Original Paper

Psychopathology 2012;45:220–227 Received: March 28, 2011 DOI: 10.1159/000331599 Accepted after revision: August 5, 2011 Published online: May 22, 2012

Epistemology of

a b Ivana S. Marková German E. Berrios

a b Department of Psychiatry, University of Hull, Hull , and Department of Psychiatry, University of Cambridge, Cambridge , UK

Key Words Why an of Psychiatry? E p i s t e m o l o g y Psychiatry Mental symptoms Brain localisation As a hybrid discipline, straddling both the natural and the human/social , psychiatry faces critical and unique issues concerning its research programme and A b s t r a c t praxis. On the one hand, following the ‘natural sciences’, In historical and epistemological terms, psychiatry is a new research is focused on determining the causes of mental discipline born during the 19th century. Rooted in both the disorders. In line with the medical approach, correlations natural and social sciences, psychiatric objects of , are sought between ‘mental disorders’ or ‘mental symp- namely mental symptoms and mental disorders, are hybrid, toms’ (understood as signs of or proxies for neurobiolog- constituted by the blending of components arising from dis- ical pathology) and putative brain addresses. On the oth- parate sources of ranging from the biological to er hand, following the ‘human sciences’, research seeks to the semantic in its widest sense. This poses problems for psy- understand why society considers certain behaviours de- chiatric research and therapy. Whilst conventional pluralism viant as well as the reasons why certain people develop may be a convenient approach to manage aspects of psychi- mental afflictions [1] . The issues raised by this deep blend atric practice, it lacks the capacity to analyse psychiatric ob- of the natural and human sciences are complex and can- jects in their entirety. For the latter, psychiatry demands a not be handled by conventional ‘pluralism’ [2] or by the new, tailored regional epistemology. This paper outlines the claim that psychiatry needs ‘different models’ [3] . What main features of an epistemology specific to the needs of needs unveiling is the manner in which this blend occurs psychiatry. It highlights the relational approach that needs within both the epistemological apparatus of psychiatry to be taken and illustrates the usefulness of this approach by and the very structure of psychiatric objects themselves. analysing the structure of psychiatric objects, exploring the Firstly, to understand why this is, we need to briefly re- manner in which they may be inscribed in the brain, and view what we mean by psychiatry as a discipline. identifying the need to periodically recalibrate the language Psychiatry is a new discipline. It was constructed of psychiatry. during the early 19th century under the aegis of med- Copyright © 2012 S. Karger AG, Basel icine. Before then, ‘alienism’ – as it had previously been

