Psychiatric treatments and most forms of psychotherapy (except family systems therapy and marital therapy) have in common that they are focused on the individual. Even very committed opponents of the DSM or the use of psychotropic medication in psychotherapy remain focused on the individual as the unit of attention and treatment. The opposition against the new DSM-5, against the alleged biological etiology of “mental illness” and the resulting medicalization of psychotherapy, and against the abuse of psychotropic medications remains stuck within the same thought paradigm underlying psychiatry and individual psychotherapy.
Psychiatrists focus on the bio-physiological organism of an individual and presume a biological, often also genetic etiology for “mental illnesses”, hypothesize measurable brain dysfunctions, such as chemical imbalances, and rely heavily on psychotropic medications. Psychotherapists focus on the intra-psychic dynamics, conflicts, abnormal behaviors, thought disorders, or cognitive and emotional confusions of an individual and treat the client through the power of one-on-one conversations by providing insight, proposing alternative behaviors, clarifying confusions about moral or practical choices, and bringing hidden strengths to bear on a person’s dilemma.
Profound as these disagreements between the treatment modalities of biologically focused psychiatrists and psychological psychotherapists may be, they are, nevertheless, based on the same thought frame. Both camps remain rooted in the same set of basic assumptions about the etiology, symptoms, diagnoses, and cures of mental disorders and illnesses. Psychiatric or psychological treatment of an individual is supposed to resolve and “cure” problems that are located in the individual. In other words, emotional, psychological, intellectual, or mood-related symptoms and “abnormal” behaviors are rooted in either brain-based biological (often genetically transmitted) disorders or in unresolved intra-psychic conflicts or in cognitive or affective malfunctions of the individual seeking help. Despite profound differences in what is considered effective treatment (use of medication vs. insight-oriented or cognitive-behavioral psychotherapy or therapies based on newer schools), the individual is the focus of treatment in psychiatry and (for the most part) also in psychological therapy.
The core point of this blog post is: Any attempt to establish an alternative diagnostic system to the predominantly biologic DSM-5 classifications or to initiate a transformation of the individually oriented mental health treatment systems needs to critically explore how, not only what, we think about health and healing, about mental and emotional suffering, about traumatic experiences and injustices, and the multiple forms of pain that are part of our human existence. The broad critique of the DSM-5 by so many national and international organizations and individual colleagues will in the end not be powerful and far reaching enough without this inquiry into the foundations of our thinking and without reflection about our ways of thinking – an endeavor called Epistemology that is fundamentally philosophical in nature.
The reflective considerations proposed here are an attempt to lay the groundwork for a radical, 2nd order change in our way of thinking, i.e. a shift in the epistemological paradigm that we use (naively or with all the accouterments of science) when we look in psychiatry and psychotherapy at the human phenomena and experiences that lead people to come to us for help.
The core of these reflections is the proposal to the community of “mental health” professionals to adopt besides the “objective realism paradigm” as alternative epistemological orientation a “relational perspective paradigm”.
The adoption of this second frame of thinking would have the following advantages:
- Two alternative thought paradigms would allow shifting the perspective of the therapist from the individual’s bio-physiological or intra-psychic reality to her or his interpersonal network or social context, and back.
- Each perspective (the “objective realism paradigm” and the “relational perspective paradigm”) would be considered as a valid paradigm, yet as never a source of the entire or objective truth, rather as yielding a “reality edit”, that is accessed by viewing others around us through a particular lens and listening to their stories with a particular mindset. There would not be anymore the assumption that the medical/psychiatric or psychological “diagnosis” would contain the objective truth about a person (even if done according to the rules guiding the profession of the “expert”).
- One decisive difference between the two paradigms is that the “relational perspective paradigm” focuses on all relationships, therefore also on the relationship between the health professional and the “other(s)” seeking help and as such includes the “participant observer” (here the mental health professional) as part of the observed field. Reflections on the continuously changing (circular) interactional process between people labeled “clients” or “patients” and someone called “the doctor” or “expert” are therefore an integral part of the “relational perspective paradigm”.
It is my contention that the efforts to construct an alternative to the DSM-5 and, more importantly, to reform the “mental health” field in general will ultimately fall short and fail without this radical shift in our thought paradigm.
