Values underpinning "therapeutic necessity" in mental health legislation

Why is there disagreement over “therapeutic necessity” in mental health law?

Introduction

In Herczegfalvy v Austriathe European Court of Human Rights ruled that imposed psychiatric treatment without consent did not breach Article 3 of the European Convention of Human Rights (freedom from torture and inhuman or degrading treatment) in situations of medicalor therapeutic necessity(Bartlett, 2011: p. 525). In order to grant this warrant to override the usual ethical position of respecting patient autonomy it is necessary to define what medical ortherapeutic necessityis. Bartlett, a legal expert, suggested therapeutic necessity should involve “treating the underlying disorder or improving outcomes” in situations of severity (Bartlett, 2011: p. 525). The courts on medical matters tend to take the view of medical experts in their field of expertise. 

I will argue that therapeutic necessityis a conjunction of two terms – what is therapeuticand what is necessity.Therapeuticinvolves a broad series of potential therapeutic goals such as preventing occurrence of negatively perceived outcomes or relieving distress (Sackett et al, 1991: 189) rather than Bartlett’s narrow definition but these goals ostensibly are supposed to be based on patient values not imposed medical values (Sackett et al, 1991). Necessityinvolves judgements by clinicians as to the current severity and risk of adverse outcomes. These judgments involve values and the decision as to whether they justify compulsion also involves value judgements.

Although much work on enforced detention and treatment is centred on autonomy even if this issue is resolved satisfactorily these ethical warrants for therapeutic necessitystill heavily involve value judgements. In particular people may value autonomy differently versus other rights such as the right to life the disputes over this issue are unlikely to be resolved.

When is enforced psychiatric treatment legally justifiable?

“A characteristic feature of mental health legislation … is the provision which is made for waiving, in certain cases, that respect for patients’ autonomy, their right not to be treated without their explicit consent, … regarded as a requirement in most fields of medicine.” (Mathews, 2000: p.59)

Psychiatric detention and treatment without consent may be regarded by some as breaching Articles 3 (freedom for torture and inhuman/ degrading treatment),  5 (liberty and security of the person) and 8 (respect for private and family life) of the European Convention of Human Rights (Bartlett, 2012:  352). On the specific issue of enforced treatment without consent the case of Herczegfalvyv Austria is “key” in establishing under which circumstances Article 3 has not been breached (Bartlett, 2011). 

Mr Herczegfalvy was detained and treated for “paranoia querulans” – essentially a diagnosis used for people who are suspicious and excessively questioning - (after transfer from prison where he was violent) which involved use of prolonged physical restraints, use of restraint to administer antipsychotic medication which involved him suffering broken bones and lost teeth and being force fed. (Curtice, 2008). The European Court of Human Rights ruled Article 3 rights were not contravened and in paragraph 82 outlined their thinking on enforced psychiatric treatment and Article 3.

“82. … the position of inferiority and powerlessness

which is typical of patients confined in psychiatric hospitals calls for

increased vigilance in reviewing whether the Convention has been complied

with. While it is for the medical authorities to decide, on the basis of

the recognised rules of medical science, on the therapeutic methods to be

used, if necessary by force, to preserve the physical and mental health of

patients who are entirely incapable of deciding for themselves and for

whom they are therefore responsible, such patients nevertheless remain

under the protection of Article 3…

The established principles of medicine are admittedly in principle decisive

in such cases; as a general rule, a measure which is a therapeutic

necessity cannot be regarded as inhuman or degrading. The Court must

nevertheless satisfy itself that the medical necessity has been convincingly

shown to exist.” (Bartlett, 2012: p.365)

An article by Curtice summarised several of the crucial issues:

“Margin of appreciation Domestic states have different accepted clinical practices and standards... Consequently, clinical decisions that are proportional, therapeutically necessary and in keeping with accepted clinical practice are very unlikely to be outside this margin…

Proportionality Clinical intervention needs to balance the severity of the effect of the intervention with the severity of the presenting clinical problem, i.e. be a proportionate response to a clinical scenario.

Threshold of severity to engage Article 3 Ill-treatment must attain a minimum level of severity; assessment of this minimum is relative. ...” (Curtice, 2008: p. 390)

Specific advice has been given firstly for necessity(Article 18) and what constitutes therapeutic(Article 19).

“The Recommendation of the Committee of Ministers to Member Statesconcerning the protection of the human rights and dignity of persons with mental disorder, Rec(2004)10,.. sets out different criteria for involuntary treatment and involuntary detention. The substantive recommendations concerning involuntary treatment are as follows: Article 18 – Criteria for involuntary treatment A person may be subject to involuntary treatment only if all the following conditions are met: i. the person has a mental disorder; ii. the person’s condition represents a significant risk of serious harm to his or her health or to other persons; iii. no less intrusive means of providing appropriate care are available; iv. the opinion of the person concerned has been taken into consideration. Article 19 – Principles concerning involuntary treatment 1. Involuntary treatment should: i. address specific clinical signs and symptoms;ii. be proportionate to the person’s state of health; iii. form part of a written treatment plan; iv. be documented; v. where appropriate, aim to enable the use of treatment acceptable to the person as soon as possible.” (Bartlett, 2012: p.374)

Legal justification for enforced psychiatric treatment without consent relies on the condition of therapeutic necessity and split into two further conditions – what is therapeuticintervention and what is necessity.  In the next two sections I will discuss what therapeutic means in  medical practice and what may be considered necessity, how values complicate both matters and how these values will prevent agreement in all parties involved in such discussions of the legal justification of enforced treatment – clinicians, patients, carers and lawyers. It is important to be clear what therapeutic necessity refers to before the issuing of ethical warrants for doctors to breach their usual convention of respecting patient autonomy.

What is Therapeutic?

What does therapeuticmean in this context? The Recommendation of the Committee of (EU) Ministers to Member States defined therapeuticas having an intention to “address specific clinical signs and symptoms” (Bartlett, 2012: p.374). Bartlett, a legal academic defines therapeuticas “treatments may appropriately be prescribed which are not therapeutically necessary. Treatments which attack the symptoms of a disorder but not the underlying disease are an obvious example” (Bartlett, 2011: p. 533) as well as “treating the underlying disorder or improving outcomes” (Bartlett, 2011: p. 531). The Code of Practice of the Mental Health Act (1983) requires that appropriate treatment “must be treatment which is for the purpose of alleviating or preventing a worsening of the patient’s mental disorder or its symptoms or manifestations” (Bartlett, 2011: p.533). So whereas Bartlett does not regard lessening symptoms as part of therapeutic necessity – only those treatments that target “underlying disease” or improve outcomes (but not outcomes such as improving symptoms) – the official viewpoints such as the Code of Practice are that improving or preventing deterioration of symptoms may count as therapeutic. These are legal and statutory viewpoints. What is the medical opinion which is the key factor (Bartlett, 2012: p.365)?

Critical psychiatrists offer two models of prescribing – one a “disease-centred model” where medication reverses hypothesised mechanisms of disease producing the symptoms (similar to Bartlett’s definition) or a “drug-centred model” where a drug is regarded as always harmful and producing many effects of which some may be regarded by the patient as beneficial such as blunting of painful emotions (Yeomans et al, 2015). A more sophisticated view of therapeuticregards medical interventions as having three potential goals:

 “alleviation of symptoms without affecting the disease course; prevention of progression, but not curative …; and curative or preventive …” (Lieberman et al, 2019: p.794

Sackett - one of the prime movers behind the “Evidence Based Medicine movement” - along with his co-authors outlined a list of objectives of treatments to be decided with the patient (Sackett et al, 1991: p. 189). I have listed them below with my suggested modifications and additions in italics.