© 2012 S. Karger AG, Basel Dr. Ivana S. Marková 0254–4962/12/0454–0220$38.00/0 Department of Psychiatry, Hertford Building Fax +41 61 306 12 34 University of Hull, Cottingham Road E-Mail [email protected] Accessible online at: Hull HU6 7RX (UK) www.karger.com www.karger.com/psp Tel. +44 1482 464 564, E-Mail ismarkova @ fastmail.co.uk termed – referred to the practice of dealing with madness within different historical periods, but might again admit or mental alienation carried out by many social agents. to some contribution of biological/psychological factors, Thus, the very notion of madness was a social one, its and so on [10]. Such answers, however, immediately raise definition dependent on the views that society formed as two important issues. to what constituted ‘normal’ behaviour. Within each his- Firstly, it is apparent that there remains a significant torical period, such prescriptions depend upon the pre- disconnection between such narratives and their corre- vailing Weltanschauung, societal fashions, religion, po- sponding research programmes. Thus, whilst acknowl- litical climate and cultural factors, amongst other things. edging an influence of or a contribution from other con- The eventual adoption by 19th-century physicians of the texts, the central understanding of madness is driven by view that madness was best conceptualised as a ‘disease the framework of the specific narrative. This is reflected state’ turned psychiatry into a ‘scientific’ and therapeutic in the development of specialist disciplinary divisions enterprise [4] . such as , psychoanalytic psychiatry Psychiatry is currently viewed as a discipline that deals and , with each propounding its own with the understanding and management of the phenom- views concerning the and management of mad- ena called ‘mental disorders’. In theory, ‘understanding’ ness. This parallel growth, however, discourages serious should mean knowledge based on the apprehension of an engagement in debates between such divisions. object in terms of its historical, social, biological and psy- Secondly, and related to this, what seems to be univer- chological context [5, 6]. In psychiatric settings this is re- sal to these independent narratives of apprehending mad- flected in the superficial appropriation of the ‘biopsycho- ness is the relative paucity of work on how the other con- social’ model [7]. In practice, however, the assumption texts might fit in with their predominant framework. that irrespective of culture all human brains are the same Thus, for example, in the biological narrative, the ques- encourages biological to consider under- tion of how psychosocial factors might influence the de- standing as tantamount to neurobiological [8] . velopment or manifestation of madness is rarely explored. Hence, the addition of social or cultural variables to the Similarly, the psychological narratives, beyond an ac- explanatory equation can only contribute minor patho- knowledgement of other contributory factors, may not plastic effects. The hybrid nature of both psychiatry and expend much effort on researching their possible mecha- its objects suggests that social and cultural variables may nisms. In other words, the nature of the relationship be- intervene much earlier in any causal cascade (more on tween these different narrative contexts is generally not this later). It is this point that needs some unpacking. addressed. Again this highlights the point that despite an Bringing us back to the hybrid nature of the discipline, it official claim to wider contexts involved in the ap- raises the crucial issue revolving around the range and prehension of madness, such contexts are understood in nature of the different origins of psychiatric knowledge, what are essentially independent ways. and whether or how they can be apprehended in an inte- Whilst such disconnection between different narra- grative fashion. tives encourages the current pluralistic approach to psy- What does it actually mean to apprehend the meaning chiatric research and understanding, the validity of such of madness in the historical, social, biological and psy- an approach must be examined [2] . Firstly, it becomes chological context? This has generally been answered by easy to forget that this disconnection is in contrived addressing each of these contexts separately. In other and does not reflect the of the objects of inquiry. words, narratives in each of these fields have been con- This inevitably leads to debates concerning which narra- structed to answer the question in a coherent way, each tive is the ‘true’ or ‘correct’ one and detracts from ques- admitting to different extents to some contribution from tions as to how they might integrate. Secondly, and cru- the others. Thus, a biological narrative might understand cially, it hides or ignores the actual interdependency of madness in terms of brain pathology, the development of these narratives, an interdependency that has been criti- which may be influenced by a range of psychosocial fac- cal in the construction of psychiatry and psychiatric phe- tors. On the other hand, a psychological narrative might nomena in the first place and that, perforce, continues to understand madness as an expression of personal inter- underpin the discipline and its subject matter. It is this nal conflicts and perhaps allow some biological (e.g. ge- interdependency that is the essential issue here. Earlier, it netic) vulnerability to contribute to its manifestation [9] . was recalled that madness developed as a social con- And social narratives might understand madness as con- struct, that is, its definition and categorisation grew out structs developed to fulfil particular needs of societies of the views and beliefs about human behaviours and