Reflecting on Thinking and Living in Two Worldviews
As denizens of the 21st century, we think (and, therefore, live) within two distinctly different, yet legitimate conceptual thinking designs resulting in two different worldviews at the same time. What distinguishes them are not only the vastly different vistas that open up in our mind depending on which thought frame we are choosing as our point of view, just as we see profoundly diverse landscapes depending whether we stand on top of a mountain or are traveling on a ship in the middle of an ocean. In their methodological reflections on themselves as paradigms these two thought paradigms (epistemologies with a small ‘e’) or “worldviews” also qualify their own status as thinking designs rooted in our mind’s structure in distinctly different ways. The “objective realism paradigm” holds on to the traditional conviction that our individual thinking about the reality outside of us can arrive at the objective truth about that reality (including other people), whereas the “relational perspective paradigm” allows for the individual or social mind to construct “reality edits” that are forever linked to how we think as individuals and interrelated human beings.
The following are philosophical, specifically epistemological reflections. As is common for philosophy, such reflections may raise many questions and may be short on definitive answers. That makes such reflections on how we think about our ways of thinking uncomfortable and productive.
1. The traditional “Objective Realism Paradigm”
The traditional, perhaps in the 21st century somewhat naïve thinking design and the resulting worldview is commonly held by most people prior to any systematic and critical review they may conduct of their own way of thinking. Here are some crucial aspects.
Fundamental to this approach to or conceptualization of our thinking is the (presumed to be objective) dualism between the (thinking) Subject and the (thought about) objects (including other human beings). In this view, the (human) person, i.e. the Subject of cognition and any other interaction with the world of objects, is seen as self-sufficient, as complete, and, as such, as separate from other Subjects and from objects. The cognitive comprehension of another Subject, in inter-subjective relationships, and the cognitive apprehension of (subhuman) objects (such as animals, plants, material world) are viewed as essentially the same process and remain extrinsic to the thinking Subject. The Subject appears like a “Monad” (Leibniz), complete within her/himself, yet with outside relations to other (human) Subjects. Although other people, i.e. other Subjects, are understood in this paradigm as a special class of Objects, the presumption is, nevertheless, that they can be examined, analyzed, measured, researched, i.e. fully apprehended, by the cognitively exploring Subject.
In this view, the only (or the most basic) way a human being can have any kind of knowledge about other people and/or (non-human) objects is through the same active process of cognition that is directed at other Subjects or at (sub-human) objects and that reflects our experience. As information (mediated by our senses) comes back from the examined (human) Subject or (sub-human) object we gain and gradually perfect a true “objective” image in our mind.
This process of cognitively comprehending a (non-human) object or a (human) Subject is in the “objective realism paradigm” the basis for relating to others. Cognition of other human beings by the reasoning Subject is prior to any interaction with them and is, therefore, in a class logically prior to evolving relationships with other people.
One consequence of the “objective realism paradigm” is that there is no more mystery: Potentially at least, given enough time and effort, cognition by the thinking and reasoning Subject directed at another person can fully comprehend, i.e. cognitively conquer that other Subject, thereby transforming the Other into an Object. At least in principle, there is no room left for the ineffable, the mysterious, the incomprehensible in a Subject who is the object of an examination. A “patient”, for example, who is exposed to a scientifically rigorous exploration by an examining, comprehending Subject, i.e. medical “expert”, is reduced in this thought design to being an Object of this exploration and remains external to the examiner’s person who renders an “objective” diagnosis.
Because the cognitive apprehension of other Subjects or (subhuman) objects, i.e. of the world around us, is an activity of the fully constituted Subject, it does not necessarily affect the reasoning Subject or change who the Subject is as a human being. The observing Subject objectively grasps the other objects’ or Subjects’ reality, but stays outside of this process of comprehending i.e. remains “objective”.
Another fundamental assumption of the “objective realism paradigm” is the following: When we look, i.e. in the process of cognitively apprehending objects distinct from ourselves, including other (human) Subjects, we perceive reality as it is; what we see is the real truth (provided, of course, we follow the rules of cognition.). All reality (including all human reality) can be examined, analyzed, manipulated, scientifically researched and fully understood, conquered, as it were. The results of ordinary inquisitiveness as well as of scientific research describe the true reality. So, normally, before our “epistemological” reflection, we assume in our exploration of the world around us that there is a reality outside of us that we can observe and study, that there is a linear connection between cause and effect, between an observed phenomenon and the underlying roots, between the physical universe and the laws holding it together. The same way of thinking we apply in this paradigm to other human beings as individuals and as society.