“1.           Cure

2.              Prevent recurrence/occurrence

3.              Limit structural or functional deterioration

4.              Prevent later complication

5.              Relieve current distress/reduce symptoms

6.              Deliver appropriatereassurance

7.              Allow to die with comfort and dignity/avoid overzealous treatment”(Huda, 2019; p. 79) adapted from Sackett et al, 1991; p. 189)

Describing these in order, cure should be applied to circumstances such as a reversal of disease process but in layman terms often refers to situations where the symptoms are eliminated or a disease mechanism is compensated for (such as when pharmaceutical insulin is prescribed to replace the body’s own insulin). Prevent recurrence refers to situations where treatment is aimed at preventing a return of the medical condition (or maintenance antipsychotics in schizophrenia) and I expanded it to interventions are given to prevent a first occurrence of a condition (such as vaccination to prevent infections). Limiting deterioration are where interventions are given to prevent further problems such as the use of plasters and surgical fixation to prevent displacement of fractures. Many medical conditions are treated to prevent known complications associated with the condition such as the use of antihypertensives in high blood pressure to prevent cardiovascular disease. Relieving distress or symptoms is an important therapeutic goal as it is often distress or other unpleasant experiences labelled as symptoms that bring people to seek out medical help. Examples include painkillers for pain or antidepressants in depression. Sometimes patients they are worried their symptoms may be caused by a dangerous medical condition but the results of tests are negative so doctors offer reassurance as the intervention. Finally, good medical practice in certain situations is not to carry out intensive interventions with little chance of success as well as to allow someone to have a ‘good death’ according to their wishes. 

This list of therapeutic objectives is broad not all could be regarded as justifying compulsory treatment (for example providing reassurance) and avoiding overzealous treatment by definition is not an imposed treatment without consent. Sackett et al emphasise the importance of patient choice for these treatment objectives.

“Since any decision about the ultimate objective of treatment is made for the sake of the patient, most clinicians involve, and even defer to, the patient’s wishes (or those of an impaired patient’s family) in this decision. And when assessing the risks and benefits (especially as they involve trade-offs between the quantity and quality of life) may not only be useful but crucial (Sackett et al, 1991: p. 188).”

Values clearly have a role in deciding which treatment objectives are valid and which should be chosen in specific circumstances. Bartlett’s own values are at a minimum highly sceptical about psychiatric treatments. He puts forwards his own view that  “benefits of psychiatric medication are not necessarily clear-cut, and the risks can be significant” (Bartlett, 2011: p.517) and contrary to his own claim to want a “balanced reflection” (Bartlett 2011; p. 517) barely mentions any benefits but instead discusses at length adverse effects including a claim that antipsychotics kills more people that it saves which is contradicted by the research evidence that antipsychotics reduce mortality (Tiihonen et al, 2009). This illustrates the perils of relying on balanced accurate evidence from someone advocating a legal argument. As for effectiveness of psychiatric treatments there is an overlap in effectiveness between medication used in psychiatry and general medicine in achieving therapeutic objectives (Leucht et al, 2012 and Leucht et al, 2015). 

Bartlett further reveals his attitudinal values towards psychiatric medication by describing them as “mind-altering drugs” (Bartlett, 2011: p.535) – a highly value-laden term that makes the medication sound frightening but just highlights conceptual confusion. After all, psychiatric medication is used to benefit people with mental health conditions whom are regarded as having unpleasant, distressing or impaired functioning of mind– hence the therapeutic aim would to be alter the state of mind in a beneficial way surely? Which begs the question what does Bartlett think psychiatric treatment should alter? The feet? These values may inform Bartlett’s views that only reversing the underlying causes of the condition or better (unspecified) outcomes but not reducing symptoms should be regarded as valid therapeutic necessity to justify enforced treatment. However, given most psychiatric treatments are justified on clinical grounds for reducing symptoms and does not reverse underlying mechanisms of mental disorders (many of which are unknown) (see Huda, 2019: p. 258-304 which also contains a discussion of how many general medical medications do not reverse underlying mechanisms either) Bartlett’s proposals -perhaps influenced by his values towards psychiatric treatment - would rule out of bounds most psychiatric treatments as fulfilling therapeutic necessitycriteria.

Enforced treatment without consent contrasts with the typical situation in medicine where therapeutic goals are supposed to be chosen at least in conjunction at the least if not actually led by the patient and their values (Sackett et al, 1991: p. 188). Here the clinician’s values (usually the doctor’s but recent changes to the Mental Health Act have allowed other clinicians to have this power) has the ultimate power in deciding the therapeuticgoals; the Code of Practice may reinforce the importance of consultation and taking on board patient views and values but the clinician’s values have the golden vote. 

Several examples of clashes of values will now be discussed. The first obvious one is the allocation of states of mind and behaviour to the category of ‘mental disorder’ by the clinician. Whilst evaluative processes are involved in both physical and mental disease concepts these are more so in mental disorder (Fulford et al (1993): 806-807) as values underlying designation of states as physical disease are more commonly shared and thus less problematic for physical illness compared to mental disorder (Fulford in Boch & Chodoff (1991): 80-82). As a corollary, deciding that certain states of mind and behaviours are ‘symptoms’ that need ‘reduced’ is an evaluative judgement that may not be shared between clinician and patient.

A patient in an elated manic state may wish to continue in this state (though there are often periods of mixed moods including depressed mood) and not see any problem with spending large amounts of money or reckless impulsive decisions that may cause problems such as sexual activity with people other than their spouse. The clinician may decide that the priority is to reduce the manic symptoms which should also have the benefit of preventing complications in the person’s life by their disinhibited behaviour. (One patient told me “you spoilt my fun” when I had reduced their manic symptoms). The clinician is making the value judgement that these therapeutic goals are sufficiently desirable to have the chance (not certainty) of achieving them by having treatment imposed despite the negatives such as enforcing treatment and potential side effects. A depressed patient who is suicidal may not agree with the doctor for starting treatment with the therapeutic goal of reducing symptoms and preventing occurrence of suicide for several reasons: they may believe they deserve to suffer and die because of guilt, they may think treatment is pointless because of depressive pessimism, they may prioritise harm avoidance of treatment side-effects rather than taking a chance on feeling less depressed or they may think the treatment is intended to punish them because the doctor dislikes them.  A patient with what the doctor regards as delusions or hallucinations may believe in the truth of what the doctor describes as psychotic symptoms. They may want to have any associated distress reduced but in consonant with their beliefs/ hallucinations (such as the persecution ending from persecutors). They may not therefore agree with taking medication for psychosis they do not believe they have, they may worry the medication can sedate them making them vulnerable to attack or they may think the medication is part of the persecution to discredit them or even poison them.

Clinicians may be choosing therapeutic aims that are similar to those in medicine as a whole but in enforced treatment against consent, the values that “doctor knows best” trumps the patient’s values in an “authoritarian” model of physician-patient relationship and given the role of state authorised enforced treatment some may regard it as an “instrumental” model in which the physician is acting as the instrument of the authorities (Emanuel & Emanuel, 1992). These value differences persist regardless of the question of impaired autonomy. One can argue that these value clashes are state-dependent and will change when they are not in such mental states but as Bartlett describes there are mixed views on compulsion as a whole afterwards (including presumably the question of enforced treatment) after the detention ends (Bartlett, 2011:p.520) which suggests that even if autonomy was impaired then after restoration of autonomy the clashes in values about the decision can persist.  

What is Necessity?

Situations of necessityjustifying legal detention and enforced treatment of mental disorders require sufficient severity with sufficient risk to health of the patient or to others and where compulsion is still necessary despite consultation with the patient who is judged to lack decision-making capability at the time and the proposed measures are proportionate to the situation (Curtice, 2008: p. 390, Bartlett, 2012: p.365 and Bartlett, 2012: p.374).

This definition of necessityinvolves values – for example the concept of margin of appreciationrecognises that in different EU states different standards and judgements will apply as to what is acceptable clinical practice (Curtice, 2008: p. 390) and this must be due to different local values not merely what specific treatments are available. 

Severity of mental disorder usually involves subjective judgements based on interviews and observations rather than more objective biomarkers which contrasts with the common use of investigation results to underpin decisions in general medicine (see Huda, 2019: p.187-206 for further discussion) and a values-influenced statement of severity such as ‘moderate’. This obviously is prone to be affected by values at various levels from culture to the individual. In mental health severity judgements may be based using ‘anchoring’ observations of such as ability to fulfil occupational demands, self-harming behaviours or self -care – these may display inter-rater reliability but are affected by values. 

Judging the risk involved is also subjective, often involving the collection and weighing up of protective and risk factors and the history of the patient but still involving an element of personal judgement and allocation to a category such as ‘high risk’ which is inevitably affected by values. Psychiatric assessments of risk may not be particularly reliable or accurate (Hope, 2004: p.81) which means that the weightone places on them and in their construction inevitably involves values.

