Philosophy and History of Mental Medicine

IHPST/CERMES3-CESAMES Seminar (20010)

(Project “Philosophy, History and Sociology of Mental Medicine”)

Philosophical and Epistemological Issues in Psychotherapy

Pierre-Henri Castel (contact : pierre-henri.castel@parisdescartes.fr)

Session 1 : Introductory remarks

A/ Goals of the seminar: selecting, editing (and translating) major papers in the philosophy and/or epistemology of psychotherapy, providing people working in the field with a Sourcebook.

A few obvious targets: epistemological papers on the evaluation of psychotherapies (quantitative methods, classical problems, like the “dodo effect”), papers on the placebo effect in RCT trials, the place of psychotherapy within psychiatric theories, psychotherapy in the scientific image...

Less obvious: problems of moral philosophy (like freedom vs. determinism, or values), conceptual issues about the mind, causal action on the mind, reasons and emotions in interaction, or, about rationality, morality, and the links of psychotherapy with anthropology or political science...

Putting the emphasis on CBTs? Almost impossible to discard the debate with psychoanalysis.

B/ Where do we start from? A brief summary of last year seminar (from “the mind only knows the mind” to “the mind only can cure the mind”).

• The ineliminability of the moral problem (autonomy is a standard requirement in contemporary psychotherapy).
• The very project of naturalizing intentionality remains obscure when psychotherapy is taken into account (but new issues are being raised with the idea of neuropsychotherapy)
• Psychotherapy is heavily dependent upon historical and sociological contexts.

C/ Toward a more integrative perspective? But first: what is “psychotherapy”, what counts as “psychotherapy”?

Remark on “psychotherapy” in Fulford, Thornton & Graham (2006).

Why is it that current conceptions of the major philosophical problems in psychiatry almost never deal with psychotherapy as such?

• Prevailing issues: logical justification, empirical accountability. Sound psychotherapy is regarded as the technical application of some explicit underlying theory (is it the case with psychoanalysis?). Only the theory should be considered.
• Techniques are a noteworthy object for the philosopher of science. Practices are to be dealt with by the anthropologist. (The Wittgensteinian view is the minority view: “forms of life” as the key issue in philosophical anthropology, beyond rules and regularities).
• Conceptual analysis and putting arguments to test: but which ones? Psychotherapeutic theories are poor (“psychobabble”!).
• The thick description issue (Ryle, Gerdt): “what do we do when...” vs. the epistemology of causal claims in medicine.
• A “second-person” perspective in the philosophy of mind (reasons count as reasons), not a causal “third-person” account of mental conditions. Psychiatry as a moral science, not as a natural science.
• Psychotherapy looks hard to naturalize. Need a fresh look at social emotions, non-reducible intentionality and other mental states, intersubjectivity, meaning, etc. The evolutionary challenge.
• Psychotherapy blurrs the line of the normal and the pathological, or leaves to much room for the (self-) interpretation of the (already quite rare non-elusive) facts.
• Psychotherapies and psychopathologies are often co-defined. Clinics and therapeutics may merge in such a way that there is little room for any rational critique.
• By and large, a challenge to Popperian epistemology: a verificationist dead-end (the allegiance effect is crucial, along with the therapist contribution to alliance, the client rated alliance remains the best predictor of outcome). Back to suggestion and hypnosis?
• Does psychotherapy even exist? Psychotherapic effects appear to exist, but are they connected to any method at all? What about random life events? How do you trace back such an effect to its cause? Could everyday life and the passing of time be therapeutic by itself? Other sources of psychotherapeutic effects: religion, magic, love, friendship, etc.
• The Bruce Wampold paradox: the non-specific effects of specific psychotherapies. They all work but we do not know why[1]. The trivialization of “psychotherapy”: just (informal) care, not cure. But a number of stunning facts: best psychotherapists get better outcome with placebo that worst therapists with imipramine...

Problems with these preconceptions: at odds with the history of psychiatry and psychotherapy; they frame the object into mainstream epistemology and philosophy of mind (e.g. bypassing the reasons, and focusing on the causes of objective behaviour).

Some problems more or less addressed in contemporary thought and relevant to the psychotherapy debate: are delusions wrong beliefs? the paradoxes of irrationality (Davidson) and the addiction problem; the normative approach to agency (Frankfurt) and the responsibility of mentally ill offenders. Some others which fell out of sight long ago: unreason beyond insanity; Evil and perversion; the intrinsic relativity of madness...

The ultimate questions: how much can you be insane and still have a mind? (From “partial madness” to the very possibility of “moral treatment” in Rush and Pinel), and how can there be a (deterministic) “science of psychotherapy” if people are (free) “autonomous” in a way or another, or are to made so? (Edward Erwin).

D/ How to proceed from medical epistemology to moral philosophy/philosophy of mind? A few guidelines.

1. First path: from evaluating psychotherapy within all the other medical therapies to situating it within the general psychiatric scheme.

One method fits all? The input/output model. (Was it designed just for BTs and CBTs?). Or: one psychotherapy/one specific form of evaluation?

The requirement of “epistemological parsimony” vs. practical-empirical constraints (developmental issues with children, group or family therapy, shared and non-shared values, etc.)

Bolton & Hill (2003), chapter 8: a quasi-deductive account of “intentionality in disorder” leading to a list of possible psychotherapies. How to ease the historical/professional constraints on what counts as a bona fide psychotherapy?

2. Second path: the value issue.

Key concepts in psychotherapy are normative or evaluative concepts (“good”). Is there anything in between biological and moral conceptions of “being well”, or “bad”?

Problems with the hierarchy of values (logical and deontological) in psychotherapy.

Fixing the mind/behaviour, or helping people?

Agency and autonomy: their logical content/their anthropological import. Political stakes in psychotherapy.

3. Other paths?

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[1] Effect size for Tx v. no Tx: d = .80. Over 80% of treated patients better than those with no treatment; 13% of variability in outcomes, NNT = 3 (Aspirin as a prophylaxis for heart attacks, NNT =129!). Superior to almost all interventions in cardiology, geriatric medicine, asthma, flu vaccine, cataract surgery.