Epistemology of Psychiatry 2012;45:220–227 221 mental states formed by society within specific historical haviours whose deviancy is generated by a primary dis- periods. In other words, madness is defined in terms of order of the brain; others result from emotional reac- prescriptions and value judgements, and, in turn, these tions to symbolic conflict, yet others will be behaviours can only be handled by the human sciences. that societies want to exclude in the name of higher prin- Once madness has been configured this way, that is, ciples of social order [14] . In all cases, the semantic and its behavioural boundaries have been prescribed accord- organic components are present and interactive, but their ing to the ongoing values entertained by the human sci- relative value differs. ences of a given period, the natural sciences become mo- Understanding these various patterns of interaction is bilised. It is only at this point that the natural sciences can one of the central tasks of psychiatry. It should clarify explore the relationship between these behavioural con- how issues pertaining to the human and natural sciences figurations and the human body. And, it is only then that become interwoven in the various ‘objects of inquiry’. any changes found can be deemed ‘pathological’. The This is where conventional pluralism is limited. What we findings of the natural sciences (i.e. the inscriptions of the have are objects of psychiatric inquiry (whether we talk configurations in the brain) do not and cannot by them- about madness, , mental symptom or be- selves produce definitions of mental disorders. This is haviour) that are in fact complexes, that is, hybrid objects most immediately evident when we consider ‘behaviours’ themselves, configured to different extents by elements that were once called ‘mental disorders’, such as morbus from multiple sources derived from both the human and democraticus, drapetomania [11] or indeed homosexual- natural sciences. These heterogeneous elements together ity. They illustrate very clearly the constructive powers of are constitutive of our psychiatric objects of inquiry. In- social and historical forces in the determination of cer- dependent narratives, arising from the pluralistic ap- tain behaviours as pathological. In the case of homosexu- proach, by definition are only able to depict specific as- ality, viewed as a serious mental disorder since the second pects of such complexes, aspects which – depending on half of the 19th century (strongly defended by Krafft- the narrative and on the object of inquiry – will invari- Ebing and Kraepelin) and following its inclusion in an ably be limited if not misleading in scope. Furthermore, early version of the DSM series, various concomitant bio- assumptions concerning the meaning and understand- logical markers have been postulated, though these could ing of the object (mental disorder, mental phenomenon, never be part of the decision as to whether or not it was a etc.) carried by one narrative (e.g. biological) will natu- mental disorder [12]. This decision was taken on the basis rally have wider ramifications in subsequent treatments of social, moral and economic arguments, amongst oth- and research programmes. ers. Thus, the ‘abnormal’ nature of certain mental states The hybrid nature of psychiatry as a discipline and its and behaviours is determined on grounds that are stud- objects of inquiry (mental disorders and mental symp- ied in the human (not the natural) sciences, i.e. in those toms) thus raise important issues for research. These is- disciplines seeking to understand the ways that individu- sues arise from the multifarious approaches that have als and societies perceive, value and make sense of their been developed to explore and explain this field. And world at any one time. these issues are complicated by the very nature of the Once a behaviour is demarcated as abnormal by social interrelationships between these approaches. This is be- prescription, the natural sciences take over and search for cause it is via these interrelationships themselves that associations between it and brain states and functions. At psychiatry is and continues to be constructed and shaped, some point in this process, abnormal becomes patholog- both as a discipline and in subject matter. In other words, ical, that is, its meaning is taken over by a statistical cor- what constitutes psychiatry and its practice, and what we relation showing a connection between the behaviour understand by mental disorders and mental symptoms, and a brain address. At this very moment, the semantic is determined by a complex interaction between and (in its wide sense) and symbolic aspects of madness and blending of ‘knowledge’ from different sources, with dif- its social origins become obliterated by the process of its ferent levels of commensurability [15] . It is for this reason naturalisation [13] . that in psychiatry research must continue to explore the It is, however, essential not to lose sight of the fact that nature and structure of its objects of inquiry from the both the semantic and the organic components of the perspective of all the elements that constitute them and psychiatric object should be preserved. The mental states their interrelationships. In other words, in psychiatry re- and behaviours that societies choose to exclude or demar- search also demands a focus on its epistemology. cate constitute a heterogeneous group. Some will be be-

