Epistemic Humility in Psychiatry: Why We Need More Montaigne and Less Savonarola

COMMENTARY

“Que sais-je?” (What do I know?)—Michel de Montaigne¹

The old joke goes like this. A man dies and goes to Heaven, where he sees an impressive looking gentleman with a long, flowing white beard and a white robe, walking around wearing a stethoscope. The newly arrived man looks puzzled and asks a nearby angel, “Who is the guy with the stethoscope?” “Oh,” the angel replies, “That’s just God, playing doctor.”

Good jokes need no explanation, but we take this one as a sly commentary on the immense power, hubris and self-ascribed godliness of physicians. Too often, in the history of medicine, these traits have worked to the detriment of our patients, who feel put down or patronized by their physicians. But there is also what we would call an intramural dynamic among physicians, ie, within the walls of the storied House of Medicine. This is sometimes manifest as a kind of epistemic hubris (Greek epistēmē ‘knowledge’) aimed at the positions or practices of other physicians. It can be summarized simply as the claim, “I know better than you, because I am in possession of certain knowledge.” The corollary sentiment is something like, “You deserve to be chastised and your ideas vilified!”

This is what we call “the spirit of Savonarola” referring to the censorious, Italian friar Girolamo Savonarola, who presided over the infamous bonfire of the vanities, in Florence in which the treasured art, writings, and other luxuries were publicly burned.² In sharp contrast, we have the figure of the French philosopher Michel de Montaigne (1533-1592), best known for his intimately personal essays and deep-seated religious tolerance. Montaigne’s motto was, “Que-sais je?”—literally, “What do I know?” The famously self-deprecating Montaigne believed “Nothing is so firmly believed as what we least know."¹

In our view, the House of Medicine is pervaded too much by the spirit of Savonarola, and too little by that of Montaigne. And, yes, this includes that section of the house known as Psychiatry. We are not going to name names here, but we suspect many readers know a few colleagues who seem to view themselves as possessing absolutely certain knowledge, and who heap contempt upon their allegedly benighted colleagues. (And, yes: During our combined 70 years in the profession, we, too, have channeled the ghost of the arrogant friar on more than one occasion.) Ironically, Savonarola and his own writings were themselves put to the torch before an angry crowd of Florentines—surely a cautionary note for dogmatists in any age.

Our Own In-House Critics

Psychiatry, of course, has its perennial host of external critics, including many “service users”—those we call patients—who believe they have been grievously harmed by psychiatric treatment. We do not doubt that some have been so harmed, even as we maintain that psychiatry has been, overall, a force for great good in the house of medicine. But our concern here is with those internal critics of psychiatry who claim certainty in a field where little is certain and who castigate colleagues who beg to differ with them.

Let us hasten to add that we are not in any way suggesting that constructive criticism of psychiatry from within the profession is wrong, or comparing those who voice such critiques to Savonarola! Quite the contrary: Our profession needs constructive criticism, such as found in numerous interviews conducted by our colleague Awais Aftab, MD. Rather, we are calling attention to certain claims from within psychiatry that, in our view, are voiced with an air of unwarranted certainty.

Many of these claims are proffered under the ambiguous rubric of “critical psychiatry”— ostensibly a different creature than “antipsychiatry.” But as one of us (GD) has documented, there is often little difference between the 2.³

The Uncertainty Principle in Medicine and Psychiatry

All medical knowledge is provisional and subject to change, as further information and research become available. As our colleague, Nassir Ghaemi, MD, has observed, “Scientific truth, after all, is nothing but corrected error.”⁴ Moreover, in all medical disciplines, there are areas of controversy and uncertainty.

Uncertainty in a field provides a general check against unilateral proclamations and orients the field toward epistemic humility. In medicine, it is not uncommon to see sweeping claims that an entire research program is invalid, or that some treatment is a miracle, when hundreds of scientists are still working on the active problem and completing necessary research. Some of these claims rise to the level of extraordinary,⁵ in that they are contradicted by a massive amount of evidence yet are reported in the lay press as definitive. We witnessed this recently when an umbrella review with numerous design flaws and incomplete data confidently dismissed the entire serotonin hypothesis of depression.⁶ Such unwarranted certainty ignores the fact that the accumulation of evidence in medicine and psychiatry tends to be slow, incremental, and probabilistic.

