Tackling the Philosophical Foundations of Psychiatry

There are numerous ways in which psychiatric concepts can be subjected to philosophical inquiry, and “philosophy of psychiatry” explores the intersection of these two fields. The importance of clarifying the philosophical foundations of modern psychiatry has long been recognized, with the work of German psychiatrist and philosopher Karl Jaspers being an example from the early 20th century. The most serious challenge to psychiatry in the form of the antipsychiatry movement was also philosophical in nature, with conceptual criticisms from figures like Szasz and Foucault. DSM-III led to a revolution in the practice of psychiatry with operationalized criteria, but it also highlighted philosophical problems surrounding the definition of “mental disorder,” a matter on which Drs. Robert Spitzer and Allen Frances have commented extensively.

Philosophical questions commonly plague practicing psychiatrists as well as psychiatry trainees. In a survey of psychiatry residents at Case Western Reserve University/University Hospitals Cleveland Medical Center (CWRU/UH), 15 out 23 residents (65.2 percent) responded with “yes” or “definitely yes” to the statement that they struggle with conceptual and philosophical questions related to psychiatry (such as what is “normal” when it comes to human thought and behavior, and how do we decide what should be considered a “mental disorder”?). Furthermore, only one resident (4.3 percent) responded with “yes” or “definitely yes” to the statement that their residency training so far had adequately prepared them to address these philosophical challenges.

I have developed and taught a didactic course on philosophy of psychiatry for psychiatry residents at CWRU/UH, with consultation from Drs. Nassir Ghaemi and Susan Stagno. A report on the details of this course and its reception by the residents was published online on November 17, 2017, in Academic Psychiatry. This report is a notable addition to the scant literature on teaching philosophy of psychiatry to psychiatry trainees. The course consists of six didactic sessions using a mix of presentations, readings, and group discussions:

• The Concept of Mental Disorder: The DSM definition of mental disorder was explored, philosophical tensions within the concept (such as empiricism versus normativity, and reliability versus validity) were highlighted, and philosophical ambiguity surrounding crucial elements of the definition, such as “dysfunction” and “clinically significant,” were pointed out.

• The Nature of Mental Disorder: This session addressed the question of whether a definition of mental disorder can be grounded in objective, natural facts, independent of our values and interests. The objective was to become familiar with and critically appraise the naturalist accounts of mental disorder offered by Christopher Boorse and Jerome Wakefield.

• Philosophical Aspects of the Antipsychiatry Movement: This session dealt with prominent philosophical themes of the antipsychiatry movement, with a focus on arguments by Thomas Szasz and Michel Foucault.

• Introduction to Pluralism in Psychiatry: Participants were introduced to Jasper’s methodological pluralism, followed by a critique of the biopsychosocial model, using the Perspectives approach by McHugh and Slavney as an example of a pluralistic model.

• Philosophical Issues in Psychiatric Nosology: This session highlighted philosophical difficulties inherent in the process of psychiatric classification.

• Philosophy of Mind and Psychiatry: Major philosophical positions relating to the mind-body problem were introduced. Also discussed was how certain positions, such as substance dualism and epiphenomenalism, are less compatible with psychiatry.

The course was well received by the residents, with 18 or 22 attendees (81.8 percent) agreeing or strongly agreeing that the course had made them aware of philosophical and conceptual issues related to psychiatry that they were not aware of before; the same number agreed or strongly agreed that philosophy of psychiatry should be part of the psychiatry residency curriculum. It is about time that we provide the next generation of psychiatrists the conceptual tools they need to work through these philosophical questions. This curriculum is only one example of a preliminary effort to do so.