The next session will be in English.
Our speaker is Virginia Ballesteros. She is Assistant Professor
in the Department of Philosophy at the University
of Valencia and her research focuses on the
philosophy of psychiatry and psychedelics on
topics such as the definition of mental disorder,
the ambiguity between self and illness, or the
treatment of depression with psychedelic therapy.
She has also investigated the birthing experience
and birth care from a philosophical point of view.
And today she is going to talk about theoretical
conceptions of mental illness as promoters of
epistemic injustice. Thank you very much Claudia
for your introduction and thanks also to the
organizers because I really think that this is
a wonderful event. Okay so as the title says
in this talk I'll address how theoretical
assumptions or conceptions may act as
structural factors that promote epistemically
unjust practices in clinical psychiatry.
And particularly I'll address the conception
of objectivity in terms of standardization.
And I'll argue that this conception of objectivity as a standardization
underpins different forms of epistemic injustice in psychiatry.
Basically because it promotes
treating patients as mere informants or worse as
sources of information rather than as epistemic agents.
Or to put it in Cristian Zaborito's terms
in his talk yesterday, because it prevents a real
dialogue between patients and clinicians.
So I'll begin by briefly introducing the literature on
epistemic injustice in psychiatry and how it
expands the original framework introduced by
Free Care and moves to analyze the link between
theoretical conceptions and epistemic injustice.
I'll then focus on objectivity and show how
it is structural to psychiatry, how it is a
theoretical commitment. And I'll explain how this
is instantiated in the DSM and why it makes it
difficult that patients can act as epistemic agents.
And then if my analysis is right and
the conception of objectivity as a standardization
is a factor that promotes epistemic injustice
structurally, then it has consequences for the
solutions or the remedies that we may implement.
That is, cultivating individual epistemic virtues
won't be enough and neither will be enough
including patients in the revision process of the DSM.
And the main idea is that structural problems need structural solutions.
And okay, what I've just introduced is some work that
has already been published a few months ago.
And in the very last part of this talk, if we,
if I still have time, which I don't know, I'll
briefly present some work in progress that I'm
doing now with my colleague Pablo Moreno, in
which we keep on investigating the relationship
between theoretical conceptions and epistemic injustice.
And now we focus on how classical
metaphysical realism, so to say, about mental
states may also be a contributing factor to
epistemic injustice in psychiatry. So psychiatric
patients are particularly vulnerable to various
forms of epistemic injustice due to factors such
as the prevailing prejudices against those with
mental illness, the challenges they may encounter
in expressing themselves, and the power imbalances
that exist not only between patients and
clinicians, but also between patients and the
professionals responsible for articulating
the theoretical conceptions that inform our
understandings and practices surrounding mental health.
All these factors can contribute to both
testimonial and hermeneutical injustice.
Patients' first-person accounts may be given less credit
than they deserve because of prejudices and
stereotypes about people with mental disorders,
such as being dominated by their illness,
being irrational, or being dangerous.
And also, the fact that patients, the mental patients,
usually have to rely on mental health professional
concepts and categories may leave aspects of their
own experience unaccounted for or not articulated
in their own terms. And moreover, recent
literature has identified other forms of
epistemic injustice that go beyond this
framework originally articulated by free care.
This includes pre-emptive testimonial injustice
in which patients and patient advocates are
excluded from taxonomic decisions because they
are wrongly presumed to lack the knowledge
necessary to make useful contributions, and
also contributory injustice in which patients
are unable to contribute to the clinical
understanding of their own experiences because their own hermeneutical
resources are systematically dismissed.
And in addition to the identification of
these new kinds of epistemic injustice,
recent literature has also targeted several
different theoretical aspects that might promote
epistemic injustices towards patients,
both in general mental health and also,
sorry, both in general care and also in mental health care.
In this sense, the dominant conception of
mental disorder, which is, as you know,
the biomedical model of mental disorder, has
attracted the attention of researchers because
of the rigidity of its conceptual basis
and its biologically centred explanations.
And a profound reform of our fundamental
conceptions of health has been posited as a
prerequisite for epistemic justice for ill persons,
and I quote, "naturalistic conceptions of health
have been identified as epistemically unjust
insofar as they promote and require the
exercise of epistemically unjust behaviours.