Let us assume these psychiatric assessments of risk ARE reliable and accurate. Say a person with depression is estimated to be at a risk for suicide of 1% in the next week. Personal values influence how we weigh this information up as to whether it justifies enforced treatment let alone detention. Those whose personally value autonomy greatly (not least the patient whose autonomy is being threatened) or those who have an antipathy to psychiatric services (sometimes with good reason due to bad personal experiences of “care”) will focus on the absolute nature of the figure – 99% will not commit suicide and point to the usual civil justice standard of ‘balance of probabilities’ i.e. greater than 50% chance needed. Others will prize autonomy so greatly they will demand a higher threshold or even accept no imposition on autonomy at all. Those whose values regard mental health problems as clinical problems that require treatment or place great emphasis on the right to life may focus on therelativeincrease in risk – in the nature of several thousand fold increase in risk for the average member of the population (assuming an annual suicide rate of 10:100,000) and several hundred fold for people with depression (assuming a lifetime risk of 5-10% for suicide that operates over several decades of a recurrent illness).This great relative increase in risk may need a further justification to convince those wavering between autonomy and right to life – such as the availability of treatment that has a chance to benefit (there are no guarantees in medicine but there can be a reasonable possibility of benefit) and if it is enforced without consent it has a reasonable chance to reduce the symptoms of depression and improve the patient’s quality of life and maybe reduce the risk of suicide. 

The occasions where patients with mental disorders may pose a risk to others might be regarded as being more likely to lead to shared agreement over justification to detention and enforced treatment without consent as people are more likely to agree that autonomy does not allow one to ham others. On the other hand concerns about the reliability and accuracy of risk to others still applies (Hope, 2004: p.81) and the use of preventative detention on the grounds of a health condition posing a risk to others is still a value choice to treat people with mental health problems differently from ‘ordinary criminals’ who pose a risk to the public (Hope, 2004 p.81) even if an argument can be made that mental illness causing somebody to be aggressive implies reduced responsibility as well as a possibility of reducing this aggression with suitable interventions which justifies this different ‘treatment’.  Those whose values justify detaining and enforcing treatment on the basis of health alone are relying on judgments of what constitutes health and illness based on values which are less likely to be shared in mental health conditions (Fulford et al (1993): 806-807and Fulford in Boch & Chodoff (1991): 80-82) and therefore less agreement with those who prioritise autonomy.

Judgements as to necessity involve value judgements – on deciding the level of severity and the level of risk. Further value judgements are involved in deciding whether severity and the associated risks justify breaching autonomy and often involve weighing up different rights such as autonomy and the right to life – these values differ amongst people hence their conclusions for the same clinical scenario will vary.

Discussion

The ethical warrant to allow doctors to enforce detention and treatment without consent in situations of therapeutic necessitygoes against the usual position of respecting patient autonomy (Mathews, 2000 p.59) and much focus has been on trying to demonstrate patients subjected to these breaches of autonomy-based rights do not have ‘autonomy’ due to their mental disorder (for example, Mathews, 2000: p. 66-69) thus allowing the doctor to act as substitute decision maker. There seems an assumption that if this is demonstrated satisfactorily then this make such enforced detention and treatment without consent uncontroversial or at least a largely value-free action.

Unfortunately for this point of view values will continue to be a source of dispute even if it can be demonstrated that patient autonomy is always impaired by mental disorder in situations of enforced detention and treatment without consent justified by therapeutic necessity. This is because deciding what are the appropriate therapeuticobjectives – such as reducing symptoms or preventing occurrence of events such as suicide – involves value judgements from the clinicians - such as what experiences are symptoms, what is a mental disorder – trumping those of the patient who may not agree that they have a mental disorder or with the therapeutic objectives when the mental disorder has improved (Bartlett, 2011:p.520). Further, many people have values that object to many psychiatric treatments regarding them as “mind-altering” in a perjorative sense (Bartlett, 2011: p.535). Deciding what is necessity further involves the role of values in deciding how severe the mental disorder is and how great the risks are as well as a value judgement in do they justify detention and treatment without consent.

One obvious clash of values is how to weigh up competing demands of autonomy versus other rights such as those of a right to life and some people may regard the restoration to what they regard as health as a right. People weigh these different entitlements differently and some people will never accept breaches of autonomy in any circumstances. 

Enforced detention and treatment without consent will never be universally accepted due to differences in values between people.

References

Bartlett, P., 2011. ‘The necessity must be convincingly shown to exist’: Standards for compulsory treatment for mental disorder under the Mental Health Act 1983. Medical law review, 19(4), pp.514-547.

Bartlett, P., 2012. Chapter 14 Rethinking Herczegfalvy: the Convention and the control of psychiatric treatment in Brems, E. ed., 2012. Diversity and European human rights: rewriting judgments of the ECHR. Cambridge University Press.

Bloch, S.E. and Chodoff, P.E., 1991. Psychiatric ethics. Oxford University Press

Curtice, M., 2008. Article 3 of the Human Rights Act 1998: implications for clinical practice. Advances in Psychiatric Treatment, 14(5), pp.389-397.

Emanuel, E.J. and Emanuel, L.L., 1992. Four models of the physician-patient relationship. Jama, 267(16), pp.2221-2226

Fulford, K.W.M., Smirnov, A.Y.U. and Snow, E., 1993. Concepts of disease and the abuse of psychiatry in the USSR. The British Journal of Psychiatry, 162(6), pp.801-810

Hope, T., 2004. A very short introduction to medical ethics.Oxford University Press, Oxford

Huda, A.S., 2019. The Medical Model in Mental Health: An Explanation and Evaluation.Oxford University Press, Oxford.

Lieberman, J.A., Small, S.A. and Girgis, R.R., 2019. Early detection and preventive intervention in schizophrenia: from fantasy to reality. American Journal of Psychiatry, 176, pp.794-810

Leucht, S., Hierl, S., Kissling, W., Dold, M. and Davis, J.M., 2012. Putting the efficacy of psychiatric and general medicine medication into perspective: review of meta-analyses. The British Journal of Psychiatry, 200(2), pp.97-106.

Leucht, S., Helfer, B., Gartlehner, G. and Davis, J.M., 2015. How effective are common medications: a perspective based on meta-analyses of major drugs. BMC medicine, 13(1), p.253.

Matthews, E., 2000. Autonomy and the psychiatric patient. Journal of applied philosophy, pp.59-70.

Sackett D.L., Haynes R.B., Guyatt G.H. & Tugwell P., 1991 Clinical Epidemiology: A Basic Science for Clinical Medicine (Second Edition)Boston/Toronto/London. Little, Brown and Company

Tiihonen, J., Lönnqvist, J., Wahlbeck, K., Klaukka, T., Niskanen, L., Tanskanen, A. and Haukka, J., 2009. 11-year follow-up of mortality in patients with schizophrenia: a population-based cohort study (FIN11 study). The Lancet, 374(9690), pp.620-627.

Yeomans, D., Moncrieff, J. and Huws, R., 2015. Drug-centred psychopharmacology: a non-diagnostic framework for drug treatment. BJPsych Advances, 21(4), pp.229-236.

Jaspers’ un-understandability of delusions and the strong psychological model of psychosis 

1.Introduction

The strong psychological psychosis model states that for all the speech, gestures, behaviour etc labelled as functional psychosis we can show how they came about purely in terms of psychological events in a social context in the same way as anxiety or shyness, are continuous with normal psychological processes i.e. are not qualitatively different states and that the meaning of what is communicated can also be understood (Cooke, 2017).  The strong psychological psychosis model applies to ‘functional psychosis’ i.e. where no biological cause is present that is likely to explain the psychosis (such as intoxication with LSD or a brain tumour) (Cooke, 2017).

I will be using Jasper’s phenomenological approach to delusions to critique the strong psychological psychosis model. Jaspers explains “primary delusions” of schizophrenia as the observed manifestation of a global change in awareness of the world with altered meanings of experiences. This differentiates “delusions proper” (also known as “primary delusions” – the terms will be used interchangeably) from “delusion-like ideas” resulting from understandable responses to morbid events e.g. depressive guilt (Jaspers, 1963): 96). In “delusions proper” there is a core to the underlying experience that is not accessible to others understanding as they do not share this changed awareness of the world (Jaspers, 1963: 282). Jaspers describes this phenomenon as a qualitative change from normal or everyday experience that cannot be understood due to lack of shared meanings. This concept if true is problematic for the strong psychological psychosis model that emphasizes continuity with normal experience and that we can understand the meaning of utterances and behaviour in psychosis.

