Association for the A A Advancement of Philosophy and Psychiatry B u l l e t i n P& P

From the Editor President’s Column This issue of the AAPP Bulletin is a play in three acts. The first and main The AAPP Community – An Open and Bright Future act is a challenge put out by Scott Wa- terman regarding the status of the psy- Over the past year the AAPP Officers and the Executive Council have been chiatric profession, following by com- brainstorming ideas for making the AAPP into a more cohesive organization for mentaries and a final response by Scott. which the benefits of membership are clear. This has been challenging for a The second act is another challenge, number of reasons. First, we are geographically spread out; not only over the U.S. this one by our president, Peter Zachar, and Canada, but over the entire world. Second, we are clinicians and academics, encouraging us to work more closely M.D.s and Ph.D.s, and ethicists, phenomenologists, social-political philosophers, together in the further development of philosophers of medicine, of science, of mind, and so on, with different scholarly AAPP. Finally, John Sadler offers us a traditions and methodologies. valuable guide in citing literature for In some ways all that ties us together is the name philosophy of psychiatry, articles in PPP. and that is a flimsy basis for building a community. We are not all interested in In lieu of a formal table of con- the same kinds of journal articles or conference topics. One would think that the tents, let me indicate that my own com- philosophy of psychiatry is a narrow specialty area – but it is not. If it were nar- mentary begins on this page, while rower, a community would be easier to build. Scott’s target article begins on page 2. Despite these challenges, there are also tremendous resources for us to grow The commentaries continue with Paul as a community and make the AAPP home to all those committed to advancing Lieberman’s contribution on page 3, both the philosophical understanding of all psychiatry/clinical psychology and and Scott’s response to commentaries advancing the philosophical literature through the study of psychological health begins on page 9. Finally, John Sad- and dysfunction. ler’s guide to references appears on Philosophy, Psychiatry, and Psychology remains the leading journal dedicat- page 12. ed to the philosophy of psychiatry. Due to its popularity, there was a backlog of articles and the issues were delayed, but thanks to John Sadler and the editorial team, the journal has worked through the backlog of articles and is now being An Imperfect Psychiatry published on time. We anticipate the publication of a redesigned website some- time in the next year and are planning on distributing an AAPP Newsletter twice a I am writing this response to Scott year with information about the recent publications and relevant activities of all Waterman following several days in AAPP members. We are also rethinking the AAPP Bulletin and hope to encour- Yosemite National Park. It is spring in age more members to submit materials. the park, with snowmelt gorging the The most important resource is our members – especially those who are in- rivers as they roar and plunge down- terested in becoming committed to the organization itself. Coming to the annual ward into the valley in violent currents AAPP meeting is an important way to get involved as you start to put faces to and massive waterfalls, tearing away names and hopefully begin to make connections. This is easier to do if you at- anything in their paths. I take from my tend multiple meetings. It may take some time. When the group you are trying to hikes through the park an impression of enter is not populated with extroverts, you typically have to become familiar be- nature as both staggeringly beautiful fore you can become known. I was an associate professor before I found AAPP, and violently destructive – and indiffer- but I quickly realized that I wanted it (and not one of the APAs) to be my home ent to the concerns of that portion of organization. I would encourage you to consider choosing us as well. nature represented by our human selves. (Continued on page 2) When Scott Waterman summarizes his reasons for no longer being a psy- chiatrist, he includes his disappoint- hoopla over “interventional psychiatry,” as its proponents, perhaps excepting ments with the DSM classificatory sys- ECT, promise more than they produce. tem, his disillusionment with psychoa- Scott doesn’t quite tell us what an acceptable psychiatry would be, but what nalysis, his concerns over the corrupt- he writes suggests that it would be a biomedical psychiatry that was truly bio- ing effects of the psychopharmacologi- medical. He talks about his early interest in neurology and “biological psychia- cal industry on the field, and his more try,” and writes: “I seized opportunities to redirect my efforts toward medical recent awareness of the limited efficac- student education, eager to exorcise what I had long identified as rampant mind- ity of pharmacological agents. He body dualistic fallacies embedded in medical discourse, training, and practice. could well have included the current Implementation of major curricular reform in the early 2000s allowed me to par- (Continued on page 6)

