Five conceptual competences in psychiatry
Authors: Miriam Solomon
Journal: World Psychiatry (2024)

Stein et al1 survey a range of recent developments in philosophy of psychiatry that are relevant to clinicians. They recommend that clinical training include the development of "conceptual competences", i.e. philosophical skills and theoretical frameworks that bring new intellectual resources into psychiatry2. Here I would like to elaborate on the conceptual competences that Stein et al mention, discuss how they have grown in the last 30-40 years, and add a further one to their account. Perhaps the most important conceptual competence is conceptual humility, i.e. the awareness of the partial and provisional nature of current psychiatric knowledge. This brings an expectation of what I have called (in the more general context of medical knowledge as a whole) "messy pluralism"3. Our theoretical grasp of psychiatric phenomena is through a variety of intellectual frameworks with loosely demarcated scopes. These frameworks may lead in productive directions, or be wrong in ways that we do not know how to anticipate, or lead to unexpected consequences that we will need to investigate and refine. Proceeding with conceptual humility means accepting pluralism, rather than forcing a premature choice between partial truths, as well as treating contradictions generated by multiple different frameworks with curiosity rather than epistemic horror. A second conceptual competence is going beyond dualism. For much of the 20th century, several psychiatric questions have been approached from either a "scientific" (such as that of neuroscience) or a "humanistic" (such as that of phenomenology) perspective. K. Jaspers' General Psychopathology4 is a typical example of this kind of dualism, as is P. Kramer's two ways of approaching clinical cases in Listening to Prozac5. These approaches sometimes compete in providing different accounts of the causes of psychiatric conditions, with neuroscientific accounts eschewing "cognitive penetrability" in favor of mechanistic causes, and phenomenological accounts aiming, sometimes dubiously, for narrative completeness. Such dualism is a simple example of "messy pluralism", involving two approaches. P. Kramer shows skill in making use of both perspectives in handling particular cases. What is called for now is an expanded ability to juggle more than these two perspectives, i.e. a more complex and nuanced pluralism. The common bifurcation into scientific and humanistic approaches is a misleading oversimplification of the theoretical options, which include a variety of scientific, humanistic and mixed approaches. Hence, going "beyond dualism" is an important conceptual competence. A third important conceptual competence is the appreciation that psychiatric concepts often aim to achieve a variety of goals in addition to traditional scientific ones such as descriptive accuracy, predictive success, and explanatory power. Psychiatric concepts are expected to identify appropriate subgroups for specific treatments, underlie appropriate guidelines for social/educational/legal eligibilities, provide categories for clinical research, support intuitions about moral responsibility, and sometimes even supply social identities. Proposed concepts can be rejected or modified because they are thought to be inaccurate, or too difficult to apply reliably, or problematically stigmatizing to some patient groups. One of the enduring lessons of the DSM process is that no single system of concepts can satisfy all such goals at all times. There are inevitable trade-offs between different important goals. Stein et al refer to this in terms of an "interplay of natural facts and human interests". Zachar6 has introduced the idea of "practical kinds" as a supplement to "natural kinds". A good example of responsiveness to different goals is the shifting way in which intense and prolonged grief symptoms have been handled from DSM-III through DSM-5-TR, trying to strike a balance between effectively addressing human suffering and avoiding "pathologization" of normal reactions to loss. A fourth important conceptual competence is an awareness of which groups, individuals, professions etc. control the discourse of psychiatry. By "control the discourse" I mean the mixture of earned and unearned authority that shapes how new ideas are received from the public, patients, families, and various health care professionals. The DSM era – from 1980 until recently – has been marked by the powerful control of the American Psychiatric Association, in which group consensus of experts, led by psychiatrists with some participation from psychologists, provided grounds for accepted categories and concepts. Recently, there have been multiple calls for a more democratic social epistemic process, especially one that includes "experts by experience" (traditionally called "patients")7. As of 2023, the DSM process itself is still conservative, allowing the input of experts by experience only during the stage of public comment on proposals. A final useful conceptual competence that I would like to add to Stein et al's suggestions is what I will call hembig awareness, taking the neologism "hembig" from Alvesson and Blom8. Writing in the academic field of organization studies, they find that the handling of some key concepts (such as "leadership", "strategy", "institution") is central and important, but confusingly imprecise and ambiguous. A "hembig" concept is one that is hegemonic (plays a regulatory role), ambiguous and big (wide and often unclear in scope). It is important to be aware of which concepts are hembig, so that problematic ambiguities and inferences can be avoided. The main hembig in psychiatry is the term "psychiatric disorder", which is a metaphor (the literal – but not the actual – meaning of "disorder" is "lack of order"). While there have been attempts to define "psychiatric disorder" technically, using necessary and sufficient conditions, these attempts have generally fallen short of their intended generality. They have included "maladaptive patterns of sense making" (K. Nielsen), "harmful dysfunction" (J. Wakefield), harmful biological kinds (J. Tsou), predictive failures in Bayesian processing (A. Clark, K. Friston), socially deviant judgments (T. Szatz), "madness as strategy" (J. Garson), and box canyon (local minimum) solutions in cognitive processing (K. Kendler). L. Wittgenstein's alternative suggestion that theoretical terms such as "psychiatric disorder" mark "family resemblances"9 has been a helpful meta-metaphor – but still only a metaphor – for starting to explore how these kinds of concepts work.