Philosophy of psychiatry as study of paradigm changes
Authors: Derek Bolton
Journal: World Psychiatry (2024)

Philosophy of psychiatry addresses many conceptual topics in psychiatry that lie on the borderline between philosophy, science, culture and clinical practice. Stein et al have produced an excellent critical review of many of these topics and major approaches towards them1. In addition, philosophy always has itself as a topic of enquiry – it is eminently self-reflective. Here I will make some observations on what philosophy of psychiatry is. Briefly put, philosophy studies conceptual issues, but what are they? While there is a long tradition of supposing that concepts are timeless and unchanging, which shows up in some positions in philosophy of psychiatry, the general trend in 20th century philosophy has been to regard concepts as embedded in symbolic systems and practices that vary from time to time and place to place. An example, to which Stein et al refer several times, is Kuhn's philosophy of science. Science has occasional revolutions in fundamental theory, so-called paradigm shifts, when old assumptions are inadequate for new major problems or discoveries, and are replaced by new kinds of science. These are followed by periods of "normal science", in which the meaning and implications of new theory, methodology and data are worked through2. Of special interest to psychiatry and health care generally are paradigm changes in their basic sciences of biology and psychology. Generally recognized revolutions in these sciences occurred in the second half of the 20th century: the genetics/information revolution in biology3, and the associated cognitive/information revolution in psychology4. Since then, normal science within the new paradigms has advanced at pace, with ongoing explorations and developments such as epigenetics and embodied cognition, as discussed by Stein et al. New paradigms typically usher in new ontology, merging into the traditional subject-matter of philosophy as metaphysics. The above-mentioned paradigm shifts in sciences basic to psychiatry do exactly this. In biology, the 19th century dominant view that physiological processes were (no more than) physics and chemistry was replaced by a new kind of ontology involving coding, information, signalling and regulatory mechanisms3. In psychology, the long-standing influence of dualism, underpinning the view that mental processes could not affect the body or behavior, gave way to a new conceptualization of cognitive processes as involved in the regulation of behavior4. The appearance of cognitive neuroscience was guaranteed both ways. First, as a biological system like any other, the central nervous system has the dual aspect of physics and chemistry combined with the new science of information processing. Second, it has the particular cognitive function of regulating behavior in the environment. The concept of information has been fundamental in this paradigm shift, with increasing recognition that information is not a representation of already made states of affairs, but is selected, processed and used in ways highly dependent on the needs and goals of the living being. The ontological status of information as cognition is among the issues currently being worked out under the heading of "embodied cognition", as discussed by Stein et al, illustrating the point made earlier – that scientific revolutions are followed by periods of normal science in which interpretations and consequences of new theory and discoveries within the new paradigm are worked out. The interconnected paradigm shifts in biology and psychology over the last few decades have major implications for health care sciences. An example is the deconstruction of several interconnected a priori supports of reductionism. In addition to energy exchanges and transformations covered by fixed physical-chemical laws, the new paradigms posit system-specific, fragile signalling mechanisms that play fundamental causal roles in regulating the physics and chemistry and other aspects of organismic function and behavior. This new ontology and theory of causation as regulation removes the basis of presumed reductions of psychology to biology, and biology to physics and chemistry. Physics and chemistry do not break down. So, the old theory – envisaging those alone as basic sciences – never was of any use for conceptualizing (let alone explaining) breakdown, or generally the difference between health and disease, or life and death. Regulatory mechanisms, by contrast, can break down, often do, and eventually always do. Another, interrelated major aspect of the new paradigms is the dependence of biological and psychological functioning on the environment. For social beings, the social environment, including social status, is highly influential in regulating access to resources necessary for biological and psychological functioning5. Stein et al remark several times on the importance of the range of biological, psychological and social factors involved in health and disease, while noting that the biopsychosocial model has been criticized for not being able to deliver specific content, conceptualize cross-domain causal interactions, and resolve causal selection questions6, 7. Statements of philosophical positions, and comparisons and contrasts between them, typically and perhaps inevitably are simplified by use of names and brief claims. Philosophy of psychiatry, like other philosophical specialties, is replete with such abbreviations: names of general models, such as "biopsychosocial" and the contrasted "biomedical"; brief statements or expressions such as "mental disorders are biological kinds", or "mental disorders are brain disorders"; and abbreviations using terms of philosophical art, often -isms, such as "pluralism", "naturalism" and "normativism". While these names and abbreviations have some use, and are probably inevitable in philosophical debates, they do not clarify fundamental questions of ontology, causation and method of the sort becoming explicit in paradigm shifts, as old assumptions no longer work and new ones are needed. Some paradigm changes in health care involve broader culture rather than science more narrowly conceived. An example is the shift over the past few decades from medical doctors having the sole authority over diagnosis of disorder to the broader community claiming recognition of the right to interpret themselves and their values. A key moment was the successful lobbying by the gay community in the 1970s to have homosexuality removed from the DSM8. Plausibly this change owed more to the general emancipatory social movements of the time than to scientific discovery. However, broader culture and science interact, or follow complementary tracks at any one time. The claiming of agency by the gay community in the 1970s coincided in time with the theorizing of personal agency in psychological science. As the cognitive revolution in psychology spread through its specialty areas, person-level constructs such as appraisals and perceived agency appeared in new causal explanatory models of behavior and well-being9. As the implications of new theoretical constructions unfold, concepts of personal agency and cognates such as autonomy are increasingly recognized as important by philosophy of psychiatry, as Stein et al note, with implications in the clinic and in public health5, 6.