Volume 26, Number 1 2019

(Continued from page 1, President) tinent then. While many in the West switch to psychiatry. The timing of my We invite AAPP members and perceived godless Communism to be change of specialty choice landed me, student members to make suggestions the paramount threat to freedom in quite by accident, in one of the nation’s about how to encourage more member 1950s America and Great Britain, most psychoanalytically oriented resi- involvement. Because the organization others were concerned that elements dency training programs. My quickly is structured with a leadership team of the anti-Communist program were formed suspicion that psychoanalytic (called the Executive Council), oppor- at least as dangerous. In that context, doctrine was fundamentally flawed was tunities to serve on committees has Edwards found in Russell’s free- reinforced by the defensive (and frank- been limited, but we want to open that thinking secularism an antidote to ly anti-intellectual) responses of my up a bit more as well. If you are inter- what he saw as the dangers of the teachers and by the publication of ested in becoming an ad hoc member ideological – including religious – Adolf Grünbaum’s 1984 treatise, The of one of our committees, please con- conformity that was increasingly Foundations of Psychoanalysis: A Phil- tact the committee chair. expected, if not imposed, as part of osophical Critique (and later by the the Western defense against recovered false memory debacle). Scott Waterman (Jaspers award com- (ironically) tyranny. Those experiences, among others, mittee): [email protected] So why should anyone care prompted my decision to pursue train- whether I am or am not a psychia- ing in research in “biological” psychia- James Phillips (AAPP Bulletin com- trist? (I am putting aside the question try. I was particularly animated by the mittee): [email protected] of whether someone who has decided notion that early-onset psychopatholo- to leave the profession is still a psy- gy, not yet contaminated by what we Christian Perring (Media/website com- chiatrist. As I am also not a Christian, considered the artifactual overlay of the mittee): [email protected] I won’t suggest that the principle of varied consequences of chronic dys- redemption should constitute the ba- function and marginalization, would be We are not an assembly line or- sis of an answer to that question!) where causes and mechanisms could ganization whose workings are auto- Perhaps the most straightforward ultimately be elucidated. That optimism mated – all the work is done on a vol- reason why anyone should care about was eventually dispelled by the reality unteer basis. We cobble it together my professional status is the purport- of an investigatory program that de- year after year – but that gives us a ed shortage of psychiatrists. As re- pended on definitions of phenotypes feeling of shared ownership that some ported in a very recent Association of specified in the DSM. My main conso- other organizations lack. It takes ef- American Medical Colleges press lation about that blind alley was that I fort to get involved, but contributing to release, 111 million Americans live recognized it for what it was and a small scholarly organization like in “mental health professional short- moved on before many of my col- AAPP can be a very satisfying part of age areas” and over half of U.S. leagues did. a career. counties have no psychiatrists. This, My subsequent focus on clinical in the context of the canonical asser- child and adult psychopharmacology *** tion that about 20% of us are mental- teaching and practice rewarded the ly ill (or, in the Orwellian parlance of abilities that had made me a very suc- the day, suffer with “a mental health cessful medical student – an excellent condition”), is said to constitute a memory for scientific findings and a Why I Am Not a Psychiatrist crisis. As Russell would surely rec- capacity to invoke them in appropriate G. Scott Waterman, M.D., M.A. ognize, implicit in the syllogism contexts. Initially, I tried to assure my- University of Vermont whose conclusion is that we need self that the generally modest benefits [email protected] more psychiatrists is the proposition our clinic patients seemed to derive that their presence in greater numbers from our efforts reflected the nature of On March 6, 1927, Bertrand Rus- would mitigate the problem of human a university-based tertiary referral ser- sell explained to those in attendance suffering. vice. But as the story of the systemati- at a presentation organized by the My skepticism about the validity cally exaggerated efficacy, along with South London Branch of the National of that implicit proposition is doubt- underplayed (not to mention actively Secular Society at Battersea Town less a reflection of my personal jour- hidden) risks, of various pharmacother- Hall why he was not a Christian. Alt- ney through psychiatry over the past apies unfolded, one conclusion became hough he does not appear to have several decades. I will leave it to the inescapable: massive conflicts of inter- discussed why his religious (non-) reader to decide whether it was a est between the profession and the beliefs should be of interest to others, voyage of discovery or a road to no- pharmaceutical industry had rendered we can logically surmise that, as a where. psychiatry a case study in institutional well-known thinker, his views were Attraction to neuroscience in corruption. I seized opportunities to considered noteworthy. In any case, medical school contributed to my redirect my efforts toward medical stu- when that 1927 lecture, “Why I Am initial intention to pursue a career in dent education, eager to exorcise what I Not a Christian,” was published thirty child neurology. Personal experience had long identified as rampant mind- years later as part of a collection with with chronic worry and periodic body dualistic fallacies embedded in several of his other essays on related gloominess, combined with a convic- medical discourse, training, and prac- topics, the editor of that volume, Paul tion that scientific understanding of tice. Implementation of major curricu- Edwards, made clear in his Introduc- mental states was on the horizon and lar reform in the early 2000s allowed tion why he believed Russell’s curiosity about the widening concep- me to participate in the formulation of thoughts about Christianity were per- tual schism in the field, led to a what was likely the most materialist integrated course in neuroscience 2 Volume 26, Number 1 2019 among all American medical schools. reality of both and recognize the limi- At the clinical education level, howev- tations of my own capacities, imagi- er, the hegemony of the DSM diagnos- nation, and resilience in this context. tic system – whose baleful influence on I look forward to their (and others’) 2020 AAPP Annual psychiatric research had become evi- assessments of and prescriptions for dent to me early in my career – present- the profession we once shared. Conference ed an impediment to students’ abilities to learn anything potentially useful *** about psychiatry. Much of my involve- Call for Abstracts ment in philosophy of psychiatry has focused on the multiple shortcomings Intuitions Meet of its diagnostic system – a message that appears finally to have been re- Experiments: Methods in Fortunate to be a Psychiatrist Philosophy of Psychiatry ceived, albeit without any clear remedy – A What? on the horizon. To this point, my story might be April 25-25, 2020 read simply as one of periodic profes- Paul Lieberman, M.D. Philadelphia, Pennsylvania, sional adjustments made in response to Brown University USA gradual acquisition of insight into my- [email protected] self and the world. It might even be Keynote Speaker spun as a record of personal success – Daniel Levinson was a psycholo- an asymptotic approach to ideal occu- gist who collaborated with Theodore Edouard Machery, PhD pational fit within the discipline of psy- Adorno studying the authoritarian Distinguished Professor Department of History and chiatry. But it doesn’t end there. Large- personality and later helped found the Philosophy of Science ly in connection with my wife’s in- field of adult development, although University of Pittsburgh volvement in the critical psychiatry he’s probably best remembered for his discovery, or invention, of the movement over the past several years, I have come to know many members of ‘midlife crisis.’ Dan once reminisced that when he was at the Massachu- Conference Organizers the consumer/survivor/ex-patient com- munity and their advocates. Their per- setts Mental Health Center at Harvard in the 1950s, working with Erik Erik- Robyn Bluhm, PhD spectives – absent from assessments of Michigan State University the psychiatric enterprise until recently son, Talcott Parsons, Elvin Semrad, – are as compelling as they are discom- Leston Havens, George Vaillant, Eric Douglas Heinrichs, MD, Ellicott, fiting. We must take seriously the pos- Kandel and other psychiatric luminar- MD sibility that the staples of contemporary ies, he felt extremely fortunate: he psychiatric thinking and practice – was working on the most important Christian Perring, PhD St John’s Univerisity, NY whose social standing is increasingly problems there were and felt that anyone doing anything else was more hegemonic in the arena of human un- Serife Tekin, PhD, University of happiness and dysfunction in ways or less disadvantaged. He also said that everyone needed to feel that way Texas at San Antonio reminiscent of the expected ideological conformity of the 1950s – have not about the work they did. Instructions only proven to be explanatorily and Although Levinson may not have therapeutically impotent in more ways been referring to psychiatry as we than most psychiatrists would like to know it, for some of us, our field has Abstracts, 500-600 words, are admit, but are in some instances frankly elicited that kind of response. For me, due by October 15, 2019 and pernicious. By the time I reached my at least, psychiatry has been an end- should be sent to Christian Per- decision to retire from psychiatry, I had lessly engaging profession, despite its ring at [email protected], developed serious doubts about wheth- weakness and corruption (1), and in and to Robyn Bluhm at er I possessed any scientific knowledge some ways because of its difficulty [email protected]. or professional skill that was of any and imprecision. Thus, while Dr. Wa- value to people who are suffering. terman has given us a remarkably For full information about the I hope it is evident that this capsul- eloquent and persuasive recounting of conference, go the conference ized account of my professional jour- psychiatry’s flaws, with which I com- website at: ney is intended to be descriptive rather pletely agree, I come to a conclusion than prescriptive. (It is, after all, not different from his. https:// titled, “Why You Should Not Be a Psy- The difference, I think, lies in philosophyandpsychiatry.org/ chiatrist.”) I leave it to the reader to what we take psychiatry to be, what a meetings-conferences/ apportion how much of it is about me psychiatrist is. When I chose psychia- and how much of it is about the profes- try, it seemed to be a field in which one could work at things both medi- sion of psychiatry. I mean no insult to my psychiatrist friends and colleagues cal and something else – hard to spec- ify, but somehow associated with a who have found ways of contributing to general knowledge and individual subject more personal, emotional, wellbeing. I have no doubt about the comprehensive and meaningful; call