" In this sense, it has been argued that what's
epistemically unjust might not be only agents,
communities and institutions, but the theoretical
conceptions of health that structure our
responses to illness and mental disorder.
And furthermore, some authors have pointed
directly to the conception of objectivity in psychiatry.
For example, Paul Crichton, Javi Carrell and
Ian James Keed have identified the high value
placed on hard or objective evidence by clinicians
as a global contributory condition
to epistemic injustice in psychiatry.
And also in a similar vein, although not
focusing on epistemic injustice, Deakin has
criticised the systematic disregard of patient
perspectives in psychiatric inquiry due to
the assumption that patient reports are
"subjective data", in her words, conflicting
with psychiatry's desire to establish
itself as an objective form of inquiry.
Now, what I want to argue is that the problem is
not per se the high value placed on objectivity
by clinicians or the systematic disregard of
patient reports because they are subjective data.
The problem, in my view, is the transformation
that patient reports have to endure to be
incorporated in psychiatric practice as
objective data or objective evidence.
So the idea is that, and I think this is pretty
obvious, that psychiatric diagnosis must be
based primarily on what patients say and how they behave.
And it is because diagnosis must be based
primarily on what patients say and how they
behave that psychiatry must find ways to
objectify both reported mental symptoms and also behaviours.
That is, if psychiatry is to be a branch of
medicine, it must necessarily rely on objective
evidence to support its diagnosis and treatments.
And since clinical psychiatry relies primarily
on patient reports and behaviours, these have
to be properly addressed as the objects of its inquiry.
And this is exactly what standardised instruments
of measurement and diagnosis aim to do.
And, as I will argue, it is this standardisation
that promotes the treatment of patients as
at best mere informants and at worst as sources of information.
OK, it doesn't leave room for their epistemic agency.
But before addressing this, let me first
explain why this is structural to psychiatry.
And to do so, we have to look back a few
decades, particularly to the 60s and the 70s.
Prior to the widespread adoption of the DSM-III,
which was published in 1980, the probability
of two psychiatrists agreeing on a
given diagnosis hardly exceeded chance.
Of course, this was not an acceptable state
of affairs for psychiatry as a discipline,
nor for patients who could receive arbitrary
diagnosis depending on the psychiatrist's
view and not receive the best treatment.
So unreliable diagnoses were problematic to
psychiatry because they were an obstacle to
the systematisation of psychiatric knowledge
and also the evaluation of therapies.
This unreliability of diagnosis also fuelled
the criticisms voiced by movements such as
anti-psychiatry and also this unreliability
prevented the use of the new tools that were
becoming available in these decades in the
field of medicine, such as those of molecular
biology, genetics, neuroimaging, multivariate
statistics or placebo-controlled trials.
And of course, there was also some pressure
from the pharmaceutical industry to conduct
clinical trials to prove the efficacy of their psychoactive drugs.
And this was also a factor which was key in this search for reliability.
We can see this, as I said, instantiated in
the DSM and this is what Robert Spitzer, who
was the task chair of the DSM-3 himself stated.
He said, "The DSM-3 committee shared a commitment
to efforts to improve the reliability of psychiatric
diagnosis as a goal of value in itself and
also of value in raising the credibility of psychiatry as a profession.
" And once again, the idea is that for psychiatry
to become a branch of medicine, it was
necessary to develop reliable diagnostic criteria,
that is, operationalised diagnostic criteria,
as well as to approach mental symptoms in an
objective way, which means as given objects
presented by patients and ready to be observed
and measured by clinicians with standardised
instruments, that is, with structured
interviews and with rating scales.
So in a nutshell, psychiatry had to objectify
mental symptoms to transform these self-reports
or observed behaviours into these objective mental symptoms.
Well, in psychiatry, reliability and
also validity is a key to objectivity.
And as I've been saying, in order to achieve
it, clinicians must use these standardised
instruments, the structured interviews and
rating scales and the operationalised diagnostic criteria.
Now, defining reliability is not an easy
task, though, and I'll be very brief here.
We can say that broadly speaking, reliability
refers to the degree to which measurement
or diagnostic procedures yield consistent
results across multiple measurements or trials.
The main idea is that reliability has to do with consistency.
OK, diagnosis is consistent, sorry, is
reliable when it is consistent across different
professionals, for example, or different points in time.
Things get much more complicated when it comes
to validity, and I'll be very brief here also.