Consider something as basic as the definition of disease. We exaggerate only slightly in suggesting that there may be almost as many definitions as there are physicians. Never mind the multitude of equally ambiguous terms, such as illness, malady, affliction, etc. (The DSM term disorder is especially nebulous.) But don’t take our word for it. Here is what the American Medical Association’s Council on Science and Public Health had to say, when asked to provide an advisory opinion on whether obesity is a disease:⁷

Without a single, clear, authoritative, and widely accepted definition of disease, it is difficult to determine conclusively whether or not obesity is a medical disease state.

This being the case, dogmatic claims regarding which psychiatric conditions are or are not legitimate or bona fide diseases should be taken with a very large grain of salt. Furthermore, even the line between health and disease is often hard to discern, and sometimes varies with one’s cultural norms.⁸

What Does Scientific Mean, Anyway?

Claims that some psychiatric diagnoses lack scientific credibility should also be taken with a grain of salt. Although we would argue that several major psychiatric categories (eg, schizophrenia, bipolar disorder/manic depressive illness, autism, and obsessive compulsive disorder) are as scientifically based as most conditions in internal medicine or neurology,⁴ we are keenly aware of the complexities surrounding the term scientific. This derives from the longstanding controversy in the philosophy of science regarding the demarcation of science from non-science. Indeed, “most philosophers believe that it is impossible to formulate criteria that demarcate science and nonscience.”⁹

It is not that the term scientific is meaningless, but it is surely complex and contested. Indeed, it took Britain’s Science Council a full year to come up with this brief definition of “science”:¹⁰

Science is the pursuit and application of knowledge and understanding of the natural and social world following a systematic methodology based on evidence.

The Science Council identified 7 key features of scientific methodology (Table). Now, we can have reasonable disagreements about which, if any, psychiatric diagnostic categories have developed through the fulfillment of all 7 methodological criteria. Indeed, we could easily have similar debates about controversial medical conditions like myalgic encephalomyelitis (also known as chronic fatigue syndrome) and long COVID. But we should be skeptical of sweeping claims that a psychiatric diagnosis is not scientifically valid, unless the claimant has carefully examined the supporting evidence with respect to each of the 7 components of the scientific method.

Importantly, even some staunch critics of the DSMs acknowledge that “many clinical pictures [in psychiatry] may be scientifically valid, and yet not represent disease processes.”⁴

In our view, the term scientific is not an inherent, unitary property, but a multifaceted process, representing one end of a methodological continuum. Accordingly, scientifically valid represents merely the far end of the continuum. For example, a particular DSM category, such as schizophrenia, might reflect a process that fulfilled all 7 of the Science Council’s methodological components. Other diagnoses with a less substantial research base might meet only 4 or 5 of the criteria. In short, the terms scientific and scientific validity are locations on a continuum. They should not be construed as parts of a binary distinction and contrasted with unscientific and scientifically invalid.

Is the DSM-5 Scientific?

We often hear psychiatry’s critics confidently claim that the DSM-5 is unscientific in toto; or that it is merely a collection of symptom checklists. The foregoing analysis tells us that the first claim is, at best, a broad-brush generalization. Yes, the conceptual and clinical shortcomings of the DSM-5 are by now well-known¹¹ and will not be rehearsed in this piece. Nevertheless, the use of scientific methods, such as determining antecedent and concurrent validators for diagnostic categories, was inarguably part of the DSM-5 process.¹² Of course, following scientific methodology does not guarantee that one has produced correct results or conclusions. Just ask Galileo. For all his scientific genius, he mistakenly believed that the planets moved in circular orbits. It took Kepler’s improved scientific methods to show that planetary orbits are elliptical.

The second claim—that the DSM-5 is merely a collection of symptom check lists—is demonstrably false.^13-15 This misleading notion is largely due to an erroneous understanding of the DSM-5 and how to use it, ie, by ignoring its clearly stated requirement that no diagnosis is complete without a biopsychosocial case formulation of the patient’s condition.