3 Volume 26, Number 1 2019 it, the psychological. Stephen Fleck relevant, still enjoy a reasonable might salvage the ‘psychiatrist in a once said that psychotherapy required standard of living relative to his box’ model)? I think the answer is that using ‘all aspects of your personality’ medical school (not to mention col- teams are fine, even essential and being ‘a special kind of friend.’ lege) classmates, and still be able to (especially when there are ‘shortages’). That was my hope for psychiatry and I earn and enjoy the prestige of a But every team needs a manager, and think I was not alone in that aspiration. valued profession, then it might not the manager needs to know the game Psychiatry promised us not only a med- be possible. Certainly, it would be well enough to ‘make the calls’ as the ical career, with all its interests and tough, and for a young physician game unfolds. There are a lot of man- complexities, but some type of more ‘psychiatry’ now means something agers and coaches who were formerly comprehensive engagement with and like that only at the margins players because to know the game it understanding of what was at the heart (‘keeping a small private practice’). helps to have played it. This is true not of things in life. Medical students still But if by ‘possible’ you mean only because there is a certain amount say things like that when they consider something like conceptually or met- of information required –to be able to psychiatry, though many, nowadays, go aphysically possible, then I think recognize, for example, when the pitch- elsewhere, since our field, as Dr. Wa- it’s not only possible, but necessary. er is getting tired, or when someone terman has shown us, has also gone It’s possible because some psychia- should work with the batting coach – elsewhere – to a narrow biomedical trists actually do seem to practice but, also, because when you make a model with all that that has implied: that way (they don’t usually ‘take choice you have to consult your values. limited ‘scope of practice,’ brief visits, insurance’), and because many oth- A home run might win the game, but so symptom checklists, over-prescribing, ers seem honestly to miss the fact could a squeeze bunt, and if you don’t computerized treatments, truncated that they don’t (as if it’s something know about that, haven’t seen it work training in psychotherapy – the they’ve lost). It’s necessary because and felt its exquisite satisfaction, your ‘baleful’ changes Dr. Waterman de- people and their psychological options are, necessarily, limited. And it scribes. All the intellectual excitement problems exist in multiple doesn’t work to submit the lineup, start is in the biological and the nosological, ‘families’ of causes and non-causal the game up and leave after the first and, while neither of these has kept the influences which overlap and inter- inning. promises of its heady, early years to put act. People are physical things Finally, the question, which is, of psychiatry on a ‘really scientific’ foot- which follow the laws of nature, but course, the point: would this psychia- ing and successfully, finally, treat psy- they are also sentient beings, talkers try, if it existed, be demonstrably help- chiatric problems, (and while those and active agents; their disturbances ful to anybody? The answer has not promises are still being made) what – especially those for which psychi- been established to the satisfaction of already seems clear is that these re- atrists may be consulted – share and many, but there is evidence: the innu- search programs often ‘pass by’ and disturb these features in ways which merable clinical studies comparing ‘don’t touch’ the human, emotional, ramify throughout our myriad forms placebo or no treatment to many psy- more ‘comprehensive’ forms of prac- of life. Reserpine really does cause chotropic medications or psychothera- tice which drew people to psychiatry at ‘depression’ and ketamine, appar- pies or their combinations in thousands one time. ently, does seem miraculously to of patients; system-wide programmatic Two questions arise. The first is cure it. But ‘feeling depressed’ is innovations which show the benefits of whether this more capacious view of not the same as seeing oneself (or introducing mental health services into psychiatry is even possible. Is it a real- being seen) as ‘a depressed per- other medical sites (‘co-location’); the istic vision, or a grandiose one, or per- son’ (or, ‘prone to depression’), and reassuring studies which show that haps a fantasy, born of ambivalence taking ketamine still leaves open ‘a psychiatric diagnosis is no less reliable, and an inability to choose between certain kind of why question’ (or, and psychiatric medications no less what are, after all, just different realms rather, many of them: Why me? effective, than their counterparts in of professional life (the medical and the Why now? Why this?). There are other branches of medicine; the testi- psychological) – a compromise which forms of ‘treatment’ – such as lis- monials of people we respect (Andrew leaves the psychiatrist, at best, more tening, understanding and valuing – Solomon, Kay Redfield Jamison, Elyn amateur than expert, and, at worst, just which help depression, and (if su- Saks, our friends and family); the vig- another victim of the fear of missing pervenience is true) change the orous advocacy of patient and family out? And the second question is wheth- brain, but which won’t work well if groups for achieving parity, increasing er such a psychiatry, if it did exist, that brain is constrained physically reimbursement and improving ‘access would be helpful to anyone – better (for example, by reserpine). And, of to care’ by making more care provid- than no psychiatry at all, as Dr. Water- course, how you think and feel and ers, including, explicitly, psychiatrists; man wonders. act will determine whether you and the fundamental fact that people To the first question, I think the even consult a psychiatrist or any- with psychiatric problems are mostly answer depends on what you mean by one else at all, and, if you do, what the same as people without them, so ‘possible.’ If by ‘possible’ you mean you’ll tell her, and how. (Is this that what ‘works’ for one will probably that a psychiatrist could practice in a more comprehensive view of psy- work for all. more comprehensive way and still meet chiatry just grandiosity, or FOMO?) Psychiatry, as Dr. Waterman his obligations regardless of patients’ Yet, one might still wonder: states, is corrupt and its treatments are economic circumstances, still learn and why a psychiatrist, why not teams weak (Andrew Solomon calls them, develop professionally among like- (one person ‘does the medication,’ ‘appalling’), But I conclude that psy- minded colleagues and learn from a one ‘does the therapy,’ and so on; it chiatry as it could be is still better than literature which is, both, exciting and no psychiatry at all.

4 Volume 26, Number 1 2019

Reference training and thereafter, I developed the strong sense that a fair portion of Lessig, Lawrence. America, Compro- practicing psychiatrists are able to mised. Chicago, The University of Chi- help a good portion of the persons Karl Jaspers Award cago Press, 2018. they treat to have better quality lives than they would have otherwise. If 2020 *** this is true, and I realize this is diffi- cult to prove, how is this possible Call for Papers given the state of psychiatry as out- lined above? This question has stimulated my Deadline Practicing Psychiatry in the interest in understanding the method- December 15, 2019 Dark Ages: A Response to ology of clinical reasoning in psychi- Scott Waterman atry. How can the psychiatrist do better in helping her patient than the very flawed information offered by The Association for the Advance- Douglas Heinrichs, M.D. ment of Philosophy and Psychiatry [email protected] the research and academic establish- ment would seem to allow? I have (AAPP) announces a competition for students and trainees Eligibility I fundamentally agree with Scott’s come to think it useful to make a dis- includes medical students, graduate characterization of the long-standing tinction between the science of psy- students in philosophy, psychology deplorable state of psychiatric research chiatry itself, where the emphasis is and relate fields, and residents and and academic psychiatry in general – on understanding and treating a fellows in psychiatry. from the doctrinaire nature of the once unique individual, and the informing dominant psychoanalytic movement disciplines that surround it; e.g. psy- The Karl Jaspers Award is given for chopathology, therapeutics, neurosci- the best paper related to the subject (which has led to many clinically use- of philosophy and psychiatry. Ap- ful babies being thrown out with the ence, psychology, sociology. I trained in psychiatry just at the transition propriate topics for the essay in- rigid and arrogant theoretical bath- clude, among others, the mind-body water) to the striking failure of the re- point when the hegemony of psycho- problem, psychiatric methodology, search program in biologic psychiatry analysis gave way to the dominance psychiatric nosology and diagnostic to generate much solid and relevant of biological psychiatry and psycho- issues, epistemology, philosophy of knowledge to aid in the treatment of pharmacology. The first half of my science, philosophical aspects of our patients. As Scott notes, much of training was in a strongly psychoana- the history of psychiatry, psychody- the problem relates to a conceptually lytic program and the second half in a namic, hermeneutic and phenome- biological and research oriented one. nological approaches, and psychiat- incoherent diagnostic system. In addi- ric ethics. Winning submissions tion, there is the hubris in arguing that I was fortunate to have a number of excellent clinical supervisors in both will be offered publication, follow- the very limited understanding we have ing appropriate review and editing of the most proximal mechanism of and was struck by the extent to which to meet journal guidelines, in the action of our therapeutic agents tells us they shared core approaches to under- electronic version of Philosophy, much that is useful about the ultimate standing the individual patient and Psychiatry, & Psychology. The experiential and behavioral effects that developing an ongoing treatment home universities or training pro- they produce as their impact cascades strategy in response to that under- grams of the award winners will be through the complex and idiosyncratic standing, in spite of wrapping their notified of the outcome. In addition, understanding in very different theo- the winning entry will be an- mechanisms that constitute a specific nounced at our AAPP Annual human organism. Furthermore the mat- retical garb. The primary focus of my current Meeting, held concurrently with the ter is made much worse by the distor- American Psychiatric Association’s tion of what knowledge we do have by scholarly work is to articulate with Annual Meeting. In 2020, the meet- an unholy alliance between academia conceptual rigor the actual methodol- ing will be on the weekend of April and the pharmaceutical industry, exag- ogy of this clinical enterprise, and not 25 and 26 in Philadelphia. The gerating the benefits and minimizing to trivialize it with the most unhelpful award carries a cash prize of $350 the negatives of our treatment options. label of the “art” of medicine. It is my and recognition in AAPP publica- After nearly a decade of full time contention that practicing psychia- tions. trists who are doing good work, and psychiatric research in an academic setting, my response to a growing ap- certainly not all are, do not simply apply generalized bits of psychiatric preciation of this state of affairs – and it took that long to shed the indoctrina- “knowledge” to a particular patient tion of my training and my personal by some process of deduction. Rather For full details regarding the prepa- desire to do meaningful work in this the clinician, by a process not unlike ration of a submission, please con- field (not unlike doubting and then re- that which many contemporary phi- tact : jecting a religion) – was to leave aca- losophers of science see as central to demia for full time private practice the actual methods of all of the sci- https:// philosophyandpsychiatry.org/ rather than to leave psychiatry all to- ences as practiced, must select partic- ular trial interventions based of a spe- jaspers-award/ gether. Why? In my exposure to psy- chiatric clinicians during my years of cific model of the problem that the individual patient poses in light of her