Here we pause and start with our meta-considerations in the name of our own inner experience (and of human dignity). Human “reality” cannot (and should not) be in the same way an object of scientific research and examination as subhuman entities or objects can be. Although human beings partake in the physical world as embodied beings and are, therefore, as such exposed and vulnerable to the attempts of potential “objectifications” by other Subjects’ inquiring minds, instruments, and explorations, they remain never fully knowable Others, they always also escape the cognitively conquering mind of any apprehending Subject, i.e. as other Subjects they remain mysterious and forever beyond the full reach of the inquisitive mind of the Subject. The other Subjects, therefore, whom we encounter have to reveal themselves. We as Subjects have to learn from them as they are opening up to us.
Of course, this traditional “objective realism paradigm” is prominent and predominant in all scientific human endeavors, including medical research and practice.
While this conceptual design of our thinking is not the only paradigm that influences medical and psychiatric practice, it is nevertheless the dominant paradigm of methodical reflection on our ways of thinking in medicine and, therefore, profoundly influential. Scientific research and the customary medical practice are closely linked. We speak of “evidence-based practice”. Medical practice focuses on the treatment of diseases and disease pathologies, which appear in the domain of the body. Symptoms are diagnosed and their causes explored. Ever more technologically and chemically complex interventions affect the human body and lead, hopefully, to a cure of the disease.
The application of the “objective realism paradigm” in the fields of medicine, psychiatry, and psychology has without question resulted in enormous scientific and technological achievements in modern medicine. But the “objective realism paradigm” also led and leads to an unavoidable, but substantial narrowing of focus on physical disease, physiological pathology and brain dysfunctions and, were it not balanced by another thought paradigm, would end up “objectifying” the person being treated. More recent “holistic” branches of medical practice and ancient Eastern treatment traditions know of these dangers and practice an alternative thought paradigm, whether they are aware of it or not.
There are significant costs connected with the predominance of the “objective realism paradigm” in medicine in general and in psychiatry and psychology in particular:
* Because we are embodied beings, i.e. because of our physical nature, we are exposed to physicians’ objective thinking and focus on the bio-physiological nature of people. The enormous diversity or “otherness” of other people as people is, therefore, mostly overlooked, rarely perceived and even less conceptualized. All human beings appear in this mind frame as essentially the same; their diversity as persons appears superficial and negligible from the point of view of the “objective realism paradigm”. Their personal relationships (including those to the examining expert), especially family relationships, and the enormously complex social networks with which individual people are interconnected are frequently overlooked in the current practice of healthcare.
Instead, unwittingly and paradoxically, perhaps constructed by our mind’s need for workable “units”, the health care system subsumes people into its own groupings that the “researchers” or “experts” often see as real. Superficial differences found in scientific studies can become essential ones. Human history, medical history included, is full of insignificant (head circumferences; skin color; height; hair type; facial patterns) or significant differences (such as the prevalence of certain medical illnesses in certain groups) that were overemphasized and often constructed as “real”, so that they then became defining features for the humanity of another person, group, or nation. Because of the assumption of the essential “sameness” of people (from the viewpoint of the exploring Subject) these superficial differences among the (human) Objects of medical research have been used as evidence to classify people into some who are more and some who are less human! (The exploring Subject, of course, included her/himself into the most human group!) Such thinking lead to the origin of racism and the genocidal mass murder by the Nazis! The “reification” of differences among people invariably led the general healthcare community (and often enough the general society) to blindness for the multi-variant personal diversity of people as people and for social justice issues apparent and visible only when our thinking reflections are guided by a “relational perspective paradigm”.
* Another consequence of the “objective realism paradigm” is the implied relational definition between someone called the professional expert (“doctor”) and someone defined as the “patient” (client or individual in need of professional help). The ownership of knowledge confers “hierarchical” status and power to the expert and involves the danger of undermining the self-determination and human agency of the one who is on the receiving end of the expertise. In this thought paradigm the expert’s diagnosis represents by definition the true reality and, therefore, determines the relationship and becomes an instrument of power and control. The language used and all the other trappings of the “expert” diminish the power of a “client” to be the expert of her/himself and in charge of their own lives.
2. The “Relational Perspective Paradigm”
Underlying every doctor-patient or psychotherapist-client relationship is a process that becomes more visible and accessible to philosophical reflection when we directly focus on it. While often hidden, the relational process manifests itself more clearly when we use as our thinking frame an epistemological paradigm that I call the “relational perspective paradigm”.