222 Psychopathology 2012;45:220–227 Marková /Berrios

W h a t I s E p i s t e m o l o g y ? chiatric objects, that is, it becomes a form of ‘regional’ epistemology. It is termed regional since it cannot be as- Having tried to make a case for the importance of the sumed that the same approach will apply to other fields epistemological approach in psychiatric research, we of inquiry. The objects of knowledge in different areas, need to clarify now what it is that we mean by ‘epistemol- clinical or otherwise, will necessarily dictate the specific ogy’. Defined as ‘the theory or of the method or epistemological approach that is relevant to their explora- grounds of knowledge’ [16] , the term is relatively new (it tion. Earlier, it was argued that on account of its strad- was only coined in 1854), but the to which it re- dling both the natural and human sciences, psychiatry fers is ancient. Human collectives have, from very early was a hybrid discipline, and that its objects of inquiry re- on, asked about the origin of their ‘knowledge’, about how flected such an epistemological structure. Constituted by it is possible for human to know what they know. elements rooted in disparate sources of knowledge such Knowledge here is defined broadly, referring to the set of as values, organic components and symbols that con- narratives, beliefs and claims passed on from generation stantly modify each other, such hybrid objects (i.e. mental to generation, allowing such collectives to successfully symptoms and disorders) fall outside the reach and pur- survive in the world. In the classical , the view of conventional epistemological approaches that are gods may have imparted such knowledge piecemeal or designed to deal with the material objects of the natural wholesale. For example, in the Platonic view, knowledge sciences [18] . was ‘remembered’ (via anamnesis) because souls (now Psychiatry therefore needs a regional and specific imprisoned in bodies) had once shared it with God. Ar- epistemology. Since general epistemology cannot provide istotle, on the other hand, saw knowledge as something the specific instruments required to unpack psychiatric which human beings obtained piecemeal. Later episte- objects, psychiatry must build its own. These tools need mologies (e.g. the Christian one) have therefore oscillated to be able to manage descriptions and prescriptions as between these two poles (Augustine vs. Aquinas) [17]. well as the historicist (diachronic) and structuralist (syn- With the secularisation of Western culture, divine ex- chronic) dimensions. The regional epistemology of psy- planations no longer sufficed. The work of all the great chiatry is thus concerned with clarifying the nature of Western philosophers, at least since the time of Descartes, psychiatric objects, which – by determining their kinds has to a certain extent revolved around epistemology. (and proportions) of constitutive sources – allows the Whether privileging the structure of the world or of the most appropriate or valid approach to be chosen to ‘han- person (i.e. their perception, intellect or memory), the dle’ such objects. Questions that need addressing [19] in- question has been what renders knowledge steady, last- clude: what is the nature of psychiatric knowledge? What ing, reliable, true, etc. For example, for Kant the noumena are the sources of psychiatric knowledge? Where does (the essential objects of the world) were unknowable and psychiatric knowledge originate? How legitimate is psy- beyond human reach. All that could be known were phe- chiatric knowledge, or what kind of legitimacy does psy- nomena captured on the basis of specific mind frames chiatric knowledge have? How stable and enduring is psy- and structures (the categories). To the supporters of the chiatric knowledge? How are psychiatric objects formed? of common sense, the mind of man How might they relate to the brain? was perfectly adapted to the world, and hence knowledge What sort of approach should the epistemology of psy- was guaranteed. Irrespective of the ways in which argu- chiatry take then? From what we have said already, it is ments have been framed to define knowledge, epistemol- clear that taking a similar approach to that of the epis- ogy remains the study of the nature, limits and justifica- temology of medicine or of general science will be inad- tion of knowledge. equate [20] . To reiterate, this is because the origin, orga - nisation and justification of its knowledge is based on varied sources, some of which in fact remain obscure or Epistemology of Psychiatry: Directions and unknown. It may be argued that since medicine is also a Approaches hybrid discipline, taking a similar epistemological ap- proach is warranted. However, whilst general medicine If epistemology is about examining the origins and le- also spans natural and human sciences, the interrelation- gitimacy of knowledge in general, then the epistemology ships between these are very different, both in the his- of psychiatry has to deal with exploring the origins, struc- torical construction of the discipline and in its objects of ture and legitimacy of psychiatric knowledge and of psy- inquiry [21] .