5 Volume 26, Number 1 2019 goals. Over time the psychiatrist must er, future practitioners are taught that help the individuals I treat to have im- constantly reassess the interventions, clinical method is largely a matter of proved lives in terms that they set. I modifying the model when indicated, applying the algorithms of Evidenced think I succeed often enough to keep at in light of the patient’s evolving condi- Based Medicine to the patients they it for now. In my limited time for tion and goals for treatment, with an are treating, reducing them essentially scholarly pursuits, I continue to try to eye to possible unexpected effects both to tokens of a type, while some vague articulate the clinical method of psychi- positive and negative. This requires lip service is paid to the need for the atry. Will anyone listen or care? I’m listening to the patient with an open “art” of medicine with little actual not sure. But perhaps a few will and mind and not applying a preconceived attention to what that entails. Rather perhaps it will help this rearguard ac- checklist of symptoms and side effects. than inculcating a healthy skepticism tion to keep good clinical care alive. It requires willingness to reformulate in the future psychiatrist toward the Scott began with a religious compari- one’s understanding of the patient re- sifting, commonly unreplicated, and son, citing Bertrand Russell. Let me peatedly during the course of treatment frequently biased “knowledge” being end with a different one, perhaps re- and striving to develop an understand- churned out by academic research, flecting a detour in my earlier life in- ing that both the psychiatrist and the often funded by and in collaboration volving four years in a Benedictine patient share. Each patient becomes an with the pharmaceutical industry, monastery. Trying to practice good N of 1 study as the lines between clini- trainees are taught a questionable clinical care in psychiatry and to under- cal practice and research blur. It is the schema for a hierarchy of evidence stand its methodology feels a bit like failure to implement this sort of indi- that suggests that randomized clinical what I imagine medieval monks to vidualizing strategy that results in psy- trial results simply trump every other have felt trying to preserve some of the chiatrists failing to see when their treat- source of knowledge available to the classical wisdom in dark times. Perhaps ments in accord with current “standards clinician. something of value can be preserved of care” are actually doing harm to a There is little reason to expect this and nurtured for future use, if at some given patient, even when that harm is to change in the near future, given the point the barbarians depart, or decide it obvious and occurring in plain view. I massive financial incentives for aca- is time to become civilized. believe there is a great need to make demic psychiatrists to keep doing what this sort of clinical method explicit, they are doing. As departments of psy- more teachable, and more theoretically chiatry rely ever more heavily on re- *** justified in scientific terms. Neverthe- search dollars, much of it with ties to less I believe that many psychiatrists to the pharmaceutical industry, the status varying degrees already practice this of researchers eclipses that of clini- An Imperfect Psychiatry sort of approach, if not well articulated cians in training programs. Consider, (Continued from page 1, Editor) even to themselves. In short I believe for instance, the incoherence of a com- that what the good psychiatrist actually mon policy in departments of psychia- ticipate in the formulation of what does with her patient is often much try that forbids residents and clinical was likely the most materialist inte- better than the theoretical “knowledge” staff from meeting with pharmaceuti- grated course in neuroscience being taught to psychiatrists at any giv- cal sales representatives, while allow- among all American medical en time. ing research faculty to accept massive schools.” Inasmuch as ‘materialism’ My deep concern for the future of research grants to carry out work of has become a superannuated con- psychiatry as practiced results from the potential value to the pharmaceutical cept, with material now a matter of change in training that has come with industry. Apparently the clinician can- waves and quarks, I assume that in the transformations in academic psy- not be trusted to resist the allure of an speaking of materialism he means chiatry. As theoretically rigid and doc- explicit sales pitch and a free sand- naturalism, the major tenets of trinaire as psychoanalysis was in its wich, while research faculty, whose which are fact and empirical evi- heyday, training in that tradition en- very livelihood may depend on drug dence. With naturalism as its philo- couraged listening carefully to the indi- company money, are free to impart sophical underpinning, scientific vidual patient and understanding their information to trainees that is assumed research involves what can be seen, uniqueness in the context of an ongoing to be objective, scientific and unbi- measured, and confirmed. The effort and evolving treatment relationship. ased. (As an aside, it has always to explain as much as we can natu- Some attempt was even made to distin- seemed to me that residents should ralistically is of course a reasonable, guish clinical theory from metapsycho- meet with drug reps but only in the scientific goal, but with one caveat: logical theory. Even if that clinical un- presence of experienced clinical super- if one moves from trying to explain derstanding was often shoved into a visors who can help them identify the naturistically to declaring that natu- rigid and questionable theoretical strait- biases and critically assess what they ralism is the only way to explain, jacket, the emphasis on listening to the are hearing. If one does not learn this one is shfting from science to ideol- individual left room for thoughtful cli- healthy and critical skepticism in ogy. This is where Scott may be nicians to develop some of the ele- training, then when?) getting into trouble. And it may be ments of a meaningful clinical method- Given this pessimism, how do I the reason why he sees psychiatry at ology of the sort I am trying to charac- think about myself as a psychiatrist? I a dead end, while others of us don’t. terize more explicitly. High status was have chosen to stay as a practicing Allow me to review some other accorded to senior clinicians upon clinician in spite of how I see the field opinions on this theme. Naturalism whom trainees could model themselves evolving. I try my best, with consider- certainly resolves the problem of in how to evaluate and treat individual able humility about what I know, to dualism, but at quite a price. We do, patients. In the current climate, howev- after all, think of ourselves as more 6 Volume 26, Number 1 2019

Whitehead takes me back to Yo- than those plunging rivers in Yosemi- te. Philosopher Simon Critchley, writ- semite. Blind nature is certainly indif- ing about his early mentor, philoso- ferent to human concerns, but those pher Frank Cioffi, and the latter’s concerns are also part of nature; as attitude toward such scientific reduc- anyone writing or reading this text tionism, says: must surely know. Rocks don’t read This is the risk of what some call or write, nor do sodium ions passing INPP “scientism”–the belief that natu in and out of neurons. But humans 2019 ral science can explain every do. thing, right down to the detail of As a final gesture in this com- our subjective and social lives. mentary, let me invoke Karl Jaspers, Experts in Mental Health All we need is a better form of psychiatrist and philosopher, who 21st Annual Conference wrote his General Psychopathology science, a more comlete theory, a of the International Network theory of everything. Lord in 1913 and revised the text into the knows, there are even Oscar- 1940s, when he had long since given for Philosophy and Psychiatry winning Hollywood movies made up psychiatry and become a world- Warsaw, 22-24 October 2019 about this topic. Frank’s point, famous philosopher. This is of course Critchley’s way Writing against a background of of noting the point made above, nineteenth-century biological psychi- Participation that claiming naturalism (or ma atry, Jaspers begins with a major dis- terialism) as a theory of every tinction between causal explanation thing is a declaration of ideology, and meaningful connections. The Panel proposals not science. former is the world of the positive sciences, the latter the world of rela- Oral presentations Let me add to this chorus another Posters philosopher, Alfred North Whitehead, tions of meaning. If a man becomes who writes: delusionally (and inappropriately) Listeners There persists, however, jealous following the development of throughout the whole period the a brain tumor, that jealousy has a presumed physical cause. If on the fixed scientific cosmology which Topics presupposes the ultimate fact of other hand a man becomes angry fol- an irreducible brute matter, or lowing an insult, there is no physical material, spread throughout space cause, only a meaningful connection Expertise in mental health in a flux of configurations. In between the two events. Jaspers is quite clear that most human interac- Role of diagnostic categories itself such a material is senseless, Psychiatric patients valueless, purposeless. It just tions involve a mixture of the causal does what it does do, following a and the meaningful, writing, Healing and psychiatric mod- fixed routine imposed by external “Biological, psychic and cultural fac- els relations which do not spring tors are an indivisible reality; they Psychiatry and values from the nature of its being. It is have to be pulled apart and interrelat- Critical perspectives ed so that we can explore them scien- this assumption that I call Psychiatry and philosophic ‘scientific materialism’. Also, it tifically; they are radically different is an assumption which I shall in meaning.” Jaspers would reject a practice challenge as being entirely un- charge of dualism and would insist Representations of madness suited to the scientific situation at that his concern is the difference be- which we have now arrived. It is tween two methodologies in studying not wrong, if properly construed. human psychopathology. In the General Psychopathology For full information, contact: If we confine ourselves to certain types of facts, abstracted from the Jaspers makes still another general complete circumstances in which point that is relevant to this discus- www.osfp.org.pl/inpp2019 they occur, the materialistic as- sion. He distinguishes a ‘case’ of sumption expresses these facts to psychopathology from the individual [email protected] perfection. But when we pass whom I am treating. beyond the abstraction, either by There is a radical difference more subtle employment of our between our perceiving in a case senses, or by the request for an instance of something gen- meanings and for coherence of eral (the scientific approach) and thoughts, the scheme breaks perceiving something which im- down at once.” mediately confronts us as To which he adds in another place: unique, an enigma which can “There are then two possible theories never be turned to good account as to the mind. You can either deny by the use of general state that it can supply for itself any experi- ments…The difference is ences other than those provided for it radical because here at the mar- by the body, or you can admit them.”