Broadly speaking, we could say that the fact
that all researchers and clinicians consistently
use the same concept and diagnostic criteria does
not necessarily imply that they are accurate.
Whereas reliability is concerned with
consistency, validity is concerned with accuracy.
So the general idea behind validity is that
it is achieved to the extent that we actually
measure what we intend to measure, or that
we classify what we intend to classify.
And psychiatry has been thought to be objective
insofar as it classifies objective entities,
right, this is the part of validity, mental
symptoms and illnesses that also exist
independently of our epistemic efforts.
But for now, I'll stick only to reliability.
OK, one of the assumptions behind this ideal of
objectivity in psychiatry, and this is an ideal,
I insist, is that there should be no values
involved in observing mental symptoms and
classifying them into mental disorders.
Which, by the way, don't get me wrong, is a good
thing in a sense, that is to avoid that
clinicians impose their own values to patients.
But the problem with that is that it can also
obscure the role that values unavoidably play
in psychiatry and in any other scientific endeavour.
But also, and arguably more importantly,
it is assumed that one must strive to leave interpretations aside.
And note, however, that not only do patients'
interpretations and perspectives have little
place in such a standardised approach,
but neither do those of clinicians.
Regardless of who they belong to, personal
interpretations or elaborations are to be
minimised because they, of course, there's a
problem, they cannot be absolutely eliminated,
but at least minimised because they are deemed subjective.
OK, clinicians' own perspectives and interpretations
have no place in psychiatry because their views
have only value insofar as they conform to
the use of reliable, standardised instruments.
And it is in this sense that I'm saying that
clinicians' views are not really theirs.
Clinicians can be objective observers because
they are trained to use the tools that presumably
enable them to achieve a view from nowhere.
And please note that I'm not supporting this view.
I'm trying to describe what I call this
ideal of objectivity in psychiatry.
And to better understand this, I think that we can turn to the DSM.
As you know, the most popular instrument for
the standardisation of psychiatric diagnosis is undoubtedly the DSM.
The third revision, which was published in
the 80s, was an essential piece in the quest
for objectivity, thanks to the introduction
of operationalised diagnostic criteria.
I'm going to skip this because I think that you get
the idea that this is very important in the DSM.
Okay, so the DSM-3 was widely adopted not
only because its diagnostic categories appear
to be reliable and to some extent also valid
or accurate, but this is more problematic
and I won't go into that, but also because
its operationalisation makes the diagnostic
criteria relatively easy to apply in different settings.
In clinical psychiatry, in education, in
epidemiological studies, in research facilities, and so on.
And often, and this is very important,
these settings are highly time constrained.
Okay, we have professionals, clinicians have
little time to actually assess patients.
And achieving this diagnostic reliability comes
at a cost, because to maximise reliability,
diagnostic criteria encompass only a few
characteristic, easily accessible features of a given disorder.
We have to get rid of the nuances and the
particularities in the construction of standardised knowledge.
And let me illustrate this with an example.
In the previous DSM-3 era, it was quite common
to find mentions of a distorted sense of the
world in both patient narratives and psychiatric accounts of depression.
But such a symptom is nowhere to be
found in the current diagnostic criteria.
And according to Kenneth Kendler, it is easy
to understand why did this not make it into the DSM.
And I quote him, "It is a subtle concept,
time consuming to evaluate and perhaps of limited reliability.
" Moreover, the problem is not just that the
DSM neglects a number of relevant features of patient experience.
In fact, when these features are included in
the diagnostic criteria, significant compromises
must be made for the sake of reliability
and utility in such diverse settings.
For example, with regards to feelings of guilt
and worthlessness, common narratives include
and I'm quoting Kendler again, "hopelessness,
pessimism, self-accusation, self-derogation,
feelings of inadequacy and of being a failure,
and a specific focus on prior moral
shortcomings often of a sexual nature.
" Which is notably broader than the DSM-5 criterion,
feelings of worthlessness of our excessive
or inappropriate guilt.
So, the idea is that for a psychiatric classification
to be reliable and suitable for use in settings
with significant time and other constraints,
it must include criteria that are easy to assess.
Classifying loss of appetite, sleep disturbance,
and diminished engagement in previously
pressurable activities, which are all criteria
for depression, is to some extent a task that
can be performed in an objective manner in
the sense that its assessment is susceptible
to standardization and to quantification
and to statistical manipulation.
