WHY AN EPISTEMOLOGICAL APPROACH IN PSYCHIATRY ? - Roxana CHIRITA, Vasile CHIRITA

Roxana CHIRITÃ*, Vasile CHIRITÃ**

Rezumat

Dacã admitem de la bun început faptul cã psihiatria implicã o problemã de specificitate si de delimitare a obiectului de cunoastere, putem întreprinde un demers epistemologic în sensul elucidãrii câmpului teoretic heterogen si al perspectivelor metodologice adecvate unei discipline medicale. Cunoasterea în psihiatrie este diluatã atât în directia frontierelor externe, acest fapt reflectându-se în vagi conjuncturi interdisciplinare, cât si în organizarea sa interioarã. Domeniul psihiatriei este parcelat în arii diverse care îsi cautã propria epistemologie, dacã ne referim la etiologie, semiologie, clinicã, terapeuticã si nu în ultimul rând, la nosografia bolilor psihice, subiectul unor permanente schimbãri din motive mai mult sau mai putin fundamentate stiintific. Ne punem întrebarea de ce nu se gãseste o cale comunã de reunire a eforturilor de cunoastere în psihiatrie.

Cuvinte cheie: obstacol epistemologic, dualism, explicatie, întelegere, paradigme metodologice.
Abstract

If we are to admit from the very beginning the fact that psychiatry has a problem of specification and delimitation of its area, we can undertake an epistemological approach towards the clarification of its heterogeneous theoretical sphere and of the methodological perspectives that would suit a medical subject. The science of psychiatry is blurry both in its external limits, which is reflected in vague interdisciplinary conjunctions, and in its internal organization. The field of psychiatry is divided into diverse areas in search of their own epistemology if we are to refer to an etiology, semiology, clinical psychology, therapeutics and, last but not least, to the nosology of psychiatric disorders, the subject of permanent change, more or less scientifically founded. The question arises why it is so difficult to find a way to join the efforts of understanding psychiatry.

Keywords: epistemological obstacle, dualism, explanation, understanding, methodological paradigms.




The desire to explain and to master the mechanisms of mental activity functioning has always existed and, in time, this has generated various theories which supported either divine intervention, or the priority of reason or morals. Generally speaking, the study of psychological phenomena was, for a long time, faced with two alternative approaches: the metaphysical way, of an intuitive and speculative nature, and the scientific methods, based on observation, experiment and, lately, on statistical studies (Searle, 1984). The dilemmatic situation was largely maintained by the presence of the Cartesian dualism, which set the frontier between mind and body, thus making room for reductive positions. The body is material and therefore subject to the empiric laws of determinism, whereas the mind, as immaterial as the soul, cannot obey the same laws that govern the material world unless the psychological phenomenon is considered a natural one. On the other hand, metaphysics came under criticism on account of the fact that it tackled issues that go beyond the sphere of mental faculties and that are not connected to immediate human problems (Dugald Stewart, 1838). The explanation of the psychological phenomenon is undertaken in numerous works on the “philosophy of the mind” which reflect not only the preoccupation for this aspect of human knowledge, but also an area of debate between ideologies having, more than once, a common origin.

The evolution of psychiatry can be regarded both from the perspective of a collection of speeches and practices referring to “madness” and in the light of knowledge accumulated in the field of natural sciences, as well as in that of human studies, equally organized around theoretical concepts, often antagonistic, but having scientific value and philosophical significance. As a rule, the work of the great philosophers is marked by the contradiction between the possibility of a priori knowledge, which would indicate the priority of mind over experience, and the idea that experience is the source of knowledge. In fact, man understood that he exists at the same time in an apparently all-encompassing, sensible world and in an apparently autonomous, intelligible world. The autonomy of the intellect helps him order the sensorial information, organizing the world of images in concepts (Popper, 2000).

If we are to admit from the very beginning the fact that psychiatry has a problem of specification and delimitation of its area, we can undertake an epistemological approach towards the clarification of its heterogeneous theoretical sphere and of the methodological perspectives that would suit a medical subject. The science of psychiatry is blurry both in its external limits, which is reflected in vague interdisciplinary conjunctions, and in its internal organization. The field of psychiatry is divided into diverse areas in search of their own epistemology if we are to refer to an etiology, semiology, clinical psychology, therapeutics and, last but not least, to the nosology of psychiatric disorders, the subject of permanent change, more or less scientifically founded. The question arises why it is so difficult to find a way to join the efforts of understanding psychiatry. The conceptual evolution was always accompanied by a history of the attitude of society towards the psychiatric patient. In the development of events we witness at the age of the “great reclusion” of psychiatric patients, who were imprisoned in inhuman conditions for several centuries. There followed the “great liberation” initiated by Pinel at the end of the 18th century, when psychiatric patients were to be institutionalized in special locations, nursed and also submitted to clinical observation of their symptoms and behaviour (Postel, 1994).

