Another “and”: philosophy as glue
Authors: Kenneth W.M. (Bill) Fulford
Journal: World Psychiatry (2024)

Offering a timely perspective on contemporary philosophy of psychiatry, Stein et al's paper1 is part-review and part-pitch for an integrative model of the mind, "embodied/4E". As such, the paper nicely captures the collegiality that is a defining feature of the field. Blossoming across the world in the 1990s, the renaissance in philosophy of psychiatry has largely avoided the tribal schisms by which so many "psy" disciplines have been marred. Indeed, Stein et al adopt an integrative stance: the dominant connective throughout is "and" ("Western and Eastern" philosophies, "facts and values"); "philosophy of psychiatry" itself is used interchangeably with "philosophy and psychiatry"; there is a helpful discussion of the varieties of pluralism; and "embodied/4E" is presented not as a panacea but as a model for integration (mind and body, normativism and naturalism, and so forth). The Swiss historian and psychiatrist P. Hoff has characterized the history of psychiatry as one of serial collapses into single message mythologies2. After all, "binary positions", as Stein et al note, "have the advantage of being straightforward". That philosophy of psychiatry is avoiding factional splitting is thus a particular strength. Yet, this brings with it vulnerabilities. Which is why another "and" should be added. To the many varieties of expertise-by-training celebrated in this paper, we should add the expertise-by-experience of patients and carers. To be clear, Stein et al emphasize the importance of what they call, variously, "lived experience", "subjective experience", "individual experience" and "first-person experience". But what is perhaps worth highlighting is the growing significance of co-production between experts-by-training and experts-by-experience in clinical work, in research, and in philosophy of psychiatry, both internally and for its wider significance across mental health care as a whole. Here, I comment briefly on each of these areas. The significance of co-production in clinical contexts derives from recovery-oriented practice, i.e. practice aimed at recovering a good quality of life as defined by the values of – that is, by what matters or is important to – the individual concerned3. So defined, the criteria of recovery, in any given case, are necessarily derived from the expertise-by-experience of the individual in question. Expertise-by-training of course remains important, inter alia, to advising on the evidence-based interventions supporting recovery, to interpreting the values defining recovery where (as in anorexia nervosa) these are empathically obscure, and to balancing conflicting values (as in compulsory treatment). The clinical importance of expertise-by-experience is thus not at the expense of expertise-by-training. To the contrary, both are needed. The requirement for co-production is, again, conjunctive not disjunctive. But the point is that, without expertise-by-experience, recovery-oriented practice cannot even get started. Similar considerations apply to research in the neurosciences, though in this instance with the importance of co-production for translation in mind. A notable challenge for psychiatry is that psychiatric scientists themselves have become increasingly critical of the persistently low rates of translation of neuroscientific research into improvements in clinical care: the architects of DSM-5 and its criticse.g.,4 were aligned on this point. Expertise-by-experience, although increasingly demanded by research funders, offers no guarantees of improved translation. Co-production, however, in requiring the adoption by researchers and patients of shared aims, would at least ensure a shared vision of what success looks like. Co-production is now a feature, too, of philosophy of psychiatry. At least in its post-1990s renaissance, both analytic5 and continental6 philosophy of psychiatry have adopted co-productive methodologies. In Oxford, a pre-pandemic institutional collaboration between the Faculty of Philosophy and the Mental Health Foundation (a London-based mental health non-governmental organization) remains highly productive. A recently launched joint venture is a Welcome Trust-funded programme on philosophy and new models of public mental health, co-led by a philosopher, A. Bergqvist, and an expert-by-experience, D. Crepaz-Keay. The wider significance of co-production in philosophy of psychiatry is connected with how the function of philosophy is understood. Stein et al note how the variety of philosophies play out in diverse formulations of complex concepts such as pluralism. This and other similarly diverse formulations point to the function of philosophy being, not to solve complex problems, but rather to forestall premature closure on answers, that, although indeed persuasive in the simplifications they encourage, are nonetheless wrong. The "forestalling premature closure" function of philosophy is important in psychiatry, not least as a barrier to Hoff's above-mentioned "collapses into single message mythologies". Again, co-production offers no guarantees of success. But the indications are positive: co-production itself is after all among the integrative models that Stein et al celebrate; other similarly open systems (such as multidisciplinary teamwork and Darwinian evolution) offer proof-of-principle; and contemporary examples5, 6 document the effectiveness of co-production in philosophy of psychiatry over earlier expert-by-training paradigms. To the extent, therefore, that co-production with experts-by-experience strengthens the role of philosophy in forestalling premature closure on complex problems, philosophy of psychiatry has a role to play in all areas of clinical work and research across mental health as a whole. Stein et al rightly acknowledge that any review has to balance depth against breadth, an especially difficult task where, as in the humanities, there are no widely-accepted external criteria of excellence, like, say, the evidence hierarchy of evidence-based medicine. This is, perhaps, a "good thing". After all, even the evidence hierarchy is not without its limitations. But, given Stein et al's mention of the North American philosopher H. Putnam, I would suggest a greater attention to his "distinction-without-dichotomy" position on fact and value (since it is by this, not by naturalism, "soft" or otherwise, that values-based practice is underpinned theoretically7). To the helpful discussion of the normativity of science, I would add mention of J. Sadler's seminal linguistic analysis of the values guiding DSM8. Moreover, since "embodied/4E" is described as representing mental disorders as "disruptions to sense-making", I would suggest an emphasis on the challenge of "delusion", memorably described by the British philosopher of mind N. Eilan as the challenge of "solving simultaneously for understanding and for utter strangeness"9. Stein et al have done an important service to the resurgent field of philosophy of psychiatry in demonstrating the still growing success of its collegial approach. Success though comes with challenges – competition for research funding, for prestige, and so forth – and with these in turn come renewed risks of Hoff's "collapses into single message mythologies". In forestalling premature closure on complex problems, philosophy provides the conceptual glue needed to bind together the multiple messages required for an integrated model of mental health of the kind for which Stein et al argue. Highlighting and making fully explicit the importance of co-production between experts-by-experience and experts-by-training, in all areas of mental health research and practice, will ensure that the glue locks tight.