Noticing that a patient is eating less, sleeping
less, or for example, partaking less, requires
little interpretation and can be easily quantified.
But on the contrary, assessing a distorted
sense of the world is a much more delicate
task, a time-consuming task more open to interpretation or elaboration.
And this is just an example among many of
the difficulties that arise when it comes
to including complex experiences in a diagnostic
manual which is designed, and you don't
have it in the presentation but I'm quoting
again the DSM-5, a manual which is designed
to facilitate more reliable diagnosis and an
objective assessment of symptom presentation in a variety of settings.
So, the DSM criteria have to strike a precious
balance between including the most characteristic
features of a given mental disorder and the
most easily accessible and reliable criteria.
This regarding clinicians' and patients'
perspectives and interpretations, and encompassing
only a few characteristic easily accessible
features of a given disorder can be said to
be a feature, not a bug of the manual.
It is necessary for generalized knowledge,
which is a good thing also to have.
It has the problems that I'm addressing,
but as I said in the beginning, we need this
kind of knowledge, for example, to systematize
psychiatric knowledge and to conduct clinical
trials and so on, because this is the kind
of approach that allows us for this general
knowledge which allows us to make inferences.
Okay, crucially, none of the things that finally
end up in the DSM are necessarily the most
distressing, the most relevant or the most
concerning aspects of a mental disorder for
patients, and also reports contain information
that simply cannot be captured by standardized
instruments, partly as a result of the compromises
that these instruments must necessarily make.
And ultimately, under this approach, patients
cannot be epistemic agents because determining
which pieces of information are to be valued,
which conceptual or terminological choices
are to be made, how data is interpreted
and so on, lies beyond their scope.
Okay, so my point is that epistemic injustice
in psychiatric practice may arise not from
the deflation of the credibility or from the
disregarding of patient reports, but from
such an objective approach, insofar as it
promotes treating patients merely as an informant
or even worse, as sources of information
rather than as epistemic agents.
Okay, it is worth noting that this idea traces
back to Fricker's distinction between treating
someone as an informant and as a source of information.
Pricker considered treating someone as a mere
source of information as a kind of testimonial
injustice akin to treating them as a passive
object rather than as a subject participating
in an epistemic practice. And a few years
later, this idea was notably elaborated on
by José Medina, who also problematized
treating someone as a mere informant.
And he said, "The epistemic agency of an
informant, who are informant, is limited and
subordinated to that of the inquirers.
Who are informant, the epistemic agency of the
speaker, her capacity to convey information
and act as a giver of knowledge is at the
service of the inquirer's epistemic agency, her
questions, her assessments, and her interpretations.
" There is, of course, nothing wrong in treating
someone as an informant, but that could be
problems of epistemic justice in treating
someone only as an informant, for there is
no full and equal epistemic cooperation where that is the case.
So, following Medina's view, we need not
say that clinician-strict patients are mere
objects of their epistemic inquiry, akin to
Fricker's view of treating someone as a source
of information in order to recognize epistemically unjust practices.
Treating patients not as objects, but as mere
informants is equally problematic as it compromises
their epistemic agency, subordinating it to
the clinician as the inquirer and more broadly
to professionals in psychiatric research.
Of course, the objectification of patients
has already been identified as one of the
factors leading to epistemic injustice, and
also the standardization of patient reports
to fit them into DSM categories is also an
issue that has been explored in the literature
as a potential source of epistemic injustice,
contributing to pre-emptive testimonial injustice,
hermeneutical injustice, and also hermeneutical ignorance.
Okay, so given the high value
placed on objectivity in psychiatry and its
conception in terms of standardization, some
clinicians may actually lack the skills or
the will to properly engage with patients'
particularities, that is, to value those
pieces of information that do not conform
to the standard, which are hence deemed as
subjective, to adopt patients' conceptual
resources and frameworks, and more generally
to treat patients as epistemic agents
seeking, for example, self-understanding.
Some other clinicians no doubt have both the skills and
the will to engage with patients in this way.
However, what I believe needs to be emphasized
here is the structural dimension of this issue.
Beyond the skills or the will of particular
clinicians, there is a fundamental theoretical
conception at play, that of objectivity, on
which psychiatric theory and practice are built.