7 Volume 26, Number 1 2019

gins of scientific knowledge biology and biochemistry of the ever. There may still be a therapeutic and arising from the immedia brain. I quickly realized that we were role for psychotherapy. In fact, there cy of experience the essential so far from being able to understand are many studies now supporting such communication is that ‘I recount the functioning of the brain to pro- a role, most for cognitive-behavioral but I cannot generalize what I duce so-called “higher mental pro- therapies, but some even for psychody- know’. cesses” that I did not see the sort of namic therapies. Jaspers is here carrying his argu- understanding I was looking for being If you want to practice a ment as far as possible from any simple found in my lifetime, if ever. I decid- “biological psychiatry” as Dr. Water- theory of naturalism. The issue is not ed if I could not understand the brain man seems to conceive of it there just that we’re in the world of human in the way that I wished that I would seems little to do but be a psychophar- meaning, as opposed to that of causal switch to trying to understand the explanation. It’s also that we are not macologist as Dr. Waterman was (or products of brain functioning. I administer such things as ECT, TMS, working with a case of a general disor- switched my major to philosophy and or other neuromodulation therapies). der. We’re working with a particular went on to graduate work in philoso- When the limitations of such therapies individual in all his or her uniqueness. phy. It was while doing that graduate are noticed there is nothing left to do - From Jaspers’ perspective we work that I came to think that psychi- if you have decided that talking with would fault Scott’s putative material- atry could be a way of bringing my your patients cannot possibly have ther- ism on two counts: first, that it misses interest in the brain and the “mind” apeutic value. the dimension of human meaning, and together, and doing it in a way that second, that it ignores the unique quali- Dr. Waterman then turns to the might allow me to help people in a discomfort he has felt from his encoun- ty of the person we’re treating. And the practical way. I did a post- ter with critical psychiatry and mem- latter means that, even at the level of baccalaureate year and went on to bers of the consumer/survivor/ex- meaning, there is a particularity of eve- medical school to become a psychia- patient community that he has met. I ry individual that renders him or her trist. have met these people as well, and in more than just another case. I have talked of “brain” and my meetings with them have found I have written this commentary “mind” and I imagine I can hear the with the assumption that my under- them to be most unhappy with biologi- materialist Dr. Waterman moaning. cal psychiatrists, who treated them as if standing of Scott Waterman’s material- But in talking this way I am not posit- they were diseased brains and thus not ism is correct. I of course wait for him ing a dualism. The mind is not some- worthy of talking with or recognizing to confirm that. I have also invoked thing different than the brain. “Mind” as full fellow human beings. When some major figures to buttress an argu- is a convenient shorthand way of re- they have had positive impressions of a ment for the limitations of what I take ferring to those products of brain psychiatrist it was because they had to be his approach. And I have done all functioning that we study in philoso- this to argue that while his approach met one that was willing to talk to them phy and psychology - and that let us as a fellow human being, one who may lead to the conclusion of a failed study the biology of brain processes might be suffering and interested in psychiatry, the more expansive ap- or other disciplines such as history. help with this, rather than with a psy- proach presented in the commentary I believe the root of the quandary chiatrist who just wanted to write out a could readily allow for a conclusion of Dr. Waterman found himself in was prescription and hand it to them to treat a flawed but quite productive psychia- an embrace of an overly reductionist their supposed diseased biology. try. materialism. His philosophical view Dr. Waterman suggests that the JP would only seem to allow room for DSM has played a major role in the

neurology, and he might have been hegemony achieved by psychiatry, and *** happier with his professional choice if in the disaster this has posed. Whether he had stuck to his original plan. But the DSM has been as much of an im- what if we think that there is a reason pediment to biological psychiatric re- Why I Am a Psychiatrist for the DSM to be the Diagnostic and search as Dr. Waterman and the propo- Statistical Manual of Mental Disor- nents of the RDoC proposal seem to Jeffrey D. Bedrick, M.A., M.D. ders? What if we think there are val- think remains, I believe, a somewhat Drexel University id distinctions to be drawn between open question. It is worth remember- [email protected] neurological and psychiatric disor- ing that the changes embodied in DSM- ders? I have addressed this issue in III and subsequent versions of the man- several papers and I do not have the ual were undertaken so as to facilitate Following Dr. Waterman, per- space to repeat those arguments here, research, most especially biological haps a capsule biography might help though I will point to some of the research. If it has not succeeded in explain why I am a psychiatrist, ramifications of such a view. this, the fault may not all lie with the though I am not a Christian nor a be- Dr. Waterman rejects psychoa- DSM. liever in god. While I appreciate the nalysis and embraces Grunbaum’s Further, the hegemony of psychia- rhetorical flourish of linking psychia- work. Whether or not he is correct in try today is largely of a biological psy- try and Christianity, I do not think the this rejection, rejecting psychoanaly- chiatry. Prescribing medication is two are analogous nor that psychiatry sis does not necessarily entail reject- cheaper and less time-consuming than is a religion. ing a notion of mental processes that talking to the people who come to us I started off my undergraduate may not be able to be usefully re- for help, and is thus supported by the career as a biochemistry major with a duced to the purely biological now, or insurance industry as well as the phar- specific interest in understanding the maceutical companies (and the govern- 8 Volume 26, Number 1 2019

