Launching the social philosophy of psychiatry
Authors: John Z. Sadler
Journal: World Psychiatry (2024)

Stein et al1 provide a state-of-the-art summary of the philosophy-psychiatry field that centers around the mind-brain-world triumvirate. They do an astounding job summarizing 30 years of activity in the field, culminating in a present-into-the-future consideration of embodied cognition. Here I look forward in a different direction. Borrowing the internalist/externalist distinction from historiography, externalist philosophy of psychiatry might be paraphrased as a social philosophy of psychiatry. Externalist philosophy of psychiatry would consider the role of the social and cultural world in shaping conceptions of mental illness and its treatments. It would consider social phenomena as environmental contributors to the complex causalities that converge on psychopathological phenomena. It would reconsider concepts of free will in terms of structural features of the human organism alongside the structural features of our increasingly complex social environment. It would draw upon philosophy of technology, social epistemology, metaphysics, political philosophy, and philosophical anthropology in placing clinical diagnosis, research and theory into sociocultural contexts. Through understanding these social contexts, we can find new clarity in the mental health project. I can make these abstract generalizations more vivid by considering some examples from our current, and rapidly changing, era. I mention very briefly three areas ripe for development by social philosophers of psychiatry: the engulfment of clinical activity by electronic medical records; the role of domination by the State in mental health; and the psychopathology of artificial intelligence (AI). Back in 1977, Heidegger2 introduced the concept of "enframing" to the then-developing philosophies of technology. "Enframing" involves the tendency of technologies to appropriate resources for their own purposes, forming a "standing reserve" of resources increasingly remote from human goals. Heidegger's thinking helped to found the now-familiar philosophy of technology tropes such as "technologies solve problems which in turn generate new problems, requiring new technological solutions". This recursive expansion of technological imperatives can be seen playing out in clinics around the world through electronic medical records. Psychiatric training directors are already noting the deterioration of interviewing and diagnostic skills when young trainees are driven to checking box after box of clinical findings, being "enframed" into the metaphysical structure of those records, and missing the big narrative picture of the patient. What made "enframing" toxic for Heidegger was that technologies change the way we think, as in the above-mentioned check-box interviews. Fortunately, philosophers of technology have been working on this set of problems for a while, and philosophers of psychiatry can find a rich literature. The response to digital "enframing" has already begune.g.,3. The archeologist/anthropologist team of D. Graeber and D. Wengrow4 reconsider world history with a particular interest in the origin of social inequity and the origin of the State (e.g., government). As social scientists, they have access to and can interpret archeological and anthropological sciences freed from the limits of written text "traces". By studying cultural artifacts, they can provide evidence about the diversity of community living over the millennia. One of their major insights is the common threads that constitute domination of people by other people – e.g., social control. They identify three factors that are apparent singly, doubly or triply in virtually all the cultural forms of dominated communities: control of violence, control of knowledge, and control by charisma. Control of violence refers to the people who are authorized to apply violence to others, whether war-making or managing crime (as just two examples). Control of knowledge has to do with the people controlling what counts as truth and knowledge. Control by charisma has to do with the persuasiveness of the would-be empowered group; the ability to bring believers/followers into the fold. The authors note that the most successful domination occurs when all three factors of the triad are seized. They also note that the means to capturing the three factors are not determinative; one can have democratic, imperial or fascist dominations, for example. I need not detail the relevance of these concepts to our current world situation, but I can point to their relevance to the social philosophy of psychiatry. We have seen the rise of populist authoritarian rule over the past decade – the charisma element. We have witnessed the loss of confidence in "elites" – scientists, professors, philosophers, intellectuals and doctors. More importantly, talk of "post-truth" and the transformation of public lying from vice to virtue is eroding our prior forms of the domination of knowledge. Control of violence is also being shaken worldwide, as social media enable the challenging of conventional mechanisms of violence control (policing, the courts, civil liberties, rule of law, subordination) through familiar tropes such as #Icantbreathe, #metoo, and the unprecedented January 6 storming of the US Capitol building. For philosophers of psychiatry, the range of tasks deriving from these social changes is huge. Some are simple to conceive: how do clinicians communicate around these phenomena? Others are definitional: how many people must believe something before a false belief is not a delusion? Still others are insidious: what counts as mental health in a post-truth world where confidence in State institutions is diminishing? In recent months we have witnessed the explosion of AI technology proffered by the major info-tech companies. We have also witnessed gushing enthusiasm as well as apocalyptic worries from many users and commentators. Somewhere in-between these social reactions resides the systematic appraisal of these systems as they evolve. We have seen how human biases are entrained in AI, leading to perpetuation of bias in later use5. We have also seen both absurd and frightening results of natural language devices when asked ordinary questions6. Social philosophers of psychiatry can envision the development of looping effects of human-AI deviant interchanges online and worry about the social consequences. Some examples of inquiries in this area point to treating deviant AI responses as psychopathology analogues7. Others consider using AI tech as explanatory models of human psychopathologies and tools for therapeutic developments8. We can also envision the engagement of AI into disputes about medical and other misinformation in the social media environment, thus connecting psychopathology of AI to social-domination theory described above. Some preliminaries of this work have appealed to a "father" of philosophy of psychiatry: K. Jaspers9. All this potential work is wide open, deep and important.