In the same century, the epistemological problem of the origin of psychiatric disturbances is raised, a problem mainly reflected by the Cartesian dualism mind-body promoted by Descartes. The psychiatric disorder has difficulty finding its place between physical afflictions, whose causes can be determined, and the damage of reason and of the functioning of the soul (Brown, 1985). In the 19th century, we begin to talk about a scientific psychiatry and about a psychopathological fact which is more and more often connected to the identification of observable cerebral afflictions. For a long time, the term mental alienation was used, as it conferred homogeneity to the subject of study; it was later replaced by mental disease, which brought psychiatry closer to medicine.

However, there arise new epistemological problems, such as defining the limit between psychiatry and neurology within the organicistic trend, or the importance of humanistic sciences in supporting the psychologistic conceptual trend, both trends remarkable by their reductive character. At the beginning of the 20th century, the evolution of psychiatry takes on a variety of conceptual approaches, which is beneficial from the point of view of the interest generated by psychiatry within the scientific world, yet heterogeneous to the point of fragmenting the field of study. Mention must be made of the scientific contribution, as well as of the originality of phenomenology, existentialism, energetic dynamics, psychoanalysis, psychodynamics, structuralism and other trends, many of them of spiritual philosophical origin, but with a new methodology. The psychiatric disturbances generally come to be regarded as the result of an endogenous process viewed in a dynamic, evolutive perspective and equally related to personality characteristics. Nevertheless, the complexity of the approach of the psychic disease leads to a vacillating attitude between the explanation and the understanding of the psychopathological phenomenon (Farell, 1985). The second half of the 20th century is obviously marked by the progress of neurological sciences, by the expansion of the sphere of psychiatric knowledge to new areas, such as neuropsychopharmacology. Another extension of interdisciplinary opportunities is offered by the interface with computer sciences, while the methodology acquires a predilection for statistics. New conceptual orientations appear, such as behaviorism, cognitivism or the dynamics of operational structures, but also a spectacular intrusion of the social, which either supports or contests any conceptual psychiatric orientation. There have even been claims to explain psychiatric disorders from a social perspective, thus denying their pathological condition proper, as it happened in the 1960’s when the “anti-psychiatric movement” initiated by T. Szasz resulted in major changes in the system of clinical assistance of psychiatric patients. Yet, we must admit the positive role played by the social involvement, especially in changing the attitude towards psychiatric patients. This aspect is reflected in the ethical dimension of psychiatry, derived from philosophy and having a strong normative component, as it emphasis’s the fact that psychiatry includes human behaviour among its subjects of study. Such notions as abuse, manipulation, competence or respect for human dignity are thus introduced, which points to the role psychiatric ethics plays as a link with civil and criminal law. Within the same social context, but from a particular conceptual and methodological perspective, we can find the notion of quality of life as a means of knowing and approaching the psychiatric patient, respectful of his subjective dimension (Hellemans Mariette, 1997).

However, apart from social connotations, we might say that the main epistemological obstacle to the assertion of psychiatry as a science remains, to this day, the absence of a general concept regarding psychological functioning as a whole, which could generate an explanatory system concerning mental pathology. If we take into consideration what has been attempted along the centuries towards the understanding of mental diseases, we could say that “madness” has accompanied the history of mankind (Porter, 2002).

Even for contemporary psychiatry, the references to the dualistic perspective of mind-body may seem at least obsolete, as long as the terms “soul” or “spirit” are not to be found in the nomenclature, and the psychopathological phenomena are, due to highly reliable technologies, objectively understandable down to molecular level. However, there are in clinical psychiatry some aspects for which the biological explanatory causal chain does not provide a clear scientific background as it does for psychosomatic syndromes or for conversion disorders (Sadler, 1991). Or, conversely, we may consider the objectification of changes at an organic cerebral level that entail no psychic disorder thus classified in the latest diagnosis handbooks and in the DSM IV and ICD 10 classifications, as is the case of homosexuality. There are further examples in psychiatric practice and theory which justify the old dilemma of the difference between cerebral and mental events (Smith A., 2003).