Epistemology of Psychiatry Psychopathology 2012;45:220–227 223 The new epistemology of psychiatry will have to give al’s mental state. Such an event can be externally (e.g. a an account of the object and context of inquiry, the role perceived stress) or internally driven (primary biological of the interlocutor (i.e. the clinician or meaningful oth- alteration). Initially, in a primitive, inchoate preconcep- er), and the manner in which these components interact tual form, this change permeates the individual’s aware- [22] . The new epistemology must therefore search for ad- ness. In order to make sense of it, the individual needs to ditional methods and approaches in history, social psy- interpret/configure the . Here, some of the chology, anthropology, linguistics and the hermeneutic first questions arise. Which factors influence the way in disciplines, amongst others. Thus, for example, the his- which a particular change in consciousness will be judged tory of psychiatry provides knowledge about the social and conceptualised? Aside from the cultural and social processes within which the objects of inquiry have been background shaping an individual’s wider outlook, fac- constructed; the philosophy of psychiatry clarifies the tors such as personality (e.g. tendency to introspect/anal- descriptive and definitional power of the language of yse, imagination, inner world), education, past experi- psychiatry, empirical research calibrates the new defini- ences and contextual events play a modulatory role. The tions against the of the human body, and the presence of a clinical interlocutor will, via dialogical ex- hermeneutic disciplines show how to include the inter- change, modify the experience further before this is then locutor in the very process of constructing and interpret- uttered or otherwise communicated as a ‘symptom’. It is ing the psychiatric object. The crucial issue, however, is the interplay of such different non-biological factors that that these approaches have to be integrative in a mean- constitutes the ‘meaning’ of the experience for the indi- ingful way. Thus, the interrelationships between the dif- vidual, which is why this has been termed the semantic ferent approaches have to be clarified and made explicit, component of the mental symptom. and the findings from one approach have to inform the Subjective symptom formation along this pathway other approaches. suggests that the factors that shape the original experi- There are various ways in which the nature of the in- ence are manifold. Moreover, formed symptoms them- terrelationships between the sources of knowledge that selves can provide the substratum on which further constitute the objects of inquiry can be explored but, as symptom construction can take place, and the process this paper advocates, an interactional or relational epis- can continue. What this indicates, however, is that there temological approach [23] needs to be taken. Here, we just has to be a complex interplay between the biological sig- want to discuss two broad approaches, i.e. (i) an examina- nal and the associated mental phenomena. One conse- tion of the structure of our objects of inquiry and (ii) a quence of this is that because of the different ways in process of calibration. which internal changes can be interpreted, one biological signal can give rise to different mental symptoms. Simi- Examining the Structure of Psychiatric Objects of larly, it can be envisaged that different biological signals Inquiry might be configured as the same mental symptom. Posing the question regarding the structure of the psy- This very process of mental symptom formation thus chiatric object of inquiry, irrespective of whether this is a helps to conceive the deep structure of such a symptom. mental disorder or a mental symptom, is already recog- It would include a biological kernel represented by a neu- nising not only that there may be different sorts of ele- robiological signal related to a site or network in distress, ments constituting it, but also that some focus needs to and a semantic shell in terms of the judgements coming be directed towards the relationships between the con- into play in constructing the symptom out of the per- stituents. Mental symptoms, for example, can be explored ceived change in mental state. Describing this structure from various perspectives [21, 24], but one way is to con- brings to the fore some of the issues around the interrela- sider the way in which they may be formed. The Cam- tionships between the different sources of knowledge that bridge model of symptom formation has been described constitute the psychiatric object. In this instance there is in detail elsewhere [19, 25] , and here only a sketch will be the biological signal representing the brain or neuronal used to illustrate the approach that picks up on the epis- changes. At the same time there are the judgements temological questions noted above. In brief, a number of shaped by the wider cultural, individual and social world pathways to symptom formation are postulated. A sub- that occur in the mental realm and that are communi- jective mental symptom such as anxiety, depression, hal- cated via language. It is the relationship between these lucination or depersonalisation can be envisaged as aris- disparate sources that forms the crux of our understand- ing from some event leading to a change in the individu- ing of and research into mental symptoms.

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This same epistemological analysis becomes particu- It follows that determining whether brain inscriptions larly relevant in relation to research on brain localisa- in association with mental symptoms are primary or sec- tion of mental symptoms, as in current ondary carries significant consequences both for treat- studies [26] . Such research makes the assumption that a ments and for research. Mental symptoms associated mental symptom issues directly from a particular brain with primary inscriptions are clearly more likely to be signalling, that is, that there is a relatively one-to-one amenable to biological therapies, whereas those whose relationship between a specific neurobiological change identification is bound up in wider semantic codes may and the mental symptom. However, if mental symptoms require different sorts of approaches. In terms of localisa- are envisaged as structures consisting of biological sig- tion research, then, neuroimaging would capture both nals configured by wider social and cultural codes, then primary and secondary representations, but the latter it becomes imperative to elucidate the extent of the con- would have little meaning as far as the nature of the men- tribution of each component. This means that whilst all tal symptom is concerned. Taking an epistemological ap- mental states are realised in the brain, and consequent- proach is therefore necessary in order to explore mental ly all mental symptoms will have brain inscriptions, the symptom structures, to determine the relative contribu- degree to which the latter can determine the formation tions of biology and semantics, and to tease out the vari- and naming of a particular symptom will vary consider- ous factors constituting the semantic codes. ably. This suggests that there may also be different types of The Process of Calibration brain inscriptions. From what has been said already, Linked to the previous approach is the issue of calibra- mental symptoms can be ‘represented’ in the brain in at tion. Calibration is an essential aspect of epistemology. It least two main ways. Primary brain representation can is an acknowledgement of the dynamic nature of the occur when the relationship between the brain inscrip- sources of knowledge that feed into a subject. All disci- tions and the associated mental state or symptom is rela- plines need periodic calibration, which consists of match- tively direct. In other words, one can envisage that where ing the resolution power of the language of description the brain signal issues from an original primary lesion or with that of the objects of inquiry. This process increases malfunction and gives rise to the changes in awareness the capacity of the discipline to capture relevant phenom- that trigger the process of symptom formation, the resul- ena. ‘Relevant’ are those phenomena whose knowledge tant mental state can be stereotyped, replicable and less increases the epistemic and predictive capacity of the dis- prone to interpretation [27] . This might be the case, for cipline. In psychiatry, the language of description, i.e. de- example, where hallucinations are triggered by an ictal scriptive psychopathology, was constructed before 1900. focus or by the specific location of a brain tumour. In Mental symptoms became the ‘atoms’ or ‘units of analy- these situations the brain inscriptions can be considered sis’ of descriptive psychopathology. This language was as valid proxy variables and are aetiologically informa- calibrated according to the epistemological requirements tive. of contemporary clinical practice and research. Impor- Secondary brain representation would occur when the tantly, it has changed little since [4]. This is in marked relationship between the brain inscription and the asso- contrast to the current research methods in psychiatry – ciated mental state does not reflect a conventional cause- which have increased tremendously in sophistication – effect chain (as in the case of primary inscriptions). In such as neuroimaging, neurogenetics and psychophar- this case the pathogenic drive (i.e. the symbols, meanings macology. Consequently, however, this has resulted in a and reasons that cause the conflict) is to be found in the significant mismatch between the resolution power of the dialogical semantic space formed by interacting human language of psychiatry and that of the instruments de- beings. Such second-order languages do not need to be vised to capture and measure its proxy variables. This is (and may not be) inscribed in the brain. If they are, tem- an important epistemological point. Firstly, it raises ques- porary inscription of denotations (not of connotations) tions concerning the validity of correlational research should suffice [28] . For example, in the case of folie à deux that, on the one hand, captures one variable in fine detail [29] it would be epistemologically crass to claim that the whilst, on the other hand, correlating this with some- symptoms are inscribed in the same way in both the in- thing that has inevitably – with changes in society, cul- ducer and the ‘inducee’. The madness of the latter is more ture and language – lost much of its original sense, be- likely to be secondarily inscribed. coming coarse grained and fuzzy by comparison. Thus, from such a correlational research perspective, it be-

