Psychiatry Unexplained

<p dir="ltr">This thesis critically examines the arguments and justifications that have maintained explanation as a prime principle in psychiatric theory and practice. This thesis starts from the widespread assumption that psychiatry is a discipline with commitments to causal explanations. It examines the recent history of philosophical accounts of scientific explanations and some of the epistemic tools used in their construction; natural kinds, levels, and the reification or “ontologisation” of abstract objects. The thesis proposes a turn from explanation to understanding as the central epistemic goal in psychiatric practice. This turn leads to a pragmatic conception of psychiatry as, fundamentally, a human practice, informed by science but not a science itself.</p><p dir="ltr">The first chapters critically examine philosophical arguments about scientific explanation in psychiatry. They focus on key ideas.</p><p dir="ltr">The first is that psychiatry relies on forms of causal explanation found in science more generally. This starts from nomological models in which explanations are validated by natural laws or high levels of inductive support. As that nomological model was eclipsed in psychiatry and in science generally, explanation turned to mechanisms dominated by genetic, neural, and “neurocognitive” mechanisms. That has not been successfully accomplished in psychiatry. In the absence of nomological or mechanistic explanation, explanation drawn from “Natural History” has been the dominant mode as in the rest of clinical medicine.</p><p dir="ltr">Secondly, natural history style explanation is built on “natural” kinds (e.g. species in biology, diagnoses and psychopathological classes in psychiatry). Natural kinds are assumed to conform with the causal structure of the natural world, hence they will support induction, causal scientific explanation, prediction, and intervention. Natural kinds and their consequent assumptions are examined and their validity questioned.</p><p dir="ltr">Thirdly, psychiatry’s objects, its diagnoses, its classes, and its processes are epistemological tools. They are mistakenly assumed to have an ontological foundation in the uncertain pathological processes underlying psychiatric illnesses.</p><p dir="ltr">More than one hundred years ago Charles Broad, writing about induction, argued that universal causation, natural kinds, and permanent substances, are interwoven as a whole and if any fails, they all fail. The preceding sections argue that they fail.</p><p dir="ltr">This leads to the Volta or turn from a conventional epistemology of psychiatric explanation. The turn starts from philosophical critiques of the causal assumptions of scientific explanation and the dogma of empirical verification of psychiatry’s objects of explanation. It is also a turn from a narrow view of science in psychiatry as the search for cause in “biological” (brain-based) scientific knowledge toward a science that includes descriptive and historical knowledge.</p><p dir="ltr">The turn hinges on the contrast between Explanation and Understanding in psychiatry. This starts from contrast of Erklärung as explanation that is appropriate to physical sciences and Verstehen as the understanding appropriate to “human” sciences. Jaspers brought this into psychiatry from Windelbandt and Dilthey. That contrast proves too sharp but it is a contrast, not the opposition as the Methodenstreit constructed it. The argument expands into an examination of a wider understanding of understanding but I signal here that psychiatry is a practice, not a science. This steers the development of the argument. In psychiatry, understanding yields a larger “epistemic gain” than is provided by explanation and is more tolerant of uncertain and incomplete information. Understanding is served by “thick” description and it serves comprehension rather than factual explanation and anticipation rather than prediction. Language plays an outsized role in this.</p><p dir="ltr">The thesis argues that transparent “thick” description that serves understanding, is the primary skill in psychiatry. It comes before the opaque postulates of scientific explanation and, while description is implicated even in the most rigorous explanation, the description most useful in understanding is the sort of topographic description that gives an overview of the field of phenomena and events. Rather than opposing methods, description and explanation are better seen as poles of a virtuous hermeneutic circle, where creative attempts at explanation focuses a light on phenomena that are comprehended in description. For some time, explanation has been overvalued at the expense of description in psychiatry. In the end, narrative drawn from thick description starts to break down the distinction between explanation and description.</p><p dir="ltr">The argument of the thesis is resolved in a coda which returns to psychiatry as an interventional practice. Practice, composed of what psychiatrists can do best, decides the domain of psychiatry. That domain is not decided by definitions or scientific delineations of mental illnesses. Psychiatric practice is informed by the human and biological sciences but it is constituted largely by the long experience of the profession transmitted in a tradition and the personal experience of the practitioner, summed as phronesis.</p><p dir="ltr">Ultimately, there is a limit to what practice can draw from causal explanation, from scientific generalisation and from theoretical postulation, except as a spur to the reconsideration of the tradition and the careful clinical description that yields judgment and considered intervention. Finally, psychiatry is a practice that whose practitioners draw mainly from the tradition in which they are rooted. The tradition requires constant updating from the sciences, from theory but most particularly from the description and redescription of the problems the profession faces.</p>