In this essay I will describe initially how the strong psychological psychosis model views understandibility of psychosis symptoms and continuity with normal experience before discussing how Jaspers characterises “delusions proper” as being the external manifestation of an “ununderstandable” experience. I will then discuss this specific meaning of “ununderstandable” for “delusions proper” and why this contradicts the strong psychological psychosis model.  I will then discuss some objections that can be made to Jasper’s ideas by strong psychological psychosis model advocates and how these can be answered.

2. The Strong Psychological Psychosis Model

Now I will briefly summarise the assumptions of the strong psychological psychosis model.

For ‘moral’ reasons including reducing stigma some emphasise continuity between psychological phenomena labelled psychosis and those regarded as normal (David, 2010). Some interpretations of research findings can also be said to demonstrate psychosis being at the severe end of a continuum with normality (Jones et al, 2003; David, 2010 and Linscott and Van Os, 2010). The utterances and behaviour of people experiencing psychosis are said to able to be understood through the joint process of creating a collaborative psychological formulation -

 “assumption is that this process will render even the most unusual or disturbing behaviour and experiences understandable: ‘…at some level it all makes sense’ (Butler, 1998, p.2)” (Division of Clinical Psychology, 2011: 6).

The strong psychological psychosis model asserts that experiences, utterances of behaviour that are labelled as psychosis can be

“understood and treated in the same way as other psychological problems such as anxiety or shyness” (Cooke, 2017: 6)

An example of how psychological formulation is presented as understanding the patient’s psychosis can be found in ‘Understanding Psychosis’ (Cooke, 2017: 51-52). This formulation however demonstrates connections between life experiences  and relevant aetiological factors (such as substance abuse) with the  onset and maintenance of psychotic symptoms as a general class but not why they had such specific experiences such as thought broadcasting through a lump in his throat. It also gave no impression of how did this feel to the person having these experiences. This issue is ignored in ‘Understanding Psychosis’. This contrasts with panic disorder formulations (for example Wells, 1997: 105) where it is easier for me to place myself in the patient’s mind and body and experience what they are going through with increased anxiety leading to physical symptoms such as heart racing and breathlessness and fears of having a heart attack. 

The strong psychological psychosis model holds that in ‘functional psychosis’ there is a continuity between psychosis and normal experience, that the utterances and behaviour in ‘functional psychosis’ can be understood and that the occurrence of psychosis and the content of utterances and meanings behaviour can be explained entirely through psychological processes in a social context.

3. Jaspers Concept of Primary Delusions and Delusion-like Ideas

Now I will describe the phenomenological model of delusions which clashes with the strong psychological psychosis model (Picardi et al, 2018) of which Jaspers is the most renowned exponent.

Jaspers has been influential on psychiatry in general and on psychosis specifically (Stanghellini and Fuchs, 2013) and psychiatry has a substantial influence on the conception and treatment of psychosis despite the objection of strong psychological psychosis model advocates (Cooke, 2017 and Cooke et al, 2019). Jaspers’ phenomenological method consists of

“classifying psychic phenomena” (Jaspers, 1968: 1314), “the sorting out, defining, differentiating and describing of specific psychic phenomena, which are thereby actualized and are regularly described in specific terms” (Jaspers, 1968: 1315-1316) and “must set aside all outmoded theories, psychological constructs or materialist mythologies of cerebral  processes” (Jaspers, 1968: 1316).

This classification of “psychic phenomena” is the essential foundation of further classification, research and clinical practice.  A comparison is made with the histologists describing what they see of the relevant morphological features that others can recognise (Jaspers, 1968; 1316). Jaspers concept of “primary delusions” with global change in awareness of reality with changed meanings permeating many aspects of experience (Jaspers, 1963: 93, 103-104) has a convincing ‘face validity’ for explaining the unusual, baffling enigmatic experiences, behaviour and utterances that clinicians who see patients with psychosis encounter. This is reinforced by the phenomenological descriptions of patients’ experiences in ‘General Psychopathology’ (Jaspers, 1963) of which elements can be readily recognised for clinicians seeing patients in their own practise as Jaspers hoped with his histology comparison. For my own clinical practise in an Early Intervention in Psychosis team I find Jaspers’ concepts of “primary delusions” and “delusion-like ideas” useful as an explanans for why patients that I assess have highly unusual experiences and behaviour whilst also using elements of the weaker psychological psychosis models especially for “delusion-like ideas”.  In my own clinical practice, I find that the claims of strong psychological models of psychosis fall short in helping me to understand why this person is having this particular experience and what it feels like and why are they saying what they are saying (see 2.).

How does Jaspers separate “primary delusions” and “delusion-like ideas”? The “external aspects” used to recognise delusions are “vaguely applied to all false judgements…1…held with an extraordinary conviction…incomparable subjective certainty; 2….imperviousness to other experiences and to compelling counter-argument; 3. Their content is impossible.” (Jaspers, 1963: 95-96). Jaspers is identifying a group of “false judgements” that can be recognised using these “external aspects”  including “delusion-like ideas” or “delusions proper” but could also include some examples of strongly held extreme political or religious beliefs due to “master interpretive systems” (Bentall in Bortolotti, 2018: 79-81 and 87). The “impossible” criterion is discarded nowadays as what is regarded as impossible varies with different cultures and some delusions e.g. of jealousy are possible.

These external aspects are themselves products of “judgments” based on “experience”. These experiences may be morbid events such as depression or hallucinations leading to “delusion-like ideas” but “delusions proper” are caused by “psychologically irreducible” “alien” experiences (Jaspers, 1963: 96).  What is distinctive about the underlying form or mode of experience associated with “delusions proper” that is different from other “false judgements” even if the content is similar (Jaspers, 1963: 58-59)? Jaspers distinguishes between the content of experience and its form which describes the nature of how the experience is presented to consciousness. Jaspers uses “hypochondriacal concerns” to demonstrate the difference – it may be experienced as a recurrent intrusive concern that one is unwell, or it may be a strong belief of being ill despite evidence to the contrary or hearing a voice saying that one is sick. Whilst the content is similar, the mode of its experience is different (and different clinically useful implications for diagnosis, prognosis and treatment).

 In “delusion-like ideas” the mode of experience can be grasped empathically as an understandable consequence of another morbid psychic event (see 5.). For “delusions proper” we cannot achieve “static understanding” (see 4.) of the mode of experience that underlies the delusion producing “judgements” expressed in utterances and behaviour for reasons I shall discuss now.

Jaspers notes that people’s experiences and perceptions of the world involve meanings – when we perceive an object it is accompanied simultaneously with implications –

“a house is there for people to live in…If I see a knife, I see a tool for cutting” (Jaspers, 1963: 99)…“experiences of primary delusion are analogous to this seeing of meaning, but the awareness of meaning undergoes a radical transformation. There is an immediate intrusive knowledge of the meaning and it is this which is itself the delusional experience” (Jaspers, 1963: 99).

People or everyday objects can acquire new often threatening or otherwise significant meanings. This can occur in several types of experience – such as perceptions, ideas, memories or awareness. The radically changed meanings then spread throughout interpretation of memories, current and recent past experiences and interpretation of current and future experience.

“Later the identical experience of significance is repeated, though in other contexts. The trail is blazed and the preparedness for the significant experience then permeates almost all perceived contents. The now dominant delusion motivates the apperceptive schema for all future percepts.” (Jaspers, 1963: 103-104).

Delusional mood is described as one example where initially subtle then progressively more compelling changes in the meanings of experiences are accompanied by mood changes such as anxiety which result in formation of a “primary delusion” (Sass and Pienkos, 2013).

The incorrigible nature of “delusions proper” is not like the “normal errors” of people reinforced by the values and beliefs of a social group (as would occur for extreme religious or political views that may meet the external characteristics criteria for delusions) nor is it like understandable psychological consequences to a prior morbid event of “delusion-like ideas” but is instead an

 “alteration in the nature of personality, the nature of which we are so far unable to describe, let alone formulate into a concept” (Jaspers, 1963: 105).

