Even More Epistemic and Hermeneutical Injustice......

My latest foray into the philosophical was reading a paper by Bennet Knox (1) called “Exclusion of the Psychopathologized and Hermeneutical Ignorance Threaten Objectivity”. In it he argues for inclusion of persons affected by mental illnesses or at least as they are defined in the DSM into the scientific process of revising the DSM. He prefers the term psychopatholigized that he shortens to pathologized to other terms used in the philosophical literature. He makes the argument against a severely truncated form of psychiatry that he can conveniently describe as hermeneutically ignorant while characterizing a brief comment by Spitzer as hostile. His argument hinges on a concept of social objectivity that necessarily means all viewpoints of the psychiatrically involved including those who want to burn the profession down are valid and must be considered.

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 4^th or 5^th 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

Dr.Ghaemi on Dr. Spitzer

Nassir Ghaemi, MD has a commentary on Robert Spitzer, MD in this month's Clinical Psychiatry News.  After citing quotes by Shakespeare and John Adams to suggest that the dead are often idealized, he settles down to criticism based on whether or not the DSM-III helped or harmed the profession and Spitzer's role in that process.  Ghaemi comes down firmly on the side of harm because an unscientific approach to the diagnostic criteria for major depressive disorder has resulted in a lack of reliability and validity.  He uses the often quoted kappa score of 0.32 for diagnostic reliability of major depressive disorder in DSM-5 field trials as the main source of evidence, as well as the fact that the diagnostic criteria are unchanged since DSM-III.

Ghaemi suggests that his viewpoint is unique because unlike other eulogists, he had no personal connection with Spitzer and therefore can speak "in forthright recognition of fact from the impersonal perspective of another generation."  I am closer to Ghaemi's generation than Spitzer's and can make the same claim, but come to an entirely different set of conclusions.

I don't see Spitzer's efforts as being as corrosive as Ghaemi does, probably because I recognize the fact that there will never be a set of written diagnostic criteria that are perfect, based on science, and unambiguous.   But before I address the scientific, let me take on the rhetorical.  I would hardly blame Spitzer for the fact that the DSM criteria for depression have changed "hardly an iota" in the intervening 40 years since DSM-III.  Over that same time span there have been hundreds if not thousands of articles on the reliability of the major depressive episode diagnosis, as well as articles that analyze the symptoms according to that diagnosis.  There have been articles on standardizing various psychiatric and psychological instruments to detect major depression.  In fact, one of the rating scales basically copies the DSM criteria and asks the patient to rate on a 0 to 3 point scale - the percentage of days that they experience the symptoms. The PHQ-9 has become the standard for depression diagnosis in many primary care clinics.  There is also the fact that Spitzer's original DSM-III effort resulted in much higher reliability figures - a kappa of 0.72 to be exact (2).

There is also the issue that there have been two intervening Task Forces for DSM-IV and now DSM-5.   The Chair of the DSM-IV Task Force has since become a prominent critic of the DSM process and psychiatry in general.  I may have missed it, but at the time that Task Force was convened, I did not notice him or other members advocating for major changes to the major depression diagnostic criteria.  These are supposedly the top minds in the field.  Highly motivated academics with one axe or another to grind.  The idea that everyone would defer to Dr. Spitzer based on his original approximate efforts seems unrealistic to me.  More than a few people would have noticed his bungled and unscientific approach.

My major problem is using a single reliability figure as the grounds for this criticism.  Every year outpatient based psychiatrists can see up to a thousand new people a year.  They may find that up to 50% of those patients have had a life-long sleep disturbance.  Many can recall nightmares and sleep terrors as children.  Another 20-30% will have generalized anxiety or social anxiety since childhood.  In some there will be a performance based anxiety that is comorbid with the social anxiety.  Another 10-20% will have post-traumatic stress disorder to some degree.  About one-third will have a significant substance use problem.  These percentages will vary by clinic location and referral base.  The majority will be referred for a diagnosis and treatment recommendations for depression.  A substantial number of people with depression have comorbid anxiety and anxious temperaments.  I don't think it is a stretch to say that on any given day, many of the identified depressives will identify themselves as primarily anxious.  It is not unexpected to find that many patients don't really understand the difference between anxiety and depression or they will overtly say that they are the same problem - indistinguishable from one another.  Unless there is a clear differentiating factor like a manic episode, the postpartum state, or psychotic symptoms I would not expect that anxiety and depression are distinct disorders for most people.  At the minimum anxiety might morph into depression, but in most cases they are coexisting chronic conditions.  A low kappa in this situation should be expected and not a shock.

