Psychiatry and Anthropology, In Search of “Science”
Psychiatry and Anthropology, In Search of “Science”
Have you been following the recent dust-up in the anthropology world? It all started, as Nicholas Wade wrote, “…after a decision by the American Anthropological Association at its recent annual meeting to strip the word “science” from a statement of its long-range plan.”1 Commenting on this radical move, Peter Peregrine, president of the Society for Anthropological Sciences,
“…attributed what he viewed as an attack on science to two influences within anthropology. One is that of so-called critical anthropologists, who see anthropology as an arm of colonialism and therefore something that should be done away with. The other is the postmodernist critique of the authority of science.”1
There are interesting parallels between the post-modern critique leveled against anthropology, and a similar argument—associated with Michel Foucault--directed against psychiatry, as Dr Nassir Ghaemi, Sarah Thommai, and I have argued recently.2 But right now, I’m interested in the other side of the double-edged sword often wielded against psychiatry: not the objections arising from the post-modern tradition, but those arising from logical positivism. This was an extreme form of empiricism associated with a group of philosophers known as the “Vienna Circle”—a very high-brow kaffee klatsch that met regularly near the University of Vienna. The Circle included luminaries like Moritz Schlick, Rudolf Carnap, Kurt Godel, and Otto Neurath, and did much to promote logical positivism in the early 1920s. (The philosopher Ludwig Wittgenstein sometimes sat in, but never fully embraced the Circle’s views--preferring, some say, to read poetry during their meetings!).
Essentially, logical positivism (LP) rejected the “meaningfulness” of any claim that was not based either on a priori logical necessity (“All bachelors are unmarried males”) or direct observation. So, the claim “This rock weighs 0.5 kg” is a meaningful statement to logical positivists. Other kinds of claims, such as “The Mona Lisa is a beautiful painting,” or “Stealing is morally wrong,” were dismissed as meaningless expressions of emotion. This positivistic view of meaning has infiltrated and colored our modern concept of “science” to a profound degree—notwithstanding the devastating critique of LP from the American philosopher W.V.O. Quine (1908-2000).3
Sixty years after Quine’s broadside, many in the medical field, in my experience, still take a positivist view of what constitutes “real science.” This has left psychiatry open to the charge of not being “scientific”—much as some have said of anthropology. But should all “science” be equated with logical positivism, and held to the rules and paradigms of, say, physical chemistry or molecular biology? And, if we adopt a broader construct of “science,” can we maintain that psychiatry is, in fact, very much a science—though it is also far more than that?
A letter in the 12/14 New York Times put all these issues in the spotlight. Tom Boellstorff, Editor in Chief of American Anthropologist, took the position that “…anthropology helps broaden the definition of science itself.” He argued that “…Science takes place not just in laboratories but in field sites…” as one would find in many anthropological studies. So far, so good—I’m with Prof. Boellstorff on that point, and would add, “Science can also take place in the psychiatrist’s office!” But the professor goes on to make another claim—perhaps without realizing just how provocative it is. Science, he claims, “…involves not just experiments but forms of non-replicable observation…” Of course, Boellstorff is correct if he means that no two sets of observations are precisely the same: it is impossible to recreate exactly the same conditions of the universe at time T2 as at time T1. And, it is widely accepted in the philosophy of science that changing the observer inherently changes the nature of the observation. So up to this point, I have no quarrel with Prof. Boellstorff’s statement. However, if he wants to claim that non-replicable observation is an acceptable and intrinsic design element of science, I would respectfully disagree—particularly as regards the science of psychiatry.
To be sure: it is difficult, if not impossible, to produce an “essential definition” of either science or the “scientific method”4,5 Nevertheless, Okasha has listed “some of the main features of scientific enquiry” as including induction, experimental testing, observation, theory construction, [and] inference to the best explanation.5 I believe psychiatry partakes of all these elements of science. However, in so far as “observation” is a feature of science, I believe it must entail replicable observation. This follows from science’s aim to be objective (more on this anon). The philosopher Amartya Sen described two essential features of objectivity: observation dependence and impersonality.6 “Objectivity demands taking observations seriously,” Sen argued.6 The second term, impersonality, implies that in order for an observation to be objective, the observer's conclusions should be more or less reproducible by other observers, within the natural limits of human perception. If I write in my mental status exam that “Mr. A. shows marked loosening of associations”, I implicitly assert that most English-speaking clinicians are likely to concur with my assessment, assuming that Mr. A’s linguistic productions remain relatively constant. The same goes for my notation that “Mr. A. shows markedly flattened affect.”
Now—notice that neither notation (loose associations, flat affect) is a straightforward observation in the sense that logical positivists probably intended that term: I am not weighing a rock on a scale, after all. I am implicitly invoking a whole range of mediating and linking hypotheses--such as, “A tightly-associated train of thought does not contain three or more unrelated ideas within three contiguous sentences”—and reaching a clinical judgment. Inevitably, a measure of subjectivity inheres in all such judgments—including those in general medicine; for example, “This liver cell has borderline atypical morphology.” Nonetheless, my mental status exam is both “scientific” and “objective” according to the general criteria I have set forth.
All this goes down the drain, however, if I allow that my observations are “just mine”—that they are, to use Prof. Boellstorff’s term, “non-replicable.” Indeed, one would be inclined to ask, “Why bother writing them down, if all your notations are non-replicable?” Our entire therapeutic approach to the patient assumes that our observations are largely replicable, both within the circumference of our own observations—eg, from session to session—and within the perceptual field of another competent clinician. (Of course, the patient’s mental status may vary according to mood polarity, course of illness, and many other factors). Without such a general expectation of “replicability”, it would make no sense asking another psychiatrist to care for our patients, when we are away!
I have argued previously that psychiatry is a human science; specifically, a science of meaning.4,7,8 This is not the same as a “physical science”, like, say, mineralogy or bacteriology—but it is a science nevertheless. However, contrary to the implication I read in Prof. Boellstorff’s letter, we cannot maintain our scientific bona fides unless we assume that our clinical observations can be replicated, to a large extent, by other clinicians. Finally, I want to be clear that psychiatry is also more than mere science: it is also an intense human encounter that defies formula or theorem. The patient cannot be merely an “It” to be “observed.” We must meet the patient empathically, in what Martin Buber called the “I-Thou” relationship. Therein lies the art—and the heart—of what we do as psychiatrists.
1. Wade N.Anthropology a Science? Statement Deepens a Rift. New York Times, Dec. 9, 2010. Accessed at: http://www.nytimes.com/2010/12/10/science/10anthropology.html?_r=1
2.Pies R, Ghaemi SN, Thommai S. Getting it from both sides: Foundational and Antifoundational Critiques of Psychiatry. Psychiatric Times (in press)
3. Quine, W.V.O. (1951), "Two Dogmas of Empiricism," The Philosophical Review 60: 20-43. Reprinted in his 1953 From a Logical Point of View. Harvard University Press.
4. Pies R. Psychiatry Remains a Science, Whether or Not You Like DSM5 . Psychiatric Times. February 25, 2010.
5. Okasha S. Philosophy of Science. A Very Short Introduction. Oxford University Press, 2002, p. 125.
6. Sen A. Objectivity and position. [September 28, 2007]. Accessed at: www.globalhealth.harvard.edu/hcpds/wpweb/90_01.pdf. 7. Ghaemi SN. The Concepts of Psychiatry, Baltimore, Johns Hopkins University Press, 2003, pp. 90-93. 8. Wiggins OP, Schwartz MA. Is there a science of meaning? Integrative Psychiatry 1991;7:48-53.