Jaspers holds that in “delusion-like ideas” there is a connection with other morbid events such as depression but in “delusions proper” there is a global change in awareness of experience with changed meanings of experience but why does this make such states “ununderstandable”?

4. Ununderstandibility of delusions proper

In this section I will outline what Jaspers means by “understanding” of experiences and “ununderstandibility”.

Jaspers separates “genetic understanding” from “static understanding”.  “Genetic understanding” describes

“empathy, of perceiving the meaning of psychic connections and the emergence of psychic phenomenon from another” (Jaspers, 1963: 27). “Psychic events ‘emerge’ out of each other in a way which we understand” (Jaspers, 1963: 302).In terms of the content of the patient’s utterances, “if we understand the contents of the thoughts as they have arisen out of the moods, wishes and fears of the person who thought them we understand the connexions psychologically or empathically…called ‘psychological understanding’…empathic connexions leads us into the psychic connexions themselves.” (Jaspers, 1974, 83).

The “static understanding” of any experience which is not directly visible to the senses of the observer such as a delusion is a

“subjective symptom” that has “to be grasped by transferring oneself… into the other individual’s psyche; that is, by empathy. They can only become an inner reality for the observer by his participating in the other person’s experiences, not by any intellectual effort. .. Then there are all those psychic experiences and phenomena which patients describe to us and which only become accessible to us at secondhand through the patient’s own judgment and presentation. Lastly, subjective symptoms also include those mental processes which we have to infer from fragments of the two previous kinds of data, manifested by the patient’s actions and the way he conducts his life” (Jaspers, 1968: 1313).

When Jaspers refers to “primary delusions” being “ununderstandable” this seems to be referring to “static understanding” rather than “genetic understanding” of meaningful connections and to the underlying experience that leads to the manifestation of the delusion (Gorski, 2012). Jaspers concept of what is “psychologically irreducible” (Jaspers, 1963: 96) in “delusions proper” refers to his concept of

  “irreducible quality of psychic phenomena, which can only acquire identical meaning for numbers of people through the incentive and the multiple clues and leads mentioned previously, may already be found in the case of the simplest sensory qualities, such as red, blue, colour, tone; it comes into play also with spatial awareness, object awareness, perception, imagery, thought, etc.” (Jaspers, 1968: 1317).  “We can have no psychological understanding without empathy into the content (symbols, forms, images, ideas)” (Jaspers, 1963: 311).

Understanding thus requires empathy which in this context requires shared meanings. In the underlying experience all or some experiences may have changed meanings and they are not shared i.e. are not “identical” between the person with the delusion and the person trying to understand them. The basic shared meanings for time, perception or object awareness and so forth may not apply.  An example of these altered meanings as part of the underlying experience has been described by Renee (quoted in Sass, 2003: 130).

“I looked at a chair or a jug, I thought not of their use or function—a jug not as something to hold water and milk, a chair not as something to sit in—but as having lost their names, their functions and meanings; they became “things” and began to take on life, to exist.”

 Note the disjunction between object and typical shared meaning. We can view this experience as a whole description of a world with different/ lost meanings at higher levels but not at the level of shared meanings as every experience or object needs to be checked what the meaning is to the person. Hence “chair” is not a shared meaning between Renee and the person talking to her – the shared meaning would have to be at a higher level – a translation guide for these different experiences/ objects i.e. the “psychologically irreducible” level is the translation guide for this anomalous experience describing the experience in terms of altered meanings. As Sass pointed out Renee is unusual in being able to convey these differences in meanings, in producing a translation guide, often such a guide is absent with the patient saying ‘I don’t have the words to describe it [the experience underlying the delusion].’

One of the key difficulties in understanding the experience that lies behind the “delusion proper” is that it is difficult for other people to “grasp” this experience by “transferring into the other individual’s psyche” because of the changed meaning of experience. The person trying to understand the person with the “delusion proper” is trying to navigate an experiential space where what seems like it could have identical meaning may have a different meaning to the person having the experience unpredictably. This is seen in patients displaying ‘double orientation’ where their behaviour is different from what is suggested by what they say – the classic example of people saying they are royalty but apparently content to stay on psychiatric back wards – which suggests more than one meaning may be held by the same person for the same term.

The patient

 “lives in two worlds simultaneously, the real one …and his psychotic one” (Jaspers, 1963: 150).

 This inconstancy of meanings and difference in meanings mean no easy shared understandings is possible when trying to form “static understanding”. The necessity of using a guide, to continually stop and check whether they have got the meaning right prevents the “grasp” by “empathy” involving a lack of “intellectual effort” that Jaspers describes is the essence of “static understanding”. Even if accurate translation guides are present the resultant staccato “intellectual effort” nature of the exploration of the experience stops the rapid empathic processes. In some cases there is an absence of this guide preventing any sort of “grasp” at all. Since we lack the same meanings we cannot directly perceive them by empathy and require interpretation by the patient these

 “phenomenological elements…. which can in principle never be seen by us,...we term ‘statically ununderstandable’” (Jaspers, 1963: 578).

If one could produce an accurate translation guide that could be applied reliably this may lead to an interpretation of the patient’s “subjective symptoms” but interpretation is not the same as “static understanding” as defined above. Even so, it could be argued that if the rules and meanings of this experience manifesting in “delusions proper” are radically different to everyday commonplace ones then we still may not be able to make sense of these different ways of meanings attached to the world (Thornton, 2004: 223-224). If one could understand through shared meanings of the same experiences i.e. that “static understanding” is possible Jaspers would state that is not a “primary delusion” but is instead a “delusion-like idea”.

Jaspers concept of “un-understandability” does not mean that the contents of utterances or the gestures of behaviours associated with the experiences underlying “delusions proper” are valueless. He noted that

“in psychotic reality we find… fundamental problems of philosophy…the extremest of human possibilities…the philosopher in us cannot but be fascinated by this extraordinary reality and feel its challenge” (Jaspers, 1963: 309).

Jasper’s concept of “ununderstandability” refers to the difference in meanings of experiences caused by the global change in awareness of the environment,

“a mutation in the ontological framework of experience” (Sass and Byrom, 2015),

 and this lack of shared meanings means that “static understanding” is not possible because observers are not able to rapidly grasp empathically what the patient experiences.

5. Delusion-like ideas, genetic understanding and the strong psychological psychosis model

In this section I will focus on delusion-like ideas and where there is compatibility between the strong psychological model and Jasper’s concepts.

 In the strong psychological psychosis model there is a core assumption that delusions are wholly   understandable through psychological formulation (Division of Clinical Psychology, 2011: 6) and for this to happen then the form of experience underlying “delusions proper” has to be eliminated and replaced with analysis of the content. The form of “primary delusion” involves disjunction not continuity with everyday psychological phenomena which is emphasised in the strong psychological psychosis model. For “delusion-like ideas” the mode of the experience has continuity with everyday psychological phenomena so this form does not have to be rejected. Jaspers says that

“the  psychologist  who looks  for  meaning  will  find  content  essential  and  the  form  at times unimportant” (Jaspers, 1963: 59).

Jaspers drew a distinction in understandability between “delusions proper” and “delusion-like ideas”.

“The most profound distinction ….between what is meaningful and allows empathy and what…is ununderstandable, ‘mad’ in the literal sense…Pathological life of the first kind we can comprehend…as an exaggeration or diminution of known phenomena…Pathological psychic life of the second kind we cannot adequately comprehend in this way. Instead we find changes…for which we have no empathy but which…we try to make comprehensible from an external point of view” (Jaspers, 1963: 577).

 For “delusion-like ideas” they are an “exaggeration or diminution” of psychological phenomena we can grasp at with empathy through shared meaning – if someone was depressed we can grasp they may feel guilty and then form delusions of guilt that their family is ruined–something that can be grasped by us and is not a disjunction with normal psychology in contrast to “delusions proper”. Here we can see common ground between the strong psychological psychosis model and “delusion-like ideas” in that they are regarded as being at the extreme end of continuum with normal psychology that we can achieve “static understanding” of.