ment as well, which seems to think Semrad and Havens were no longer Responses to Commentaries present but whose still-fresh legacies that help for people in need is almost on “Why I Am Not a always an unnecessary expense, while reverberated within those decrepit supporting the military and big corpo- Psychiatrist” walls. Their abilities to “connect” rations is crucial to the nation). Stud- with psychotic people were legendary, ies have shown, however, that being G. Scott Waterman but do any of us wear red hats that instructed to think of psychiatric say, “Make Psychiatry Great Again”? symptoms as symptoms of a “brain Memoir-writing – even the 1200- Perhaps if psychiatric practice at that disease” rather than a mental disorder word variety – is an act of self- time had been widely reflective of the decreases empathy rather than in- indulgence and I appreciate the seri- purported humanity and skill of such creasing it. A psychiatry without em- ousness with which four eminent clinicians, we would. But it surely pathy is perhaps a psychiatry none of physician-scholars, each of whom I was not. us should be a part of. But I do not have known and respected for many Paul asks whether a “more capa- think it is the only psychiatry possi- years, have prepared commentaries cious view of psychiatry” is possible. ble. on mine. Not unexpectedly, there are I wonder if it is desirable and, related- Habermas, a member of the areas of agreement and of disagree- ly, whether that ambition has been our Frankfurt School, argued in ment among the five of us on the sta- undoing. Although what Paul labels Knowledge and Human Interests that tus of psychiatry. Far more surprising “a narrow biomedical model” (brief psychiatry, which he saw as rooted in is the extent to which at least some of “med checks” guided by symptom psychoanalysis,could be a truly liber- the commentators believe their views checklists, etc.) is a caricature of med- atory practice, as long as it was not to contrast sharply with mine, even icine, is there reason to expect that the derailed by positivism. That psychia- on matters for which that is evidently discipline of medicine could or should try has not followed this course is a not the case. While formulating my have the capacity to encompass within testament to the power of the econom- responses I have come to see that last it the range of perspectives and skills ic interests of insurance and pharma- observation as being almost as inter- required to understand and address all ceutical companies and the govern- esting as the ideas the commentators of the variegated and complex miser- ment, and the hegemony of biological and I expressed in our individual ies and dysfunctions to which mem- psychiatry that they have champi- pieces. My replies to each of the bers of our species are prone? Paul’s oned. I think we need to fight for commentaries, avoiding redundancy wonderfully articulate and succinct such a liberatory psychiatry, not aban- to the extent possible, are below. description of those complexities don it. And to those who would say seems to suggest a negative answer to that such therapeutic practices do not Response to Paul Lieberman: that question, at least when it comes belong within the biologically based to populating such a discipline with arena of medicine, but to theology or I thank Paul Lieberman for a actual people. I would suggest that it some other field, I would argue that wonderfully engaging, well-reasoned, also undermines the notion – conven- expelling these practices from medi- and generous commentary. It left me tionally taken as axiomatic – that psy- cine would be to diminish medicine feeling that, were I a better person, I chiatrists should be the managers of and to reduce its freedom of thought. too might have appreciated having treatment teams. The assumption that They have been within medicine and been a psychiatrist. And, to a signifi- physicians are (or should be) the fore- should stay there. Psychiatry, unlike cant extent, I did. To amplify Paul’s most experts on human problems priv- Santa Claus, does exist and can move points about what he refers to as psy- ileges (by definition) medical concep- people. chiatric practice that reflects “a nar- tualizations of those problems, which row biomedical model” – what I begs one of the primary questions at *** think of as simply a crude caricature issue in this discussion – thereby re- of medicine: During my career I had turning us to the matter of just how (or took) the luxury of never needing capacious the psychiatric enterprise to practice in that way. I found, and can or should be. taught my students and residents, that Lastly, the evidence Paul adduces regardless of one’s “theoretical orien- to demonstrate the efficacy of the ide- tation,” the complexities of the prob- alized psychiatry he cautiously pro- lems with which patients present are poses is a bit of a bait-and-switch, as such that even a barely adequate the subjects of the studies grasp of them does not come easily or (contemporary psychiatric diagnostic quickly. Thus, I couldn’t possibly and treatment procedures, employing have made a living as a clinical prac- outcome measures that are dubiously titioner in the contemporary environ- reflective of the sort of human flour- ment and I am grateful that I didn’t ishing many believe we should be need to. Should those observations aiming for) and observations engender nostalgia for an era that has (including “vigorous advocacy” for passed? Paul’s first paragraph brings “access” by organizations whose me back to my days as a chief resi- funding derives predominately from dent at the Massachusetts Mental the pharmaceutical industry) to which Health Center, when the likes of he alludes are mostly reflective of the