In its pursuit of generalized knowledge,
this approach often excludes anything that
does not fit the standard. And in my view,
this is a structural factor that promotes
epistemically unjust practices, as it encourages
the adoption of a third-person perspective,
that of a scientist investigating an object
of knowledge rather than viewing patients
as epistemic agents. Okay, what can be done?
If this is a structural issue, the solution
cannot be merely individual. Of course, the
cultivation of epistemically virtuous habits
and practices by clinicians, as well as the
observance of epistemic duties by individual
clinicians, could improve the situation.
Okay, I think this is not the solution, but it can
improve the situation. For example, Rosa Ritunano
proposes the adoption of a critical phenomenological
stance in which patients and clinicians engage,
and I quote her, "in a form of hermeneutical
humility and sincere openness towards alternative
horizons of possibility." I think that
phenomenologists in the room know more than me about this.
Okay, this is Ritunano's proposal
to address localized forms of hermeneutical
marginalization. And also, okay, here, Anna
Drostovits, for her part, has argued that clinicians
have a proton to epistemic duty to attend to and
to solicit reports of patients' first-person
experiences in order to prevent epistemic losses
in healthcare interactions. And as I've said,
this could improve the situation but cannot
be the solution of a structural issue.
And furthermore, and this has been a proposal,
we could include patients and patient advocates
in the revision process of the DSM, okay, and
likewise, this could be an improvement of the
situation, but it doesn't prevent the exercise
of epistemic injustice in clinical practice.
To put it briefly, if the clinical encounter
is limited to checking DSM boxes, and more
generally, if the clinical encounter is limited
to the use of a standardized assessment and
diagnostic instruments, we will still be far from
attending to patient perspectives and engaging in a real dialogue.
Standardized instruments can do better or worse
in accomplishing their theoretical and practical
goals, as well as in promoting more just epistemic
and social practices, but they will always be
insufficient to address each patient as a complex
and unique subject and as an epistemic agent.
If, as the literature argues, treating each
patient as more than an object of inquiry or
as a mere informant is necessary for epistemic
justice, then the inclusion of patient perspectives
in the DSM or in any other standardized instrument
is not sufficient to ensure epistemically just
practices in the clinic. And to be clear,
in making this point, I do not mean to deny
that including patient perspectives can provide
helpful input on the accuracy and the completeness
of diagnostic criteria or that they can make
other contributions, for example, about what
terminology should be used. I'm not denying that.
What I am arguing is that as a standardized
instrument that moreover has to be useful in
very different settings, the DSM has intrinsic
limitations that cannot be surmounted by just having patients involved.
So, what is the solution? I'm sorry to disappoint
you, I don't have one I would like to say yet.
Okay, I have the intuition that what's
necessary is a deep reform of psychiatry,
a theoretical endeavour similar to that carried
out in the 70s that culminated with the DSM-III.
In my view, what is needed is a collective
theoretical effort similar to the one undertaken
decades ago when psychiatry aligned its theory
and practice with the demands of standardized knowledge.
We must articulate the conditions
under which knowledge and understanding of
individual patients can be objective.
So, the role would be to recognize that objectivity is not only
achieved through the objectification of mental
symptoms but also through its very opposite,
a fine-grained detail and accurate account of
patients' particularities, one that seeks coherence
and an understanding of each case's personal and
sociocultural context. This requires sustained
engagement with patients' perspectives so that our
understanding of each case can evolve and expand
over time, resonating with patients and helping
them to make sense of their ailments.
Patients should be able to participate in their own
artist's understanding as epistemic agents,
which also involves that they should be able to
pursue the epistemic goals that they deem valuable.
And furthermore, we should not abandon the
idea that objectivity involves resisting the
imposition of arbitrary narratives or external
values onto patients. However, this should not
be mistaken for a denial of the fact that we
always operate from a particular perspective.
[Moderator]
Okay, we still have like five minutes or... [Moderator]
20 minutes total.
[Moderator] Okay.
[Moderator] Q&A.
[Moderator] Yeah, yeah.
It'll be very, very brief.
In addition to this, or before we do all of
this, I think that it is necessary to clarify
our metaphysical commitments concerning mental
symptoms and more generally, mental states.
And I'm not going to elaborate on this because
I don't have time and because I also hope that
this is precisely the topic that Victor
Fernandez is going to address in his talk.
[Laughter]
No? Are you not going to? I don't know.