Further common ground also exists in the strong psychological psychosis model’s assertion that if we knew a patient’s life history and their personality then we can appreciate why they experience “delusion-like ideas” in the same way we can for anxiety or shyness (Cooke, 2017). The DCP guidelines on formulation (Division of Clinical Psychology, 2011: 6) emphasise how the utterances and associated behaviour that are called delusions should be framed in terms of the person’s context, life experiences and psychological processes continuous with normality and that if we do it “makes sense”.  This is what Jaspers refers to as “genetic understanding” (see section 4.) using empathy in a specific sense

 “We sink ourselves into the psychic situation and understand genetically by empathy how one psychic event emerges from another.”(Jaspers, 1963: 301) “When we understand how thoughts rise from moods, wishes and fears we are understanding the connections in the true psychological sense, that is by empathy (we understand the speaker)” (Jaspers, 1963, 304).

This could easily apply to the part of the psychological formulation (see 2.) as to how a clinical problem came about. For “delusions proper” there may be some aspects from a patient’s life history and previous morbid psychological events that we can see linking together as part of “genetic understanding” but at some point this fails as we are unable to follow the psychological connections to the experience underlying “delusions proper” as we cannot achieve “static understanding” of important aspects of this state (Sass and Pienkos, 2013 in Fulford et al, 2013: 644) for reasons explained in 4. We may see a patient with a history of childhood trauma then a triggering life event that we can grasp as generating vulnerability for mental health problems but understanding is lost when they talk about Martians are passing electricity through their body.

Psychological Formulations also include ‘maintenance factors’ i.e. why does the problem not resolve itself. In the cognitive model of delusions several maintenance factors are outlined including anomalous states (Freeman, 2016). There is often also a diagram showing a variety of thoughts, feelings and behaviour in an environment interact with each other. Jaspers may refer to this interlocking system of beliefs and processes as “rational understanding” and “relational understanding” (how mental contents relate together).

 “Rational…understanding…is a purely cognitive understanding of rational content, common to all (e.g. we can understand the logical structure of a delusional system in which an individual lies submerged)” contrasting with “empathic understanding - is the proper psychological understanding of the psyche itself” (Jaspers, 1963: 307).

Jaspers conception of “delusions proper” does not necessarily rule out one contention of the strong psychological model of psychosis – that the aetiology of ‘functional psychosis’ is always due to psychosocial causes so long as a mechanism for these causes to cause this disjunctive state can be demonstrated.

The strong psychological psychosis model would not recognise the distinction between “delusion-like ideas” and “delusions proper” and just view them all as delusions. The definitions of delusions in classification systems used in research - for example, DSM-V (American Psychiatric Association, 2013: 87) - or rating scales used to measure delusions in research - for example, PANNS (Kay et al, 1987) – are based on the external characteristics of delusions which are shared between “delusions proper” and “delusion-like ideas”. As these are lumped together in classification and measurement then advocates of the strong psychological psychosis model will often not be presented with research that contradicts their view. On the other hand the research demonstrating continuity with normal psychology often fails to convince in the clinic when faced with examples of “delusions proper” due to failure to achieve “static understanding”.   

In summary, some elements of the strong psychological psychosis model is compatible with Jaspers especially for “delusion-lie ideas” but the disjunction with every day experience and psychology and inability to achieve “static understanding” which Jaspers proposes as underlying “delusions proper” is not.

6. How can the Strong Psychological Psychosis Model deal respond to Jaspers?

I will now discuss how one prominent strong psychological psychosis model advocate Bentall questions the phenomenological method. Bentall states the difficulties of people reporting on their own experiences, whether phenomenologists can “bracket out” preconceptions completely and the problems of trying to understand what people are communicating about private experience often using metaphor (Bentall, 2015). The second concern seems to be about the true objectivity and reliability of the method but any observation is impacted upon by preconception, the important matter is whether like the histologist the resultant description allows recognition by others and Jaspers’ vivid descriptions and subsequent classifications passes this test. The first point also refers to what Jaspers refers to as “subjective symptoms” and his answer may be that it relies on the skill of the phenomenologist but to ignore “subjective symptoms” for “objective symptoms” would seriously impair understanding what patients experience by focussing on measuring external aspects  Jaspers, 1968: 1313). The third point would be used by Jaspers to say Bentall has proved Jaspers’ point – the patient is forced to use inadequate metaphor because of the lack of shared meaning. People in the same culture often use common metaphors for inner experience such as “butterflies in the stomach”.  These descriptions are sound odd but because they are shared metaphors we can at the least come close to what they feel like or mean unlike experiences underlying “delusions proper” which are so different from everyday experience that shared descriptions seem impossible – how does it feel to have one’s thoughts be broadcast or withdrawn and how to communicate this to somebody not having these experiences?

Bentall could point to phenomenological theories on understanding “delusions proper” such as from Minkowski, Blankenburg and Kimura (Sass, 2001), Maher,(Maher, 1974), Sass and various colleagues (Sass and Byrom, 2015 and Sass and Pienkos, 2013), Rhodes and Gipps (Rhodes and Gipp, 2008) but they all involve complicated mental steps that preclude “effortless” static understanding and in any case are based on qualitatively different experiences discontinuous from normal psychology.

7. Conclusion

Jaspers concepts of “delusions proper” and “delusion like ideas” with former term used to describe experiences that are qualitatively different from normal experience (and are “ununderstandable” due to the subsequent lack of shared meanings) with the latter term used for delusions that can be understood as responses to prior morbid mental events These concepts seem closer to the reality of psychosis encountered in the clinic than the strong psychological psychosis model which regards all psychosis as continuous with normal psychology and is always able to be understood.

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Should psychiatry abandon "natural science" methods as critical psychiatry says we should?

Should psychiatry abandon “natural science” based methods?

Introduction

Critical psychiatrists claim that natural science methods are of little use in studying humans and their problems that form the subject matter of mental health  due to their ignoring important factors such as intentionality, meaning and being embodied in social contexts and that social science methods such as hermeneutics  are preferred (Middleton & Moncrieff, 2019).

I will argue that natural science methods include descriptions such as observation of outcomes of interest to provide the information on causes, complications and treatment responses needed for medical practice. Natural science techniques even in unquestioned natural sciences such as physics may also struggle to discover universal laws because of the effect of multiple interactions, yet we still use them to explain relationships between observable entities hence this is no reason to disbar them in mental health. They can be used to establish causations of organic mental disorders.  Even for functional mental health problems where natural science methods are not used to explain causation these problems are negatively defined using natural science methods. Finally, it may be possible to use natural science methods to study relationships between social contexts and mental health problems. Psychiatry should still use natural science methods.

What is the attitude of critical psychiatry to the use of natural science techniques?

An article describing critical psychiatry (Middleton & Moncrieff, 2019) stated one key attitude was the applicability of scientific methodology in psychiatry. This is quoted in full to avoid any summarising on my part being misleading about their position.

“Medical knowledge is identified with the scientific approach that was developed to study the natural world; systematically investigating assumed-to-be immutable truths by measurement and manipulation of particular elements in a controlled environment. The application of this form of knowledge-seeking to the world of human affairs is referred to as ‘positivism’, an approach that has been criticised for oversimplifying human affairs. Earlier scholars distinguished between Geisteswissenschaften, human or moral sciences, and Naturwissenschaften, natural sciences. The distinction remains a core feature of social science, where it is argued that the study of human beings is irreducibly different from the study of the natural world. Human behaviour is intentional, interactive and inextricable from its social setting. It has meaning, rather than causes, that can only be discerned by reference to its context.

Therefore, if mental disorders are to be understood as human reactions rather than as physical diseases, a positivist perspective cannot provide adequate or comprehensive knowledge. Different approaches are needed that can study social phenomena appropriately.” (Middleton & Moncrieff, 2019: 49)

Alternative social science approaches such as hermeneutics and social constructivism are suggested as alternatives (Middleton & Moncrieff, 2019: 49)

The article summary stated:

“Critical psychiatry does not reject science, but questions the applicability of positivist research paradigms to the study of complex human responses, suggesting that other epistemologies may often be more enlightening.” (p. 53)

An article on the ‘Critical Psychiatry Network’ also described the views of critical psychiatry (Double, 2019) including their view on the role of “natural science” methods.