Conclusion

The American pianist Oscar Levant once quipped, “What the world needs is more geniuses with humility; there are so few of us left.”¹⁶ Indeed, humility is hard to come by these days, and we would suggest that this is particularly true among a subgroup of psychiatry’s internal critics—although we believe the problem is widespread in the medical world. Although many of psychiatry’s critics may act with good intentions, some seem bent on casting psychiatry in the harshest possible light, sometimes passing judgment on their colleagues with casual disdain.

And yet, our response should not be to dismiss these critics out of hand. We should consider their critiques in an open-minded manner, while resisting the temptation to meet arrogance with arrogance. Finally, like the rest of the medical field, psychiatry needs to acknowledge its own limitations with suitable epistemic humility.

A good beginning is to recall Montaigne’s humble and penetrating question, and to ask: What do we know?

Dr Pies is Professor Emeritus of Psychiatry and Lecturer on Bioethics and Humanities, SUNY Upstate Medical University; Clinical Professor of Psychiatry, Tufts University School of Medicine; and Editor in Chief Emeritus of Psychiatric Times (2007-2010). Dr Pies is the author of several books. A collection of his works can be found on Amazon. Dr Dawson is recently retired from clinical practice and is a freelance writer and researcher on psychiatric topics. He writes the Real Psychiatry Blog.

References

1. Gaylor AL. Michel de Montaigne. Freedom From Religion Foundation. Accessed October 10, 2023. https://ffrf.org/ftod-cr/item/14235-michel-de-montaigne1

2. Cavendish R. Execution of Girolamo Savonarola. History Today. May 5, 1988. Accessed October 10, 2023. https://www.historytoday.com/archive/months-past/execution-girolamo-savonarola

3. Dawson G. An effort to distance critical psychiatry from antipsychiatry. Real Psychiatry. March 2, 2019. Accessed October 10, 2023. https://real-psychiatry.blogspot.com/2019/03/an-effort-to-distance-critical.html

4. Ghaemi SN. Taking disease seriously in DSM. World Psychiatry. 2013;12(3):210-212.

5. Deming D. Do Extraordinary Claims Require Extraordinary Evidence? Philosophia (Ramat Gan). 2016;44(4):1319-1331.

6. Pies RW, Dawson G: The Serotonin Fixation: Much Ado About Nothing New. Psychiatric Times. Aug. 3, 2022. Accessed October 10, 2023. https://www.psychiatrictimes.com/view/the-serotonin-fixation-much-ado-about-nothing-new

7. American Medical Association. Is obesity a disease? Report of the Council on Science and Public Health. Accessed May 5, 2022. https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/public/about-ama/councils/Council%20Reports/council-on-science-public-health/a13csaph3.pdf

8. Norbury CF, Sparks A. Difference or disorder? Cultural issues in understanding neurodevelopmental disorders. Dev Psychol. 2013 Jan;49(1):45-58.

9. Eflin JT, Glennan S, Reisch G. The nature of science: A perspective from the philosophy of science. Journal of Research in Science Teaching. 1999)., 36:107-116. https://digitalcommons.butler.edu/cgi/viewcontent.cgi?article=1296&context=facsch_papers

10. Our definition of science. Science Council. Accessed October 10, 2023. https://sciencecouncil.org/about-science/our-definition-of-science

11. Ghaemi SN. After the failure of DSM: clinical research on psychiatric diagnosis. World Psychiatry. 2018;17(3):301-302.

12. Dawson G: The first 25 pages. Real Psychiatry. April 26, 2021. Accessed October 10, 2023. https://real-psychiatry.blogspot.com/2021/04/the-first-25-pages.html

13. Pies RW. Poor DSM-5: So Misunderstood! Psychiatric Times. March 23, 2021. Accessed October 10, 2023. https://www.psychiatrictimes.com/view/poor-dsm5-so-misunderstood

14. Ruffalo ML, Pies RW. Why psychiatric diagnosis matters. Psychology Today, Aug. 10, 2019. https://www.psychologytoday.com/intl/blog/freud-fluoxetine/201908/why-psychiatric-diagnosis-matters

15. American Psychiatric Association. Diagnostic and Statistical Manual. 5th ed. 2013.

16. The Diagram Group. Little Giant Encyclopedia: Toasts & Quotes Encyclopedia. Sterling Innovation; 2009.