Does that mean that psychiatrists should be wringing their hands and blaming Spitzer for it?  Neither response is appropriate.  Psychiatrists are highly successful in diagnosing and treating mental illness, not because of a DSM manual, but because of clinical training.  When it comes to anxiety and depression there are no known ways to parse all of the symptomatic possibilities.  The human brain is designed to realize all of the possible combinations of human experience.  Why would we expect it to be different when it comes to experiencing anxiety and depression?  The only chance that a psychiatrist has to make sense of the world is a number of patterns of diagnoses based on their training and practice experience that they can match against the patient they are currently seeing.  These patterns guide the diagnosis and treatment plan.  A clinically astute psychiatrist is not plowing through the interview to see if the patient "meets criteria".  A clinically astute psychiatrist carefully attending to the patient's conscious state and trying to figure out how they can be helpful.  That includes figuring out the real problems and prioritizing them in a complex matrix psychiatric and medical problems.  None of that flows from the DSM and none of that resembles research based on lay people interviews using DSM criteria.

In closing, any commentary on Dr. Spitzer should include his role in eliminating homosexuality from the diagnostic manual.  This detail and how it occurred is never taught to residents.  I had to learn it from public radio many years after residency.  This detail is significant any way you cut it.  It invites criticism that monolithic psychiatry is currently moving too slow in other areas or that monolithic psychiatry was just responding to public pressure.  There is also criticism directed at Dr. Spitzer for a paper based on self report that was withdrawn years later on this same issue.  There are always advocacy groups seeking publicity by their own spin on the issue.   In my opinion, none of that diminishes that significant achievement that put psychiatry four decades ahead of most people in the United States.  Say what you will about the DSM, that accomplishment alone is enough.  I am thankful that Dr. Spitzer was open minded enough to listen to the advocates and eventually side with them.              


George Dawson, MD, DLFAPA


1:  Nassir Ghaemi.  Commentary:  Dr. Robert L. Spitzer - An impersonal appraisal.  Clinical Psychiatry News.  March 2016. p 12-13.

2:  Riskind JH, Beck AT, Berchick RJ, Brown G, Steer RA. Reliability of DSM-III diagnoses for major depression and generalized anxiety disorder using the structured clinical interview for DSM-III. Arch Gen Psychiatry. 1987 Sep;44(9):817-20. PubMed PMID: 3632255.

On the Validity of Pseudopatients

Every now and again the detractors and critics of psychiatry like to march out the results of an old study as "proof" of the lack of validity of psychiatric diagnoses.  In that study,  8 pseudopatients feigned mental illness to gain admission to 12 different psychiatric hospitals.  The conclusion of the study author was widely seen as having significant impact on the profession, but that conclusion seems to have been largely retrospective.  I started my training about a decade later and there were no residuals at that time.  I learned about the study largely through the work of antipsychiatrists and psychiatric critics.

Several obvious questions are never asked or answered by the promoters of this test as an adequate paradigm.  The first and most obvious one is why this has not been done in other fields of medicine.  It would certainly be easy to do.  I could easily walk into any emergency department in the US and get admitted to a Medicine or Surgical service with a faked diagnosis.  I know this for a fact, because one of the roles of consulting psychiatrists to Medicine and Surgery services is to confront the people who have faked illness in order to be admitted.  Kety (9) uses a more blunt example in response to the original pseudopatient experiment (1):

