Reality and mental disorder

Psychiatry has a philosophy problem

22 09 19.metaphysicsmentaldisorders.ara

Psychiatry is caught up in a number of philosophical errors. One is reductionism, as psychiatry tends to seek underlying biological causes for mental disorders. The other is dualism, as it thinks of mental disorders as either caused by our brains or caused by our minds. Both these errors are a result of seeing the world as made up of a hierarchy of things. Instead, if psychiatry saw the world as fundamentally made up of processes, dynamically interacting with each other, a much more nuanced understanding of mental disorders would become available to it, argues Elly Vintiadis

Following the tradition of Democritus and the atomists, traditional metaphysics in the West has seen the world as made up of things that are in turn made up of smaller things - and so on all the way down. This, however, is only one possible way of seeing the world. Another one is that of Heraclitus who famously said that everything flows. According to this view, the world is constantly in flux and made up of a hierarchy of intertwining processes that exist at different time scales. For instance, a human organism whose properties change throughout its development is a process, but a more extended one than the underlying process of cell renewal that our bodies constantly undergo.

Clearly, there is change and there are processes even in non-processual metaphysics,for instance, we talk of events, like my throwing a ball. In such a context it is generally understood that the change that happens during processes are changes that an enduring subject undergoes (e.g., a person whose properties change). In contrast, in process metaphysics, processes in dynamic interaction are the underlying nature of everything that we experience as stable. The key in this debate is to contrast a static versus a dynamic view of the ultimate constituents of reality. This distinction can help us see how many mistakes of modern psychiatry rely on traditional metaphysics, and thus motivate a shift to process metaphysics for a better understanding of mental disorders.

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There is no one underlying biological cause of major depression - it can result from a number of different possible causal pathways.

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If we think of the world as made up of a hierarchy of different levels of organization, as is common when we think in terms of things, we often think in terms of the ‘lower’ levels determining the properties of the ‘higher’ levels. This can easily lead to the idea that the lower levels are the (only) genuinely causal ones. In psychiatry this reductionist picture is reflected in the biomedical model which aims to uncover the biological causes of patients’ symptoms, focusing on the brain as the locus of mental disorders. This can lead, in turn, to essentialism about mental disorders. That is, it leads us to ask what a mental disorder really is, what its biological ‘essence’ is, or what it is that all instances of a particular disorder have in common -  the causal agent of their symptoms.

However, we have not managed to reduce mental disorders to disorders in the brain, or find their ‘essence’. Most mental disorders are multicausal (caused by many factors) and causally heterogeneous (the same disease can be caused by different combinations of factors) and evidence shows that the onset and post-onset course of many disorders is caused by environmental, social and cultural factors. For instance, there is no one underlying biological cause of major depression - it can result from a number of different possible causal pathways.

What is true of mental disorders though, is that they take time to develop and they affect persons, not just brains, who have genetic predispositions but also have a personal history and construct a narrative of their experiences — that is, they have explanatory models through which they use to make sense of their condition and which, in turn, can have an active role in perpetuating mental disorders. So in order to understand mental disorders we need to take these factors into consideration and understand the life experiences of patients, their values, goals and narratives, as well as their brains.

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Beyond the problematic search for essences and ultimate levels of reduction, another problem in psychiatry that often goes unacknowledged is dualism: we still tend to see psychiatric illnesses either as brain-based or mind-based. This dualism can also be seen in our attributions of responsibility and blame; the more a disorder is seen as psychological or environmental/social causes, the more the patient is considered blameworthy and responsible for it. While if the disorder is seen as biological it is the other way around: it is typically thought of beyond a person’s control. In addition to this, dualistic thinking underpins the conventional dichotomies of nature vs. nurture and biology vs. culture that try to establish which of the two in each dichotomy is more fundamental, often giving secondary importance to anything relating to the larger social context.

These three problems of essentialism, reductionism and dualism, do not necessarily go hand in hand with a non-processual metaphysics, but they are only possible within such frameworks. By adopting process metaphysics, we can explain why questions such as whether a disorder has biological or social causes or what a disorder really is, are ill-posed while providing a context in which such questions do not arise. Because mental disorders are complex phenomena that manifest in different ways, operate at different timescales and emerge through diverse causal pathways they are better understood as processes, made up of a collection of processes that interact in non-linear ways.

At the same time, process metaphysics can ground criticism of both the biomedical and the biopsychosocial model of mental disorders, while also allowing us to improve the latter. If the world is, indeed, fundamentally made up of processes rather than things, any reductionist model like the biomedical model, and any model that does not address mental disorders multidimensionally, cannot do justice to the complexity of such a world. On the other hand, though the biopsychosocial model incorporates biological, psychological and environmental factors when trying to understand mental disorders, in practice it remains static and fragmented, arguably, in virtue of the metaphysical framework within which it is embedded. The conventional dichotomies of nature vs. nurture, and biology vs. culture are ingrained in this model, despite the fact that it tries to highlight the importance of their interaction.

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The complexity of mental disorders renders the very question of whether its causes are physical, mental or social overly simplifying.
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In contrast, because processes have no hard boundaries, but flow into one another multi-directionally and sustain each other dynamically, we cannot properly talk of distinct ontological levels, let alone of a hierarchy, so the dichotomies that arise in the metaphysics of things are not available in a process framework. In such a framework a person is the product of an ongoing developmental process, so rather than thinking in terms of different factors belonging to different domains, e.g. the biological and the social acting on each other, in a processual framework we can see the person as one unified process embedded in a environment. Such a view can add a more dynamic aspect to the biopsychosocial model thereby helping to improve it.

A mental disorder is never purely biological or purely psychological or purely psychosocial; the complexity of mental disorders renders the very question of whether its causes are physical, mental or social overly simplifying. This means that we cannot pick one process or level as ontologically more fundamental than another and it also means that we cannot exclude one component a priori when trying to understand a disorder. Addiction, for instance, cannot be understood without taking into consideration the person’s character, background, past experiences and social environment, as well as how the patient himself experiences his addiction. The physiological changes that the brain undergoes during addiction are important but on their own they will not explain why a person became addicted or remained addicted. For this we also need to have an idea of what motivated the use of drugs and what helped maintain it.

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A view that naturally follows from process metaphysics is that. in order to understand mental disorders, we need to see them as dynamic and physically, socially, and historically situated. That is, we have to address the specific embodied person who is in a specific sociocultural reality who relates to it in a specific way; not as subject to opposing forces but as a whole in which all these aspects work together and mould each other as time progresses. Disorders are essentially dynamic and there is no way of pinning down the disordered state of a person into one or more stable features. But this is not an accidental feature of them — because of the way they result from events in people’s lives and on-going interactions, they cannot be understood merely in terms of a succession of states.

Therefore, one advantage of adopting a process metaphysics is that it allows us to get a better handle of the complexity of mental disorders and draw a dynamic picture of them, something which is not always easy to do within a non-processual metaphysical framework. Moreover, thinking about mental disorders within a different conceptual framework requires that we address the many levels that interact to bring them about, so a process metaphysics requires a pluralist explanatory approach but also opens up the way for better treatment and prevention options.

In terms of explanation, because mental disorders are multilevel phenomena we need to approach the overal process at different levels of abstraction, different timescales with different methodological tools. This in turn entails a diverse allocation of funds for research - including research on how non-medical services can improve mental health outcomes. In terms of treatment, process metaphysics naturally leads away from a one-model-fits-all approach and towards a pluralist, flexible and person-centered therapy. Such an approach to therapy may not be a feature unique to process metaphysics, but it is a direct implication of a process-based ontology and in this sense, it can help ground, and explain, already existing views.

 

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