Okay, I just want to say a few sketchy
things about this because this is the
part, the work in progress part, okay?
What are we doing now? This is the work that I'm doing with
my colleague Pablo Moreno, as I said before.
This part is not very clear, okay? We are articulating
the idea that what we call the discovery model
should be questioning. What is this discovery model?
The discovery model is what I've been presenting.
The idea that a patient goes to
the clinic and presents some mental symptoms that
the therapist can observe through the use of this
standardized instrument, which allow for an
objective evaluation of those symptoms that
are, so to say, out there. In this sense, it is
that we speak of discovery, observing, describing,
and classifying those symptoms that are out there.
This conception involves what we might call a
classical, realist component, and I say here
classical because I want or we want to actually
defend a realist stance, but not like this
classical stance, okay, in which the task of
psychiatry is conceived as an epistemic task of discovery.
And although we believe that certain
aspects of clinical practice involve discovery,
knowing what is happening to the patient,
there is another complementary dimension,
that of construction or creation, okay?
So what I am experiencing is not something to be merely
observed, rather the clinical setting is also a
space for its construction. One way to address
this could be, for example, as some scholars have
done, to resort to Hacking's looping effect.
You know, to argue that diagnostic categories do not
function merely as a map, but as a script.
And this way, diagnosis can interact with the person
who receives it and modify both their
self-conception and their behavior, and in this
way introducing a creative or constructionist
element in diagnosis itself. But here we don't
want to focus on Hacking, but on Bernard Williams.
And to our knowledge, Williams's ideas have not
been explored within the framework of epistemic
injustice in psychiatry, and particularly we are
interested in this notion of the steadying of the
mind, that we think it is useful for articulating
that construction dimension of the clinic that I
have just mentioned. And it is interesting also
because Miranda Fricker herself turns to
Williams's model of subjectivity in her book on
epistemic injustice to explore the secondary
harms that stem from epistemic exclusion.
Very, very, very quick. In his chapter from
sincerity to authenticity, in truth and
truthfulness, Williams reflects on sincerity,
authenticity, and social identities, and he
presents his own model of subjectivity,
which holds that intentional mental states
have to be steadied, that steadiness is a social
necessity, which is a requirement for social
cooperation, and that the mind can only be
steadied through, and this is the important part,
an intersubjective process by engaging in
communicative and epistemic social practices.
Those of you who are familiar with the
mindshaping framework will see how this has
significant similarities with Williams's
model of subjectivity, but we could say,
I'm trying to see what's the most relevant
idea because I think I have no time. Okay.
I know, I know. Thank you. Okay.
Very briefly, the main idea is that our mental
states are constituted by social practices and
also by the clinical encounter, that is that
there are different epistemic activities that
come to constitute our very minds, and if patients
are excluded or do not fully participate in those
epistemic activities, that might have harmful
consequences for the steadying of the mind and
also for the formation of the social identity.
So, the idea would be to think about the ontology of
our mental states and also our mental symptoms,
to abandon a classical, realistic stance in which
psychiatry is understood as describing an objective
given reality and thinking about how it is
constructing, I would say, mental symptoms,
self-narratives, and also social identities.
And given that this construction is done through
communicative and epistemic practices, the fact
that patients are excluded from these practices
or not participating as epistemic agents is
problematic, not only in those epistemic dimensions,
but also in the formation of the very own minds
and the social identity. That would be the idea.
And that's it. Thank you very much.
Questions here in the room?
Thank you. Actually, I'm sorry that we switched
to English like that. It was scheduled, but
well, so for our guests who are English speaking,
but feel free to talk in any of languages.
I've got a question for you. I enjoyed your talk.
For you and really all this panel on psychiatric topics.
And it comes from my natural ignorance.
The question of DSM. Okay. So, it is something
we're talking about a lot. And I'm wondering,
because I'm hearing when I try to address that
with different people, the answer differs.
So, some of the psychiatrists say, "Oh, no,
we don't use DSM." Really? Yeah, it's there,
but we don't use it. So, is DSM an issue because
it's actually used to diagnose or it's used in
the practice or it's an issue because it's there
and you don't use it because it's not working.
It's not what the psychiatric practice is.
And I know it's not exactly on your topic here, but
since it seems that there are problems with it,
I wonder to ask you, maybe all of you, if there is
something you can say about that. Just curiosity.