“However, critical psychiatry’s challenge to reductionism and positivism, including mechanistic psychological approaches, does create a framework which focuses on the person and has ethical, therapeutic and political implications for clinical practice. It also has consequences for psychiatric research, which has become too focused on speculative neurobiological notions” (p.62)

These articles particularly the former promulgate the view that “natural science” methods  

“systematically investigating assumed-to-be immutable truths by measurement and manipulation of particular elements in a controlled environment” (Middleton & Moncrieff, 2019 p.49).

are not suitable for “the study of human beings” (Middleton & Moncrieff, 2019 p.49).   

Critical psychiatry regards the subject of psychiatric research and clinical practice – what problems people present with and are seen by psychiatrists– as “human reactions” or “meaningful responses” (Middleton & Moncrieff, 2019 p.49). The article by Double places a limit on what is referred to is mental health problems not clearly linked to somatic disease such as hypothyroid induced depression or Alzheimer’s disease

“the essential position of critical psychiatry is that functional mental illness should not be reduced to brain disease...Functional mental illness is a personal experience that does not have an underlying brain pathology. No definite biomarkers have been linked to functional mental illness” (Double, 2019 p. 62).

 “Natural science” techniques are described here as controlling for potentially confounding variables whilst altering the experimental variable with results being used to produce “immutable laws”. For the problems that come to psychiatrists this method is regarded as not being able to provide “adequate or comprehensive knowledge” because they are “human reactions” and as such are driven by intentions and are meaningful in response to multiple contexts. Thus, controlling for these contextual factors – regarded as confounding by the “natural sciences” – in order to examine the effects of a single experimental factor (even if it is a social factor such as class) cannot explain why the behaviour happened. There is also a view that meaningful intentional behaviour belongs to the “space of reasons” and may not conform to the “realm of laws” (McDowell, 1994) and hence natural science methods cannot thus provide explanations.

What kinds of information do psychiatrists need for clinical practice?

To address the question of which type of scientific methodology is best for psychiatry we need to know why they need science.

“The link between psychiatry and medicine confers legitimacy on psychiatry as a professional enterprise because its practitioners are seen to hold and exploit expert medical knowledge” (Middleton & Moncrieff, 2019. P. 48-49).

Science is thus used to gain information – for critical psychiatry this is to cement psychiatry’s professional status. Another reason, which may still apply with the previous reason, is that doctor’s professional role to advise on, coordinate, or deliver interventions for health improvement should be based on the best possible evidence gained from science (Shah & Mountain, 2007).

The type of information doctors need for clinical practice can be ascertained by descriptions of ‘clinical utility’ that is stated to come from diagnostic constructs. Diagnostic constructs are used as containers of information – the question of their suitability as carriers of information in psychiatry is not relevant here but given the centrality of making a diagnosis is to medical practice, the purported information attached to a diagnosis is clearly thought to be essential.

Examples of the type of information include

“nontrivial information about prognosis and likely treatment outcomes, and testable propositions about biological and social correlates” (Kendell & Jablensky,2003. P.9)

A more exhaustive list of useful information is listed below

“1.  Conceptualizing diagnostic entities

2.  Communicating   clinical   information   to   practitioners, patients and their families, and health care systems administrators

3.  Using diagnostic categories and criteria sets in clinical practice (including for diagnostic interviewing and differential diagnosis)

4.  Choosing effective interventions to improve clinical outcomes

5.  Predicting future clinical management needs” (First et al, 2004. P.947)

In this list points 2 and 3 relate more to the use of diagnosis in other functions so will be ignored.

Therefore, the types of information that doctors including psychiatrists require include information on likely outcomes (prognosis), the effectiveness of various interventions for this type of problem, what problems may occur in future (complications) and what possible causative mechanisms may be involved (aetiology). The other important thing to note is this type of information is in the form of a range of probabilities not binary information. Even with conditions with almost certain mortality, it is important to know the likely range of possible survival time.

What is the best way to acquire this information?

Doctors can use the patient’s history to provide some of this information in an idiographic fashion. If they have had episodes of low mood in the past in response to interpersonal stressors then you can predict that an upcoming family wedding mixing with hated in-laws may trigger low mood; if they found that a certain type of medication helpful then it may be helpful in the future. If patient had an abscess and they were allergic to penicillin in the past then even If the microscopy culture and sensitivity showed penicillin was the most effective antibiotic you would not prescribe penicillin. This relies on the patient’s past predicting the future – so long as the patient has all the relevant experience.

Often though this information is not available – the patient may not have experienced this type of health problem before to provide guidance on treatments or prognosis, the patient may not be able to recall accurately the information, the patient may be at risk of a complication or problem they have never experienced so cannot be guide in themselves as to the risk of this problem (they may have never had a heart attack but the doctor may be interested in their risk of a heart attack or whether vaccination to prevent a disease is advisable) or they may not have tried a potential treatment so cannot tell you whether it will be effective or if they experienced any side effects.

The commonest way in current medical practice to get this useful information is research on people whose problems resemble the problems of the patient in the clinic in front of them in some way (Kendell in Shepherd & Zangwill (1983): 191-198). This type of research may be simple observation by a clinician that is recorded or remembered in some fashion all the way up to multi-million pound projects involving many researchers. The information gained from this research can then be used to give some idea of probabilistic information of the types described in the previous section.

The natural scientific method is described as a method of investigation to ascertain laws (Middleton & Moncrieff, 2019) but scientific methods are used to describe phenomena as well as explain what is described using laws (Hempel in Sadler et al, 1994: 317-18). Descriptive goals can be achieved by observation and use of standardised terminology to facilitate communication, replication and application by others such as doctors in their clinical practice. For medical practice, important information can be gained by observation of participants with some commonality of their problems - at repeated intervals if necessary – of classified events to gain knowledge on prognosis/ complications of mental health problems, effectiveness and side-effects from treatment.

For this nomothetic approach from research to be useful it relies on several possible mechanisms. One is that the similarities between research participants and the patient in the clinic increases the chances of making successful inferences - the probabilities of recovery or rates of response to treatment -as they have an increased chance of sharing some fundamental quality even if it is unknown. Practical kinds that perhaps share external features such as similarities in symptoms rather than common mechanisms or causes have a greater degree of uncertainty making inferences from research to the clinic. Another possibility is that even if the mechanisms are unknown and the participants are heterogenous there maybe some common elements of mechanisms (mechanistic property clusters) allowing greater degrees of certainty. For natural kinds with common mechanisms and/or causes the certainty is greater still (Kendler et al, 2011). The knowledge gained from research has a degree of uncertainty, greatest when relying on “practical kinds” but also influenced by the effect of multiple contextual factors (such as participants in research differing markedly from patients seen in clinical practise) but information even with great degrees of uncertainty is still better than no information at all so long as this degree of uncertainty is taken into account in decision-making.

If general laws are demonstrated that can offer explanation of observed descriptive data – such as increase in neurochemical x leads to increase in symptom y then this can allow a greater degree of explanation and extrapolation from research participants to the patient in the clinic. With this higher degree of explanation comes increased predictive ability – it can lead to increased understanding and explanation of the patient’s situation; an increased knowledge of the mechanisms can allow increased predictive ability for complications and prognosis and more rational choices in treatment and development of more effective treatments in future.

It is important to recognise that there are certain limitations to using natural science methods in mental health. The information gained even if only descriptive uses classifications varying from a “black box” type where we have little explanation to types with a great degree of explanation. There is always a degree of uncertainty but even in the most uncertain cases, information with high degrees of uncertainty is better than no information at all so long as one is aware of the degrees of uncertainty (see evidence pyramid and subsequent strengths of recommendation).

Do natural science techniques have limits for explaining and establishing causation in mental health problems?

Middleton and Moncrieff state that human beings cannot be studied by natural science but later specifies “behaviour” and “human reactions”. It makes the case that behaviour, thoughts, emotions and so forth cannot be studied in a natural science way because this ignores context, personal history, meaningfulness that do not apply to the subjects of natural sciences such as subatomic particles and animals.

Middleton and Moncrieff describe natural science’s “immutable truths” derived from “controlled” “manipulation” of “particular elements”. It is true that scientific practice often tries to generate observations from experiments aiming to minimise the effects of confounding variables to clarify the role of the experimental variable. Are these experiments in natural sciences such as physics or chemistry producing “immutable truths”? No, they provide results that operate under certain conditions. For example, determining the state of water as a liquid depends on certain conditions of temperature and external pressure. Even what we may regard as relatively stable phenomenon in physics such as the passage of time are changed by near-relativistic speeds and the laws of physics were different at the time of the big bang and continued to evolve even during tiny fractions of a second afterwards.