"If I were to drink a quart of blood and, concealing what I had done, come to the emergency room of any hospital vomiting blood, the behavior of the staff would be quite predictable. If they labeled and treated me as having a bleeding peptic ulcer, I doubt that I could argue convincingly that medical science does not know how to diagnose that condition. "(9)

I also know that this happens because of the current epidemic of prescription opiate abuse and the problem of drug seeking and being successful at it.  An estimated 39% of diverted drugs (7) come from "doctor shopping."  By definition that involves presenting yourself to a physician in a way to get additional medications.  In the case of prescription opioids that usually means either faking a pain disorder or misrepresenting pain severity.  So it is well established that medical and surgical illness well outside of the purview of psychiatry can be faked.  And yet to my knowledge, there is hardly any research on this topic and nobody is suggesting that medical diagnoses don't exist because they can be faked.  Does that mean the researchers consider the time of these other doctors too valuable to waste?  More likely it did not fit a preset research agenda.

The second obvious question has to do with conflict of interest.  It is currently in vogue to suggest that psychiatrists are swayed in their prescribing practices by incentives ranging from a free pen to a free meal.  Compensation as a company employee or to give lectures is also thought of as a compromising incentive. The free pen/free meal incentive is pretty much historical at this time.  What about intentionally misrepresenting yourself?  What is the conflict of interest involved at that level and how neutral can you stay when you are trying to escape detection in order to prove a point?  A vague script like a mono-symptomatic presentation of schizophrenia should suggest that the intent is to escape detection.  How should a person with a vague script act when they are face to face with a real clinician?  The logical conclusion is that they would be as evasive as possible even if they were adhering to that protocol.

The bottom line is that the pseudopatient experiments were seriously flawed out of the box.  Continuing to promote them as meaningful reflects a serious lack of scholarship in reading the relevant literature and a need to suspend the reality that in fact mental illness does exist, that distinctions can be made among various types of mental illness, and that those distinctions are useful to psychiatrists trying to help people with those problems.

George Dawson, MD, DFAPA

1: Rosenhan DL. On being sane in insane places. Science. 1973 Jan 19;179(4070):250-8. PubMed PMID: 4683124.

2: Fleischman PR, Israel JV, Burr WA, Hoaken PC, Thaler OF, Zucker HD, Hanley J, Ostow M, Lieberman LR, Hunter FM, Pinsker H, Blair SM, Reich W, Wiedeman GH, Pattison EM, Rosenhan DL. Psychiatric diagnosis. Science. 1973 Apr 27;180(4084):356-69. PubMed PMID: 17771687.

3: Bulmer M. Are pseudo-patient studies justified? J Med Ethics. 1982 Jun;8(2):65-71. PubMed PMID: 7108909; PubMed Central PMCID: PMC1059372.

4: Spitzer RL, Lilienfeld SO, Miller MB. Rosenhan revisited: the scientific credibility of Lauren Slater's pseudopatient diagnosis study. J Nerv Ment Dis. 2005 Nov;193(11):734-9. PubMed PMID: 1626092

5: Spitzer RL. More on pseudoscience in science and the case for psychiatric diagnosis. A critique of D.L. Rosenhan's "On Being Sane in Insane Places" and "The Contextual Nature of Psychiatric Diagnosis". Arch Gen Psychiatry. 1976 Apr;33(4):459-70. PubMed PMID: 938183.

6: Zimmerman M. Pseudopatient or pseudoscience: a reviewer's perspective. J Nerv Ment Dis. 2005 Nov;193(11):740-2. PubMed PMID: 16260928.

7: Inciardi JA, Surratt HL, Cicero TJ, Kurtz SP, Martin SS, Parrino MW. The "black box" of prescription drug diversion. J Addict Dis. 2009 Oct;28(4):332-47.  PubMed PMID: 20155603; PubMed Central PMCID: PMC2824903.

8: Millon T. Reflections on Rosenhan's "On being sane in insane places". J AbnormPsychol. 1975 Oct;84(5):456-61. PubMed PMID: 1194506.

9: Kety SS. From rationalization to reason. Am J Psychiatry. 1974 Sep;131(9):957-63. PubMed PMID: 4413516.