As a matter of fact, we seldom wonder these days whether there is indeed a mind-body dichotomy and we refer more to ways of interrelating, from several different perspectives, such as causality, conditioning and influencing. Yet, we cannot confine our research to this dimension of dichotomy, without thinking of possible ways to discover the nature of the human mind, the cause of mental phenomena and the laws that govern the development of such phenomena (Grieze, 1996). If we look at the historical evolution of ideas in the field of “mind philosophy” we can note the contribution of several philosophers, most of them belonging to the “Descartes century”, for instance T. Hobbes, Spinoza, Malebranche or Blaise Pascal, covering a wide conceptual area, from spiritual idealism to an authentic rationalist materialist monism (Hollier, 1973). We can also remark the contribution of E. Husserl, who adopts Descartes’ opinions but focuses on the subject and on the importance of the act of reflection on one’s own ego, as well as on everything that represents the physical individual surrounded by an objective world. (Husserl E., 1994)

Dualistic beliefs resulted from man’s power of knowledge, or rather from what he himself considers to be an act of knowledge. We might also say, to this day, that the present psychological state of a person can be described after the observation of certain elements subject to perceptions, but his future actions cannot be predicted, as some natural phenomena that follow a comprehensible determinist mechanism can. Thus, if we confine ourselves to the examination of facts, we should use the observation as well and consider that the development of the psychological phenomena observed is not accidental, but does not observe the laws of physics. Neither should we invoke, in extremis, the divine. We could then, aiming at a scientific approach of psychological phenomena, consider the utility of the laws of reasoning and of offering answers through logic, although the latter may be valid for a certain structure at a certain moment, without being able to explain the diachronic processes by which one thought follows another (Churchland, 1986). The question concerning the laws that govern the development of mental phenomena therefore remains unanswered. For the sake of common sense, we will not take into consideration the theory of chaos, yet we may return to the hypothesis of divine intervention in the way in which the events that constitute a person’s psychological life evolve, but this way the act of knowledge would thus become an epiphany.

In fact, we could consider the human ontological status in a much wider context, including an undeniable spiritual dimension besides the three-dimension biopsycho- social system supported by the instruments of classical gnoseology. C. Bãlãceanu-Stolnici (1997, pp.73) makes reference in “The Spiritual World” to the fact that “all religious or philosophical-religious systems accept the co-existence of spiritual (transcendent) realities along with material (immanent) ones, a coexistence that defines the Cartesian dualism specific to most theological systems. The two worlds, are not parallel, they are interconnected and influence each other; the spiritual world is the prime factor, and the material one is the secondary factor (its product, its creation)”. Equally, when we speak about human souls, the spiritual component, unlike the psychological activity proper, represents the component by which man resembles divinity and which (according to Genesis) was instilled by God into the material body. Unfortunately, we cannot yet think of a possible scientific way of knowing it. We can plead, though, for rediscovering the spirit within our conscience. In “The Intelligence of the Unconscious” (2004, pp.12), C. Romanescu mentions the fact that, beyond philosophical and religious concepts or medical observations, “the soul has remained a subject which is the more undetermined and fascinating as it is impossible to define”, and he even maintains that this “problem of problems” has surpassed the power of science.

In this way, we may also refer to the axiological dimensions of human behaviour, as the spirit relates to such fundamental values as truth, justice, freedom or beauty. Within the same context, we may include discernment, which, besides its medical connotation, that of awareness of the fact, can also be understood as the recognition of spiritual imperatives (Kress, 1996). Even though finding a reasonable explanation for the psychopathological phenomenon remains an important desideratum in psychiatry, its observation still is the main element in the application of the empirical method. A psychopathological phenomenon will be the same whether or not we understand its causes, and it is reflected in the same way in the patient’s behaviour during the natural evolution of his disease. Accepting empirics in psychiatric knowledge offers clear advantages, but also some limitations in explaining specific phenomena. Thus, observation of recurrent phenomena with more or les obvious causali leads, insofar as human behaviour is concerned, to conclusions pertaining to regularity, but not to predictability. However, according to Hume reason urges us to reject solutions to knowledge offered by recurrent situations, and this non-inductive point of view is also supported by Popper (1999). All the more so, a psychopathological phenomenon, such as hallucination, can be repeatedly noticed, with the same characteristics in different persons, but this remains, in the final analysis an experience lived at a certain moment, and we cannot expect a new situation subject to experience to coincide with an experience due to repetition conditioning and the law of association. Still referring to the experience of a psychopathological phenomenon we may wonder if, since the human psyche functions according to natural laws, we prefer universal statements on reality or particularised empirical sentences.

The necessity of scientific validation of psychiatric knowledge is also emphasized by the “debate” on the relative importance of qualitative studies liable to particularize the psychopathological phenomenon and the epidemiological studies beside measuring or quantifying the mental phenomenon, named psychometrics (Prince, 2003). Over the past few years, we have witnessed a remarkable diversification of measuring strategies, which try to prove their validity and reliability so they can enter the context of scientific research. Psychometrics is included both in broad clinical-statistic studies and in clinical-pharmacological ones, where it actually represents the study of evolution markers of cases undergoing a certain treatment.

