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 : firstname.lastname@example.org)
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”).
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?
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?
 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.