Epistemology of Psychiatry Psychopathology 2012;45:220–227 225 comes imperative that increased effort is also directed at calibration, this means that the focus needs to be directed revisiting the language of descriptive psychopathology at exploring the relationship between changes in such a and what it tries to capture [19]. wider sense and resultant current mental symptoms and Secondly, the mismatch between resolution powers mental disorders. This is necessary in order to be able to and the need for calibration highlight one of the impor- refine the language of descriptive psychopathology and tant features of psychiatric objects (mental disorders/ align it to the needs of contemporary society. In addition, mental symptoms) as hybrid objects, namely, their fluc- such work can also help develop methods of ongoing tuating structures, that is, their variable stability. This re- fine-tuning of this language in response to changes in the lates to the abovementioned dynamic nature of the sorts social world. of knowledge sources that go towards constituting these objects. If we accept that psychiatric objects are complex- es of biological and semantic codes, then, whilst aspects Conclusion of the biological may more readily be viewed as invariant, the same clearly cannot be said about the semantic space, Current emphasis on empirical research in psychiatry that is, the interpretation and sense that individuals will has led to some neglect of the conceptual problems that put on changes happening to them and their environ- are integral to the discipline and its subject matter. Psy- ment. As already discussed, such interpretation, starting chiatry is a hybrid discipline the work of which is rooted at the very experiential level, will depend on contexts in both the natural and the human/social sciences. Psy- spanning the wider (societal, cultural, political, etc.) and chiatry’s objects of inquiry, that is, mental symptoms and personal spheres (concurrent events, past , mental disorders, are likewise hybrid objects whose con- individual inclinations/biases/outlooks, etc.). By defini- stituents originate from both knowledge sources to form tion, these sorts of contexts are not static. Societies and biological-semantic complexes of variable stability. Tak- cultures are constantly changing along with fashions, ing a relational epistemological stance is essential in or- politics and outlooks, and such changes will play a part der to try to clarify such structures and to determine the intrinsic to the way in which sense is made of internal and relative contributions of biological and semantic (social, external experiences. If interrelationships between dif- cultural, individual, etc.) components to them. In turn, ferent knowledge sources are to be taken seriously, then this can help to select appropriate methods of managing attention must be paid not only to putative biological sig- such structures – whether this be in terms of further em- nals, but also to the semantic envelopes constituting the pirical research or indeed in terms of developing thera- objects of inquiry. Thus, in the case of epistemological peutic strategies.

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