines hermeneutical ignorance in
psychiatry somewhat clearer. He suggests that marginalized groups (like the
pathologized) develop their own conceptual resources that are not shared with
other groups. The example suggests that willful
hermeneutical ignorance results when the marginalized group does not share
the conceptual resources and the dominant group (inferring psychiatry)
are unaware of the resources or dismiss them.
There are numerous examples of how this is not the case with psychiatrists. Obvious examples include Alcoholics Anonymous
and other 12 step groups as well as community psychiatry programs that actively
use advocates and develop resources with the active input from people with
severe mental illness who are affiliated with specific programs. Psychiatrists
see a general knowledge about non-psychiatric resources as necessary to provide
people with additional assistance. In
many cases that can include discussions of how to better utilize the resource
and what to expect.
There are several additional points of disagreement with the author on many points where he seems unaware of how psychiatrists actually practice or he is unwilling to give credit where credit is due. The best example is his description of Spitzer’s brief commentary (2) on a paper written in Psychiatric Services. He was responding to a lead paper (3) on including patients and their families in the DSM process. The author characterizes Spitzer’s general attitude toward the idea as hostile and characteristic of injustices that he writes about but important context is not given. Spitzer was the major architect of DSM criteria and studied the process for decades. He wrote a comprehensive defense of psychiatric diagnosis in response the Rosenhan study that has been discredited. He was also responsible for removing homosexuality from the DSM and he did that by directly engaging with activists who presented him with clear information about why it was not a diagnosis. Critics like to use the homosexuality issue as a defect with psychiatry while never pointing out it was self-corrected and that correction happened decades before progress was made at societal levels. Even now there is a question about whether societal progress is threatened by the normative thinking and agenda of conservative groups. Spitzer was responding to the political aspects of the process with political rhetoric.
The best argument against
inclusion in the original paper was: “The
DSM process is already compromised by excessive politics.” by several groups
who are not psychiatrists. That argument
has been expanded in the past 18 years to the point where it is a frequent criticism
in the popular media. Even in the original paper the authors suggest that these
political processes may have stifled innovation and scientific progress.
Psychiatry has not “escaped” from considering values – as noted
in the above examples they are incorporated into clinic practice when the
specific social and cultural aspects that apply to a certain patient are
explored and considered. Contrary to
philosophical opinion – the pathologized are not a marginalized group to
psychiatrists. It is who we are interested in seeing and treating. Our interest in treatment goes beyond what is
typically considered evidence-based medicine. We are interested in any
modality that might be useful and that includes using resources developed or
available to the people who need them. It is clear that the DSM has been overly
politicized and it is routinely mischaracterized in the media. Adding additional elements - some that have strictly political
agendas that include the destruction of the field - adds nothing to improving
that process. There are existing avenues for that input and they are readily
available outside of the DSM process in day-to-day psychiatric practice.
George Dawson, MD, DFAPA
References:
1: Knox B. Exclusion
of the psychopathologized and hermeneutical ignorance threaten objectivity.
Philosophy, Psychiatry, & Psychology. 2022;29(4):253-66.
2: Spitzer RL. Good
idea or politically correct nonsense? Psychiatr Serv. 2004 Feb;55(2):113. doi:
10.1176/appi.ps.55.2.113. PMID: 14762229.
3: Sadler JZ,
Fulford B. Should patients and their families contribute to the DSM-V process?
Psychiatr Serv. 2004 Feb;55(2):133-8. doi: 10.1176/appi.ps.55.2.133. PMID:
14762236.
4: Dawson G. More on epistemic injustice. https://real-psychiatry.blogspot.com/2023/01/more-on-epistemic-injustice.html
5: Dawson G. Epistemic injustice is misapplies to psychiatry. https://real-psychiatry.blogspot.com/2019/07/some-of-greatest-minds-in-psychiatry.html
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