Thanks. Thank you for the question.
I've talked about the DSM just as an example of a standardized tool.
I think that the problem is deeper, lies in
the transformation of a narrative of the patient
report into an, so to say, object of standardized
knowledge in the sense that if you, in the first
place, if you based, that's the point.
I'm not saying that psychiatry shouldn't try to objectify
mental symptoms because this is what allows for
inferences, for example, to have statistics and
to be able to manipulate data.
The problem is that this seems to be the very foundation,
at least of the biomedical model of mental disorder.
And if this is all that the practice
has to offer, then we are, I don't know, doomed
to commit epistemic injustices because this way of
approaching, of understanding what mental symptoms
are and what is going on in the psychiatric
interview and in diagnosis, this approach prevents
patients from being epistemic agents and it also
has to disregard a lot of the particularities.
So I know that some psychiatrists actually don't rely
on the DSM and, well, I've left outside of the
talk, for example, the re-indications that are
being done right now, for example, by the new
diversity movement in which they say, no, the
act of diagnosis and the DSM might not be valid,
but it is useful because it allows us to have a
social identity. And I don't want to say that,
I don't know, we must burn the DSM or something like that.
I just want to say that this idea of
objectivity and placing a high value on objectivity
and saying being objective is objectifying mental
symptoms in this way, this is epistemically problematic.
This is the point. And it can be
instantiated in the DSM or in, I don't know,
rating scales or other standardized instruments.
If this is all that psychiatric practice has to
offer, then we probably are not engaging
with mental patients as epistemic agents.
Okay, so it would be a symptom of a certain approach. Thank you.
Well, my comment is almost the same that I
wanted to make about Veronica's presentation.
And I do see that the main problem is the
difference between the lived body and the
experienced body. And that most clinicians, we are
trained to think about the physical body and not the lived body.
And if we, as Veronica said, and
also as you mentioned, we could find a middle
point between those two, or not even a middle
point, a bridge between those two concepts,
I think we would provide much better care.
About the DSM, the thing is that our lived body comes,
our physical body comes from evidence-based medicine.
And we needed evidence-based medicine to get to where we are right now.
And the DSM was very important at some point,
not only when it started, but because of all
the things that it changed. The DSM has changed.
At first, like sexual preferences were considered
a mental health disorder. Now they're not.
Autism, as they were talking yesterday, they were seen as a disorder.
Now we see them as a spectrum.
So, I do think that that objectivity is important.
But what I think was very interesting that you said
was that if psychiatry should be a branch
of medicine, it really made me wonder a lot,
because maybe mental health should not be
treated in the same way as physical health is.
So, that I think is a very interesting question.
Thank you for your comments.
Yeah, well, I've presented this idea that
psychiatry must be a branch of medicine because
it was the motivation that was in the
background, so to say, in the 60s, 70s,
not only to gain credibility, but also to
have this kind of standardized knowledge,
which was important, as you said, and I'm not
trying to deny the necessity that we seem to have
about this, the necessity for this kind of
knowledge, for example, in order to know which
drugs are useful and which ones are not.
Okay, regarding the distinction between the
lived body and the physical body, I'm not a
phenomenologist and I'm not using that distinction.
Well, it resonates with some of the things that
I think, because of course, I think that you are
more prone to, or more inclined to, adopt this view
of mental symptoms and this view of objectivity
if you also have the assumption that mental
disorders are actually brain disorders,
in that sense, because then it is easier to
disregard personal interpretations because
symptoms are just the manifestation of an
underlying reality, which is that brain disorder.
And if you share this commitment, then you
are much more inclined to adopt this approach.
If you think that mental illness or mental
disorder is something else, then you are probably
more inclined to approach it in a different way
and to not try to ratify mental disorders and
to try to actually attend to patients' elaborations,
self-understanding, etc. I think that it is related
to that distinction in a way, although I don't
use that distinction in my work. Thank you.
I have a question myself. So it's about this
idea that the objective approach leads to
treating patients as sources of information rather
than epistemic agents. And I'm very sympathetic
in general to this idea, but I was thinking that
the question here would be why should we, in this
context, treat patients as epistemic agents and
not as sources of information? And I wanted to
ask you about why you think so, because I see two options here.