We cannot expect “immutable truths” very often, if at all, in the hard sciences. What we get is contextual-influenced observations. Hacking suggests that whilst proving that theories (these explanatory underpinning “laws”) are real may be an ultimate goal of scientists but in practice most scientific work is concerned with manipulations of observable entities and the relationships between them (Hacking in Boyd et al, 1999: 247-260). So in psychiatry we natural scientific methods may be used to observe interactions between say giving an antidepressant and effects on depression without necessarily proving an underpinning law predicting the entire effects of the antidepressant on speech and behaviour (it might demonstrate a relationship between a reduced tendency to have less negative thoughts but not the exact content of the negative thought).

In terms of explanations of human behaviour and speech there is always going to an effect of culture, history and environment. Delusions in the 19th Century were often religious due to the importance of religion in culture; nowadays people often have delusions around technology such as television or the internet which were not around in the 19^th Century. Now if we posit a biological causation for delusions then a purely biological model cannot explain this variation – it may say delusions around available technology have a biological basis but not why the patient talks about being controlled by wifi now and emissions from natural gas used in lighting in the 19^th Century - that is due to historical contingent factors as to what technology is available.

Psychiatric symptoms and signs have been described as ‘hybrid objects’ (Markova and Berrios in Zachar et al, 2015) where this model leaves aside the question of causation. The term ‘objects’ describes constructs that are used to depict or explain aspects of the world. The generation of psychiatric symptoms as signs are said to be ‘hybrid’ because they involve combinations of biological and semantic elements—a biological element/kernel is contained within two layers of configurating envelopes.

The cause of the biological element is not depicted in this model. The biological element refers to the brain activity associated with the symptom or sign. This might be, for example, nervous activity that is a corollary of the patient’s thoughts.

C4.P4

 The two configurating envelopes describe the semantic and contextual elements that act to configure and modify the interpretation and expression of the biological element successively. The first envelope involves individual and sociocultural forces (such as personality traits and culture) whilst the second envelope consists of interactional forces (e.g. between doctor and patient or within a broader social context) (Markova and Berrios in Zachar et al, 2015)).The second type of  configurating envelope describes interactions including that between the patient discussing their experiences with somebody else.

Thus, any explanation of a patient’s behaviour or speech will necessarily include contextual social and interpersonal factors. This means any explanation from laws derived natural scientific methods will also need to explain these contextual and interpersonal factors in order to claim a full explanation of the mental health problems expressed in behaviour and speech.  For laws derived from natural science methods to be able to explain the entire reasons for behaviour they have to be able to explain these contextual social and interpersonal/ interactional factors.

Even in what seem paradigmatic natural sciences such as physics it has been argued that laws derived from the uncontested use of natural science methods fail to explain as much as people think. They often have certain assumptions such as “all things being equal” which in practice is hard to achieve to control for all contextual factors absolutely even in experiments let alone in naturally occurring situations (Cartwright, 1983). Cartwright puts forward the argument that natural science methods even in physics only allow us to make predictions about relationships between observable events rather than hidden laws. Interestingly, Cartwright makes a direct comparison between the behaviour of particles and people.

“I imagine that natural objects are much like people in societies. Their behaviour is constrained by some specific laws and by a handful of general principles but is not determined in detail, not even statistically. What happens on most occasions is dictated by no law at all.” (Cartwright, 1983: 49).

 Even in physics it is also hard to establish causality.

“All the counter examples I know to the claim that causes increase the probability of their effects work in this same way. In all cases the cause fails to increase the probability of its effects for the same reason: in the situation described the cause is correlated with some other causal factor which dominates in its effects. This suggests that the condition as stated is too simple. A cause must increase the probability of its effects; but only in situations where such correlations are absent” (Cartwright 1983: 25).

Given these problems with uncontested use of natural science methods in paradigmatic natural sciences such as physics in being able to establish laws that can explain everything and to establish causation, it would be reasonable to infer that for the experiences/behaviours patients have that are disvalued that result in them receiving psychiatric care may not be able to have laws discovered that predict and explain them totally or establish causation using natural science methods. There may be at least a gap where different types of methods may be useful, a “space of reasons” perhaps where the social science methods advocated by Moncrieff and Middleton may be advantageous.

Can we really do without natural science methods at all in psychiatry?

There may be certain situations or certain areas when natural science methods may fail to explain fully the speech, thoughts or behaviour of people with mental health problems. It is possible that in all patients the contextual broader sociocultural factors and interpersonal factors that affect speech/ thought/ behaviour (as described by Markova and Berrios in Zachar et al, 2015) are the “space of reasons” requiring different methods than the natural science methods. On the other hand, it is well recognised there are cases when mental health problems are at least in part “the psychological consequences of cerebral disorder” such as general paralysis of the insane, hypothyroid induced depression or the dementias (Lishman, 1997). It is untenable that in cases of what would be regarded as ‘organic mental disorders’ that natural science techniques would be of no use. As Berrios & Markova suggests yes the exact content of speech and behaviour is affected by broader contextual factors but surely the presence of neurosyphilis is germane to the patient talking of their fantastical schemes or an underactive thyroid in a patient with depressed mood and paranoid psychosis? Natural science surely has a role to play when clear-cut biological factors seem to be strongly related to the mental health problems – not only for judging aetiology but also prognosis and treatment even if they cannot fully explain all the details of someone’s speech or behaviour.

Double suggests that ‘critical psychiatry’ is only referring to ‘functional’ mental health problems. But what is a ‘functional’ mental health problem? It is a negatively defined state – one where there is an absence of a biological cause that has been demonstrated in the research to cause the defined problem. How do know what biological causes cause these problems? By using natural scientific methods to demonstrate an absence of a demonstrated biological cause. So even if we adopt the position of only using the social science methods suggested for functional mental health problems these need to be defined by using natural science methods to confirm they are functional mental health problems. Furthermore, one cannot state that with further advances in scientific techniques we will not identify in future biological causes for some cases of mental health problems that are not apparent now. We already have an example in antiNMDA encephalitis that in the time of Szasz he would describe as a ‘problem in living’ as the ability to detect the relevant antibodies was unavailable.

It may be possible to use natural science methods to study the effects of social contextual and interpersonal factors on a variety of outcomes such as the relationship of employment to ethnic minority status. In line with Hacking’s view, Brown and Harris used a standardised interview with reasonable reliability – the Life Events and Difficulties Schedule – to measure the relationships between described observable entities:  social contexts, life events and interpersonal difficulties and the risk of developing depression in women (Brown & Harris, 1978). This demonstrated that social contexts and interpersonal factors (three or more life events, lack of social confidants) and their effects on depression (an increased risk in women) could be measured and a relationship demonstrated even though the full meanings and a satisfactorily predictive law of all resultant phenomena were not demonstrated.

Conclusion

Critical psychiatry states that natural science methods should be replaced by social science methods such as hermeneutics because such techniques cannot explain the speech and behaviour of people with mental health problems as this requires understanding of social contexts and interpersonal interactions. The critical psychiatry view ignores that natural science has descriptive and explanatory aims. Descriptive methods can be used to gain information on information that is important to medical practice including psychiatry such as probabilistic information on prognosis, complications, and treatment responses.

Natural science methods can struggle to establish laws that fully explain behaviours of bodies and particles in physics due to the difficulty of fully accounting for contexts and this may apply to establishing laws that can fully explain speech and behaviour due to the effect of social contexts.  Natural science methods can have some explanatory value in ‘organic’ mental disorders. Even if we accept that natural science methods cannot be used to explain speech and behaviour at all  in ‘functional’ mental health problems then we still need natural science methods to negatively define these ‘functional’ mental health problems and in the future scientific advances may allow us to identify biological cases of what seemed to ‘functional’ mental health problems  for which natural scientific methods could be applied to. Natural science methods can still be used to establish relationships between reliably described and observed contextual and interpersonal factors even if the full meanings cannot be described or explanatory laws established.

In conclusion, natural science methods should not be abandoned by psychiatry.

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Fine NOA

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