9 Volume 26, Number 1 2019 current practices we both decry. They without being explicit with patients questions (some of which Doug raises nevertheless can be interpreted as indi- about what that framework and the himself): Is there any reason to believe cating that the profession of psychiatry rationale for adopting it is or what the that significant portions of the popula- has the capacity to do some good – a conclusions drawn from employing it tion of people becoming psychiatrists low standard, of course, but an im- are, thereby generating misunderstand- can be taught to think and practice like portant conclusion with which I will ing at best and potential harm to pa- Doug? Is he correct that many already not quarrel. tients (and, in related ways, to train- do? Are his suggestions for psychiatric ees) at worst. On the other hand, there practice scalable? From where would Response to Doug Heinrichs: were those who were clearly drawn to support for that come? psychoanalysis as the then-dominant Having retired from medicine to way of channeling their deep interests Response to Jim Phillips: pursue graduate studies in history, I in and intuitive understandings of peo- appreciate Doug Heinrichs’ allusion to ple, and of taking seriously the reports My first reaction to Jim Phillips’ medieval monasticism. To carry the of individual human experiences, cog- commentary was to make mental note reference to its conclusion: If any work nitions, emotions, and behaviors. They to visit Yosemite one of these days. I from our own time is to survive to be were skilled at generating a sense of have savored my time at Yellowstone, “rediscovered” (as Aristotle’s was in understanding and thereby providing Glacier, and the Grand Canyon; per- the Christian West) in some future re- benefit to patients (and trainees). If haps Yosemite should be next. My sec- naissance, I hope Doug’s is included. that typology is accurate, then the goal ond reaction was a combination of ad- He has long drawn a useful distinction might be to replace the flawed theoret- miration and envy of Jim’s poetic sen- between the “N-of-1” focus of clini- ical edifice of psychoanalysis with sibilities, which I surely lack. My third cians and the sought-after generaliza- something that is, at best, more empiri- reaction – presumably the pertinent one bility of the disciplines that are meant cally valid, and, at least, more humble in this context – was that his brief essay to inform their work, though of course in its claims and more open and demo- is worthy of readers’ attention in its (as Doug recognizes) these are not fully cratic in its methods. This might be own right. It might also serve as a re- distinct methodologies and goals but one way of describing the impetus buttal to someone’s views and asser- rather gradations along a continuum behind the sort of practice Doug seeks tions, albeit not mine. Jim’s diagnosis from fully generalizable “laws of na- to capture in his clinical and scholarly of “scientism” is wide of the mark, but ture” (not to be found in the biological, work. I share some of the blame for that error. let alone human, sciences) to thorough- Finally, although this was explic- Diagnoses are only as good as the in- ly idiosyncratic and thus unintelligible itly an aside, Doug touched a nerve formation available to those who for- processes that are presumably inacces- with his comment on pharmaceutical mulate them, and the “history of the sible by scientific methods. I agree representatives that I am unable to presenting problem” that I provided in wholeheartedly with his assessment of ignore. It is, unfortunately, naïve to my target piece was necessarily trun- applying the label of “art” to the abili- believe that clinical supervisors will be cated. It is the case – and Jim and I ties of skilled clinicians to navigate that found to perform the role of modelling have known each other long enough for continuum productively. It is both inac- interactions with pharmaceutical com- him to be aware of this – that among curate and (as Doug points out) trivial- pany representatives that Doug envi- the factors that drew me to philosophy izing of what is likely the most vital of sions. His suggestion elides the funda- of psychiatry was the observation and all elements of clinical reasoning. mental difference between the goals of consequent frustration that medical Although he is hardly naïve to the medical profession and those of discourse (including that of psychiatry, some of the pitfalls of the psychoana- salespeople. Pretending that there is and especially that of neurology) is lytic theory and practice to which he common ground to be found only adds highly dualistic. But it isn’t dualistic in was exposed earlier in his career, Doug to the confusion that the ethical imper- the sophisticated sense by which im- credits his experiences with psychoana- ative of eschewing such contacts ad- portant objections to dogmatic materi- lytic teachers with imparting – via the dresses. Spending valuable time in alism (or naturalism or physicalism or premium placed on careful listening pseudo-intellectual sparring with peo- the positivism of which Jim spuriously and an emphasis on individual unique- ple well trained to perform a function accuses me) can be cast as dualistic. ness – a capacity to engage in the sort antithetical to our own is at best silly. Rather, it is dualistic in the unreflective of clinical thinking and understanding The “healthy and critical skepticism” and simplistic folk-philosophical sense he has so persuasively described and of which Doug writes is better em- by which illnesses are either “organic” championed over the years. Although I ployed in the service of questioning or “functional,” “medical” or find his observations on that topic com- the notion that anything beneficial to “psychiatric” (and, oddly, these well- pelling to a degree, my training experi- patients or the profession can come worn dichotomies are not congruent ences led me to formulate an admitted- from attempting clinical-scientific with each other). It is dualistic in the ly crude typology of psychoanalytically discourse with marketers. Likewise, sense by which “biological” therapies oriented practitioners and teachers. research faculty members whose live- are effective for “brain” problems There were those who took as axiomat- lihoods depend upon industry relation- while “psychological” therapies are ic the claims of psychoanalytic theory ships (“thought leaders,” as the drug indicated for “mind” problems. It is as a complete and valid system for un- companies’ description-cum-wish dualistic in the mangled sense by which derstanding human mental life, includ- would have it) have no business taking anxiety is (redundantly) a “mental ing but not limited to its pathologies, part in medical education or training. symptom” while pain is and who sought to squeeze all clinical Returning to the main points of (oxymoronically) a “physical symp- observations into that framework, all his commentary, I am left with these tom” – rendering their mutually rein- 10 Volume 26, Number 1 2019 forcing effects a purported case of might bring us back to the matter then at least these points would be “mind-body interaction.” It is a dualism of the nature and extent of psychi- more pertinent to the topic at hand. by which “psychiatric” conditions are atry’s flaws, which inhere not in In discussing my observations what remain after “medical” illnesses the rarified formulations of the regarding the testimonies of members are “ruled out.” I’m guessing that all handful of psychiatrists interested of the consumer/survivor/ex-patient clinicians quickly recognize the dualism in its theoretical underpinnings community, Jeff avers that it is to which I refer. Moreover, it is a dual- but, rather, in the effects of its “biological psychiatrists” with which ism that runs rampant among those who practices on actual people. such people find fault. And to the ex- conceive of themselves as thoroughgo- tent that the type of practice to which ing monists (i.e., most physicians). It is Response to Jeff Bedrick: most people are currently exposed true that for a stretch of time I embraced falls under that heading, his assertion eliminative materialism as a solution to Having appropriated the lin- is surely accurate. But his interpreta- this problem, but its flaws (some of guistic form of Bertrand Russell’s tion of the problem is too narrowly which are explicated in Jim’s commen- essay title for my own, perhaps I drawn. The problem is, in fact, far tary) have been evident to me for quite should have anticipated that oth- more generic to the psychiatric enter- some time now and, in fact, underlie to ers might think I was assimilating prise than Jeff recognizes. It entails a an extent my current concerns about the the status of psychiatry to that of disease model whereby an expert col- ever-expanding medicalization of hu- religion, though I confess – er, lects evidence, renders a diagnosis man misery and dysfunction. sorry, admit – that I did not. Be- (whether framed in “broken brain” or Having (I hope) cleared up that yond that, I find myself at a loss “diseased mind” terms, and whether misunderstanding, let me comment on to say much in response to Jeff explicitly shared with the patient or one element of Jim’s erudite recitation Bedrick’s commentary that I have not), and embarks on a course of ther- of the use to which Jaspers puts the Ger- not already said. As I hope I have apy, whether drugs, talk, behavior man philosophical distinction between made clear, my commitment to a modification, or combinations of such Erklären (causal explanation) and Ver- materialist ontology – hardly a modalities. These procedures as con- stehen (meaningful or interpretive un- rarity among people of our era ventionally carried out – whether by derstanding). Although Jim notes that a and educational class and, more to modern “psychopharmacologists” or grasp of human phenomena generally the point, only an aside in my psychoanalysts or harried physicians requires a combination of the two meth- assessment of the state of psychia- in public mental health clinics – often odologies, his examples contradict that try – leaves plenty of room for fail to include acknowledgment of the prescription in a way that is instructive. recognition of the ongoing value, problematic nature of the database on He notes, as examples, that delusional and in fact necessity, of attention which psychiatric understandings and jealousy in the context of a brain tumor to phenomena best described and interventions are founded, and are has a “presumed physical cause,” while understood in terms of “mind.” I experienced by many as usurpations of in the case of anger following an insult, recognize some problems with their epistemic authority and thus as- “meaningful connection” rather than nosologies that posit principled saults on their dignity and humanity. “physical cause” does the explanatory distinctions between “mental” and Jeff is correct in locating in the neolib- work. There is, of course, a sense in “neurological” conditions (e.g., eral order under which we have been which this dichotomization is reasona- seeing obsessive-compulsive and living for the past three decades the ble, but it can provide sophisticated cov- Tourette disorders as being more impetus for the switch in the predomi- er for the unreflective, folk-intuitive different from each other, reflec- nant mode of psychiatric practice to dualism I outline above. For example, tive of their positions on opposite brief encounters dominated by pre- many members of the consumer/ sides of the “mental/neurological” scription-writing. And it is, indeed, survivor/ex-patient community testify divide, than the former lamentable. But it is the more general- that the denial by mainstream psychia- is from mania or the latter is from ized elements of psychiatric practice trists that psychotic experiences can multiple sclerosis), but I cringe across its various incarnations – rooted validly be viewed as having “meaning” even more when I hear the patent- in paternalism and manifested in large – based on the conviction that we now ly ridiculous, banal mantra that and consequential power and perspec- “know” that the conditions that are asso- “mental illnesses are diseases like tive differentials – that are the more ciated with hallucinatory or delusional any other.” fundamental underpinnings of the dis- experiences have “physical” causes Jeff’s assertion that many satisfaction such people are experienc- (never mind that we don’t know what studies support the efficacy of a ing and reporting. The question this those causes actually are) – is a source variety of psychotherapies is as analysis raises, then, is whether a lib- of invalidation and consequent suffer- uncontroversial as his apparent eratory psychiatry – which Jeff and I ing. Explanatory pluralism might be the implication that I “have decided agree is desirable – is possible. intent of invocation of the twin methods that talking with … patients can- of Erklären and Verstehen, just as it not possibly have therapeutic val- Conclusion: avowedly is of the biopsychosocial ue” is baseless. Moreover, if model (about which I have commented “talking with patients” were an What began as a highly capsul- many times previously), but the result in activity specific to the psychiatric ized recounting of the various turns – practice is often indistinguishable from enterprise, or if there were reason and my reasons for making them – of the naïve, folk-intuitive ontological du- to believe that psychiatrists pos- my professional life has culminated in alism to which I refer above. And that sess such skills while other do not, a wide-ranging, if rather unruly, dis- cussion of psychiatric theory, training,

11 Volume 26, Number 1 2019 and practice. To whatever extent a On citing literature in nifer Radden’s interpretation of Burton “target” piece is supposed to engender Philosophy, Psychiatry, on melancholia, you should probably such results, mission accomplished. cite Burton’s book on melancholia as