From a conceptual point of view, the starting point is the idea that a psychic disorder is a dimension, and the clinician is not to decide between two alternatives, but to establish corelations between the different dimensions of the same phenomenon. This multi-dimensional vision is dynamic and also different from the idea of a “structure” of psychic life. In fact, as G. G. Grager (2001) maintained, statistic reality is one of the orientations that stand at the basis of scientific knowledge in psychiatry, along with structural reality, clinical reality and historical reality. In the final analysis, statistics represents a conglomerate of real facts presented in virtual form, since the investigator does not proceed through genuine observation, and at the moment of entering the data there is no possibility to record or reproduce the circumstances that confer reality to the phenomenon subject to research and understanding.

The psychological phenomenon can be linked to causal explanations based on the invariability of natural laws, or to final explanations according to which the intention of purpose of an action can only represent its cause (Tatossian, 1996).

The hermeneutic method is considered to be appropriate for the study of human psychic activity, as the actions of man are determined by his intentions which vary according to the purpose he tries to achieve. Identifying the intention of an action can lead to its understanding and its explanation will be teleological in nature (G. H. von Wright, 1995). When we refer to the subject of psychopathology, that is the study of anomalous experiences, cognition and conduct, we notice a prevalence of the explanatory side of the mental phenomenon, which includes the psychodynamic approach, behavioural, cognitive, etc., but also the presence of descriptive aspects which include clinical observation and phenomenology based on empathic evaluation of subjective experience (Taylor, 1985).

The very fact that the psychiatrist is “at the patient’s bedside” sanctions psychiatry as a branch of medicine, but also offers new dimensions to the understanding of the psychopathological phenomenon. Clinical activity can be regarded as a permanent source of information oriented towards a clinical methodology typical of psychiatry (Widlöcher, 1999). From a conceptual point of view, the clinical approach of psychiatric disorders imposes an individual manner, followed by an analogical-comparative effort of including the symptoms in pre-established categories. The latter in their turn came into being by a somewhat forced standardization, which no longer accompanies a conceptual orientation on psychic life. If we consider the current diagnose and classification criteria of psychiatric disturbance and the criticism directed against this nosographic system, we come to the conclusion that the term clinical can acquire various significances (Sadler, 1991).

The fundamental problem of the clinical method still remains the elaboration and instrumentation of behaviour observation, corroborated with introspective narratives, with intentional identification of mental states to finally understand the normal or pathological behavioural act. The clinical method may still prove to be a possible solution of compromise or reconciliation between scientific objectivity and the subjectivity to be found at both ends of the psychiatrist-patient relationship. The current trends of psychiatric knowledge are reflected by new conceptual models and by the validation of methodological paradigms that are to place psychiatry among sciences, beyond all doubt (Lanteri- Laura, 1998).

To this day, the moment we attempt a definition of the concept of psychic disorder we come across a number of difficulties that result not so much from insufficient empirical knowledge of the psychopathological phenomenon as from social and ethical implications (responsible for moral values) and from political, legal and economic-financial requirements. Contemporary psychiatric nosology itself faces two alternatives, one of which is scientific precision and the other is represented by the influence of the social, which seems to have more demands than responsibilities (Longino, 1990).

Another challenge of contemporary nosology is the existence of numerous tacit assumptions, of a scientific, social-cultural, evaluative and therapeutic nature. Despite the fact that it represents a pre-requisite of knowledge, as it imposes limitations, a large proportion of clinical reality is omitted, as the specialist only collects the data he is prepared to receive (Fulford, 1990). The heuristic role of assumption is reflected in the imposition of a certain direction of research and of a certain scientific methodology. Philosophy tries to highlight both the implicit assumptions and all that may come under the name of statements, theories, classifications, attitudes, decisions and implications, wondering, after fully enlarging on the fore-mentioned categories, what their logical implications are. The real challenge for future study in psychiatry results, as T. Dima (1981) said, from the fact that we can hope for “objectivity of scientific representations, independent of appearances and circumstances or singular and variable situations.”

At the end of this paper, a rhetoric question is asked, whose purpose is not to underline a genuine concern for the future of psychiatry, but to draw attention to the deviation from the scientific goals and from the endeavours towards the knowledge of the psychopathological phenomenon. We hope that psychiatry needs the manifestation of a “free spirit”, not completely committed to what has been conceptualized so far more than a “revolution”, albeit scientific.

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