Let’s start with our own inner experience. As is also evident from observing a child’s early development, we experience ourselves from the beginning of our existence not as closed or self-sufficient beings, but rather as fundamentally oriented by existential need and desire towards relationships with other human beings. Relational openness and inter-subjective connectedness with others define our existential humanity. In other words, the individual Subject is constituted as such by “inter-subjectivity”, i.e. by the relational process and by our inter-dependence with other (human) Subjects. The existential inter-relatedness between (human) Subjects, i.e. between us as embodied and mindful beings, bridges the (dualistic) distance between Subjects, enables individuality and relatedness, and constitutes our humanity.
Finding ourselves inescapably within a network of relationships with Others, i.e. human Subjects like ourselves, is in the view of the “relational perspective paradigm” in a class logically prior to the process of cognition of Others, i.e. of other Subjects like ourselves. The adoption of this thinking frame is a radical epistemological departure from the Cartesian Dualism of (thinking) Subject and (comprehended) Object. The “relational perspective paradigm” posits that it is first and foremost the human Subject’s relational orientation and openness to others that enables the process of cognition of other Subjects. In this view, connecting and building relationships with other human beings is not an outgrowth of first cognitively comprehending these others – a process that then would lead to a relationship with them. Rather, cognition of other human Subjects is grounded in our relationship with them.
Existing as ‘Beings-in-Relationships-with-Others’ prior to cognition, prior to ‘going-out-into-the-world’ to “objectively” know the world outside of us leads to another insight. Our relational interconnectedness with Others determines what we can see and what we can hear, how the human world and the world of sub-human objects appear to us. How we look and listen (which in turn is dependent on our unique web of relationships) governs our conceptual frame of perceiving (especially human) reality. Together with others we construct through our unique inter-generationally created perspective a “reality edit”, i.e. we see the Others, not as objects, but as who they appear to us according to our relationship with each other. Our mutual relationship determines our cognitive vision of the Others. And we “are” as who we appear to the Others according to the relation to these Others that we have constructed together.
It is not the comprehending Subject who gains knowledge and expertise by studying the Others, it is the Others who have to reveal themselves to us (and we to them) in order for us to start the relational process of mutual recognition and understanding.
The “relational perspective paradigm” with its priority of relationship over cognition is (or should be) prevalent in all (non-exploitative) personal and “therapeutic” relationships. It is powerfully present in doctor – patient relationships, whether explicit or implicit. In any medical or psychiatric context the energy rooted in the doctor – patient relationship is indispensable for understanding and healing.
In the psychotherapeutic context the emerging powerful relationship between therapist and client is explicitly examined and studied. And, as numerous studies have shown, it is the very quality of the doctor – client relationship, not the particular theoretical model the therapist may “apply” to arrive at her/his “diagnosis” and treatment model, that constitutes the most essential ingredient of the healing process. I call this “(relational) practice based evidence”.
Diversity defines our very humanity. What makes us all essentially members of the “same” class “human beings” is our, is every single individual’s, unique “otherness” to each other according to so many essential, contextual, and relationship dependent perspectives and narratives, such as social class; race, ethnicity, culture; gender identity; sexual identity and orientation; age; religion; health; ability; the sum of personal experiences in relationships and social networks, family legacies etc. It is relational interdependence according to these and many other perspective and narrative categories that creates unique people in unique relationships. These relationships enable cognitive processes that are characterized by surprise and new relational discoveries, by interruption during traumatic events, and by the infinite richness of human relational life.
Once we conceive of medical treatment, psychiatric interview or clinical psychotherapy as encounters between two or (in the case of family therapy) more people who are others for each other, any professional hierarchies so common between experts and clients invariably are faced with the process of deconstruction. The helping professional forfeits expert status and power and becomes herself/himself vulnerable to the Other. The professional needs to be taught by the Other, the patient or client. The expertise of the Others seeking assistance is privileged and meets with curiosity by the examining and treating professional. In face-to-face conversations and in a collaborative spirit they not only explore bio-physiological facts or intra-psychic processes, but also construct together hypotheses guiding treatment, exploring the meaning of health and illness or, broader even, discover together all that has happened to the Other(s).
Thinking, Living and Practicing in Two Worldviews
The presented philosophical reflections are intended to contribute to a deepening of the process of not only constructing alternatives to the new DSM 5, but of transforming the psychiatric and psychotherapeutic health system. I hope that it is also evident from these reflections that the “relational perspective paradigm” can highlight how much human suffering, nonconforming behavior and existential pain is profoundly related to traumatic injustices inflicted upon individuals and families by unjust societal structures surrounding them.