But as I & Psychology (PPP) well as Radden’s book on Burton. hinted in my introduction to these However, what ideas require an abbre- responses, I was taken aback by the John Z Sadler MD viated mention in a scholarly paper are vehemence of some of the argumenta- Editor-In-Chief, PPP not limited to ‘background’. tion that purportedly (albeit not actu- Peritz (1983) describes a function- ally) refuted my positions. Is that a As an editor and as an author, al classification of citations for scholar- reflection of the impossibility of I learned how to cite prior publica- ly works. She provides eight general providing (or, at least, my failure to tions informally, through example categories of citations, which I believe provide) a fully coherent explanation and the sometimes-painful process are mostly transparent, and often par- of several decades of professional of peer and editorial review. I tially overlapping: (1) Setting the stage career decisions in 1200 words? That don’t think I’m unique in this re- for the present study, (2) Background is doubtless a contributing factor. I gard. So for this short paper for information, (3) Methodological, (4) suspect, though, that much of our dis- the AAPP Bulletin, I thought it Comparative, (5) Argumental/ course has become so schematized might be useful, albeit not particu- speculative/hypothetical, (6) Documen- that we jump to rehearsed responses larly sexy, for PPP readers and tary, (7) Historical, (8) Casual. Not all to what we recognize (even if not authors to know some of my prin- of these categories warrant more dis- entirely accurately) as indications that ciples for appropriate citation of cussion in a short, practical, and our interlocutors are in some “camp” the literature. Making my tacit nonscholarly paper like this one, but a other than our own. I have not thought principles overt is also a useful few do. #3, Methodological, for philos- this through sufficiently and will be exercise for me as an editor, and ophy papers typically refers to the intrigued to learn of others’ assess- presents an opportunity for discus- methods of philosophical analysis or ments. sion amongst our colleagues. supporting claims, but could include If I was left bewildered by some It turns out that library science methods of reviewing a literature as elements of the commentaries, I cer- and related fields have generated a well. I find that philosophical papers tainly wasn’t by others. Most specifi- literature on the use of citations, often assume their methods rather than cally, despite my explicit (and sin- and scholarly organizations often spell them out; hence, the consternation cere) disclaimer that my essay was offer assistance. I refer the reader encountered by philosophers of psychi- intended to be descriptive rather than to the three references below that I atry from medical journal requests for prescriptive, all commentators to one found helpful, as well as online ‘methods’ in the abstract portion of the degree or another evinced a defen- scholarly organizational advice manuscript. #4, Comparative, refers to siveness of their (our?) profession that like the following from the Inter- papers which, in philosophy, the author was not only expectable but encourag- national Consortium of Medical wishes to critique or provide the frame ing. My own assessment of the pro- Journal Editors: of the research question. #5, Argu- spects for psychiatry are not rosy, but mental/speculative/hypothetical, Peritz if there is hope, it lies in the commit- http://www.icmje.org/ lists as ‘all citations made in supporting ments of smart, talented, and caring recommendations/browse/ the formulation of new hypotheses and people like Paul Lieberman, Doug manuscript-preparation/preparing- conjectures, suggestions for future re- Heinrichs, Jim Phillips, and Jeff Bed- for-submission.html search, speculations, and other argu- rick and (importantly) those they ments’ (p. 305). #6, Documentary, re- teach and influence. If I or anyone I However, instructions ad- fers, in philosophy, to prior publica- care about seek psychiatric attention dressing mechanics of citation, tions from which the author draws ide- (a near-certainty, of course), I hope like those of the ICMJE, don’t as or viewpoints in developing a new we are met by the likes of them. The really address the questions I face analysis or argument. Finally, #8, Cas- odds of that, I’m afraid, are not high. as an author and editor: When is a ual, refers to cited work of an inessen- None of this is to deny the seri- citation needed for scholarly rigor? tial, amusing, or anecdotal interest. ous needs toward which a successful How many? What are inappropri- These functions of citation are of psychiatry would be directed. People ate and inadequate citation practic- descriptive interest, but as an author who suffer deserve both public poli- es? So I’ll take these questions one and editor I’m interested in prescriptive cies and individual interventions that at a time. questions - when should I cite? I have help them live less painful and more When is a citation needed for a few rules of thumb for this for philo- connected and fulfilling lives. Psychi- scholarly rigor? sophical papers. Authors should cite atrists should have a voice in formu- I see the basic function of when: lating both –just not the loudest one. citations as relieving the necessity Which brings me to my final point: of recounting the entire history of (1) They make an empirical, factual All five of us are older men with ideas relevant to a paper’s topic. claim that is not transparently true from M.D. degrees. I would like to know, From this standpoint, citations ordinary life experience or brief reflec- formally or otherwise, the reactions to provide reference to an expanded tion. I would not ask an author to cite a this exchange of those readers whose background supporting a new pa- reference for the claim “The sun sets in backgrounds differ systemically from per. For example, if you are plan- the West.” I would want citations for those of the five of us. That would ning to respond to a facet of Jen- the claim “Psychiatric diagnosis is in likely be instructive for us all.

*** 12 Volume 26, Number 1 2019 crisis.” or “The efficacy of antidepres- scholarship and journal publication, sant drugs in bulimia nervosa is 70%.” with a wide range of article quality. (5) Often people new or unschooled in Many of you may have noticed the philosophy writing will write non- (2) The author is building a paper as a trend to limit reference citations. For original opinions without citation, or, step in a research program in which PPP, main articles are limited to 40 without an effort to situate their view- earlier steps have been published earli- references, and review articles 75. point in the literature. Opinions can be er. This is an example of Peritz’ The reasons are various, and will be situated in the literature as well, and “Documentary” and/or “Historical” more apparent from the discussion in should be. To not do so is citation function. the next section. The main reasons negligence. are to avoid allocating undo editorial (3) The author is making sweeping space to reference lists, and the pro- generalizations about a state of affairs liferation of crap publications. Re- Suggested reading: which is not transparently true or is garding particular articles and guide- controversial. “Psychiatric diagnosis lines there: is in crisis.” is relevant again here as Bonzi S, Snyder HW. 1991. Motiva- an example. (1) Revisit principle (6) in the above tions for citation: A comparison of self section. The emphasis is on citation and citation to others. Scien- (4) The author is using a technical term ‘minimum’. If one reference will do tometrics 21: 245-254. or concept which either has multiple to aid credibility judgments, pick the meanings in the literature, is an uncon- best one and cite that. Frost CO. 1979. The use of citations ventional use of an ordinary-language in literary research: A preliminary term, or is a new word or concept used (2) More citations are needed if a classification of citation functions. by a few scholars. For example, the topic has diverse opinions, view- The Library Quarterly: Information, word ‘Dasein’ when Heidegger’s Sein points, or findings, and you want to Community, Policy. 49 (4): 399-414. und Zeit was first published would illustrate treatments of each. need citation. A more recent example Peritz BC. 1983. A classification of might be ‘moral enhancement’. (3) Citations of books over articles citation roles for the social sciences can condense multiple threads of ar- and related fields. Scientometrics 5: (5) When making a complex argument, gument and content, especially if the 303-312. authors often need to acknowledge a books are good, and have rigorous prior publication (theirs or someone peer review like, for instance, OUP *** else’s) with the suggestion that “for a performs. detailed discussion of X see Author, 2012". (4) Avoid citation abuse - described below. (6) We’ve had some discussion within What are inappropriate and inade- the PPP Senior Editor staff about the quate citation practices? issue of self-citation. While this can be abused, self-citation is the founda- Here I describe some citation practic- tion for both a science as well as a phi- es that I find objectionable or negli- losophy research program. The princi- gent. ple is self-citation is appropriate when it is needed to advance an argument or (1) Citation assault: listing multiple analysis in a new paper with an origi- references that make the same point, nal thesis. for this or that claim, for the purpose of rhetorically bolstering a claim, (7) The following is a more encom- regardless of its intrinsic merits. This passing principle of when one should is an abuse of citation. cite works: When complete, a set of citations should provide the minimum (2) Minimize in-press, in-preparation, additional information needed to sup- personal communications, and other port a credible argument or analysis. I citations which are short of material see reference citation as establishing a actually published. level of credibility in this age of tweets, where anyone can say anything (3) While shameful that I need to with no evidence or logic and, unfortu- mention this, but incomplete, incor- nately, be taken seriously. rect, or fake references drive editors crazy. How many citations are appropri- ate? (4) Finding reasons to cite one’s We live in an age of exploding work, with peripheral relevance to the task at hand, is citation abuse.

13 Volume 26, Number 1 2019

The Association for the Advancement of Brent M. Kious, M.D., Ph.D. Philosophy and Psychiatry was estab- Bulletin Editor Robert S. Kruger, Ph.D. James Phillips, M.D. lished in 1989 to promote cross- Paul Lieberman, M.D. disciplinary research in the philosophi- 88 Noble Avenue Douglas Porter, M.D. Milford, CT 06460 cal aspects of psychiatry, and to support Nancy Nyquist Potter, Ph.D. educational initiatives and graduate Phone (203) 877-0566 Claire Pouncey, M.D., Ph.D. Fax (203) 877-1404 training programs. Kathryn Tabb, Ph.D. E-mail [email protected] Serife Teikin, Ph.D. OFFICERS G. Scott Waterman, M.D., M.A. President J Melvin Woody, Ph.D. Philosophy, Psychiatry, & Psychology Peter Zachar,Ph.D. Jon Tsou, Ph.D. Duff Waring, LL.B, Ph.D. K.W.M. Fulford, D.Phil., MRCPsych. Vice-president Founding Editor Christian Perring, Ph.D. EMERITUS MEMBERS Secretary John Z. Sadler, M.D. James Phillips, M.D. Jerome L. Kroll, M.D. Editor-in-Chief Treasurer Jennifer H. Radden, D. Phil. John Z. Sadler, M.D. Louis Sass, Ph.D. AAPP Web Site www3.utsouthwestern.edu/aapp

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