One would be an instrumentalist,
answer, which is like, well, we need to treat them
as epistemic agents because in order to achieve
whatever it is we are trying to achieve with
psychiatric practice, we can only do that if we
treat them as epistemic agents. I don't know,
because self-understanding requires treating
the other as an epistemic agent or because of the
practical goods that we are supposed to get from
this from psychiatric practice or whatever.
So that would be an instrumentalist option.
But then there could be perhaps an ethical point
of view here so that we are supposed to treat
others always as epistemic agents no matter what. And I wanted to ask you
whether you were thinking about one of these options or something else.
Thank you very much. Well, I see problematic
both treating patients as sources of
information and as mere informants, mere
informants in the sense of a clinician as the
enquirer directing which pieces of information are
to be valued and so on. And yeah, the intuition
that you have is of the both intuitions are the right ones.
And it is also connected with
the previous question. If we think that mental
disorder is something else or not entirely
reducible to brain disorder and that it can
benefit from things like self-understanding,
which is an epistemic endeavor, then it would
be therapeutic to treat patients as epistemic agents.
And it is in this sense also that I think
that we have to address the ontology of mental
symptoms and to clarify what is going on with the
clinical interview and with diagnosis, because I
think that there's an ontological or a metaphysical
difference between physical symptoms and mental symptoms.
And mental symptoms are in a way
constructed or constituted by the categories
and by the very words that we use to describe them.
And this is, as I said, a communicative
and an epistemic practice. And if the ontology of
mental symptoms is like this, then I think that
it follows that patients have to be involved
in a way in their self-constitution or in their
self-construction or something like that.
That would be the idea. And thank you.
Thank you. We have two questions and very few time left.
Well, it's 2020, but...
Cristian and then David.
I would like to hear more about the constructive
part of your paper, maybe this work you've
done with Pablo Moreno, who was the name?
So, because I'm quite sceptical about how to use the
Williams approach to the theory of psychiatry,
because I don't know if I can understand that
you can use this approach to understand what
a mental state is, but I'm not so sure about
the normative aspect. I don't know how to
do... How do you use this Williams approach to
distinguish between when a mental state is
normal or healthy, when the mental state is pathological?
Because this is crucial in psychiatry.
This is the core problem, the
hard problem in the theory of psychiatry, how to
distinguish between the normal and the pathological.
I don't know.
Perfect. Thank you. Well, this is the...
Quick answer to this question.
Eh?
Quick answer.
Quick answer. Ah, it's working.
No, no, no, no. The idea is not to use the
framework and I'm not sure at this point if
Williams's model of subjectivity has to offer
more things than the mind-shaping framework has to offer.
Perhaps I should just stick with the
mind-shaping framework. The idea is to understand
the metaphysics of mental states and to
acknowledge the role that communicative and
social practices have in the constitution of those states.
And then I know that we have the problem of normativity and I don't
have to address it, but I don't have time.
No, no, I mean, but our goal is not to use
Williams's model of subjectivity to distinguish
between normal and pathological thoughts, but
just to articulate not a classical, realist
view of mental states. That would be the point.
Thanks, Virginia, for your talk.
I'm going to ask this in Spanish, but
feel free to answer me in English.
I found the idea and the proposal very
stimulating and to understand it a little better,
I would like to know how you visualize or what
is the vision you have of a therapeutic encounter
between a patient and a psychiatrist after
this new conceptual revolution of psychiatry.
How would that encounter be?
Thank you. Well, since it's the last
question, I think I can answer it in
Spanish, which in any case I like better.
Well, I was hoping that the phenomenologists could give us a clue here,
maybe, or the hermeneutics.
Let's see, the idea would be to understand
objectivity not only in the standard,
in the knowledge that can be generalized, but
also to establish a real dialogue with the patient
and to build a narrative or self-understanding,
probably a self-understanding,
that is rich, detailed, that addresses the context,
and in that sense, to talk about objectivity
in those terms, of resonance with the
patient, of utility when it is also therapeutically actionable.
Well, I guess what I'm proposing in the
last instance, and this is in the paper,
but I haven't said anything, is this distinction
between the hermeneutics and an ideographic approach,
to go to that ideographic approach and from there
think about the objectivity of each particular case,
to understand it in its singularity, and not in what can be generalized.
That would be the idea, but I can't say much more.
Thank you very much, Virginia.
Thank you.
We're almost out of time.