Abstract
Work at the intersection of philosophy and psychiatry has an extensive and influential history, and has received increased attention recently, with the emergence of professional associations and a growing literature. In this paper, we review key advances in work on philosophy and psychiatry, and their related clinical implications. First, in understanding and categorizing mental disorder, both naturalist and normativist considerations are now viewed as important – psychiatric constructs necessitate a consideration of both facts and values. At a conceptual level, this integrative view encourages moving away from strict scientism to soft naturalism, while in clinical practice this facilitates both evidence‐based and values‐based mental health care. Second, in considering the nature of psychiatric science, there is now increasing emphasis on a pluralist approach, including ontological, explanatory and value pluralism. Conceptually, a pluralist approach acknowledges the multi‐level causal interactions that give rise to psychopathology, while clinically it emphasizes the importance of a broad range of “difference‐makers”, as well as a consideration of “lived experience” in both research and practice. Third, in considering a range of questions about the brain‐mind, and how both somatic and psychic factors contribute to the development and maintenance of mental disorders, conceptual and empirical work on embodied cognition provides an increasingly valuable approach. Viewing the brain‐mind as embodied, embedded and enactive offers a conceptual approach to the mind‐body problem that facilitates the clinical integration of advances in both cognitive‐affective neuroscience and phenomenological psychopathology.
Keywords: Philosophy of psychiatry, naturalism, normativism, scientism, reductionism, values‐based care, pluralism, mind‐body problem, embodied cognition, enactivism
Work at the intersection of philosophy and medicine makes an important contribution by considering key metaphysical issues (e.g., what is the nature of disease?), epistemological questions (e.g., how do we determine the validity of diagnostic concepts?), and ethical matters (e.g., how does disease impact personhood?). Analogous questions arise at the intersection of philosophy and psychiatry. Since ancient times, implicit and explicit responses have had a crucial influence on clinical practice. In the West, for example, Aristotle's reply to these questions involved a notion of the “golden mean”, while in the East an approach emphasizing concepts of yin and yang was developed – these frameworks were employed to understand disease and deviant behavior, and have influenced clinicians since 1 , 2 .
Advances in science after the Enlightenment raised new conceptual questions about medicine and psychiatry. K. Jaspers is a particularly seminal figure in the history of philosophy of psychiatry; he not only wrote a key textbook of clinical psychiatry (General Psychopathology), but also advanced ideas about how best to conceptualize and research mental disorders 3 . His approach has had an enduring and substantial influence on clinical concepts and practice 4 . In recent decades, these questions have received increasing attention, with the emergence of professional societies and conferences, as well as journals, textbooks, and book series specifically devoted to philosophy and psychiatry 5 , 6 , 7 , 8 , 9 .
An influential literature has emphasized the various competences that health care professionals should acquire 10 . More recently, the notion of “conceptual competence” has been proposed. In health care, conceptual competence refers to “the transformative awareness of the ways by which background conceptual assumptions held by clinicians, patients, and society influence and shape aspects of clinical care” 7 . These assumptions relate to a range of issues, including concepts of disease, professional values, causal explanations, and the mind‐body problem. Here we aim to bring attention to and emphasize the importance of conceptual competence for psychiatry.
In the health care sciences, there has been growing attention to evidence‐based approaches, and state‐of‐the‐art reviews are expected to synthesize the literature in a rigorous way 11 . In philosophy, there is an ongoing debate not only about the parameters of good philosophy, but also about whether the field actually makes progress over time 12 , 13 . In this paper, we focus on three areas at the intersection of psychiatry and philosophy, exemplifying a broad range of conceptual debates in the field, which suggest that some progress has indeed occurred – if not in resolving all conceptual issues, at least in articulating them clearly – and which have particular relevance for clinicians.
We begin by considering responses to the key question of the nature and boundaries of psychopathology, an issue that has long been at the core of philosophy of psychiatry. We then move on to consider questions about the nature of psychiatric constructs and explanations in general, and about how best to think about the brain‐mind relationship in particular. In outlining the advances that have been made, and their clinical implications, we argue that there has been a growing and useful emphasis in the field on soft naturalism, on explanatory pluralism, and on embodied cognition, concepts that we will explore in more detail.
THE NATURE OF “DISORDER” AND THE INTERPLAY OF FACTS AND VALUES
In the latter part of the 20th century, a group of thinkers, often referred to as neo‐Kraepelinians, saw themselves as ending the dominance of psychoanalysis, countering the antipsychiatrists’ critique, and re‐orienting psychiatry into the mainstream medical tradition 14 . In doing so, they looked back to late 19th century European psychiatry, which became aligned with the rest of medicine when E. Kraepelin proposed an influential classification of mental diseases based on rigorous clinical description and natural history. Likewise, the neo‐Kraepelinians claimed that precisely defined diagnostic criteria could be used to discover the specific biological causes of psychiatric syndromes and establish psychiatry as a branch of medicine 15 , 16 .
Although the ideas of R. Spitzer, the architect of the DSM‐III, differed in some respects from those of the neo‐Kraepelinians, this approach helped to undergird the development of that diagnostic manual 17 , 18 . Furthermore, advances in psychopharmacology in the 1960s helped support a view that psychiatric disorders are discrete entities with specific pathophysiologies, and so respond differentially to medications. Indeed, D. Klein, a psychopharmacologist whose work influenced the development of the DSM‐III, put forward the notion of “pharmacological dissection”. He held that not only did mental disorders respond selectively to particular medications, but so did specific disorder subtypes. For instance, atypical depression responded preferentially to monoamine oxidase inhibitors 19 , 20 .
In the 21st century, however, the relationship between the DSM and biological psychiatry has shifted, with biologically‐oriented psychiatrists emerging as prominent critics of the manual. T. Insel, during his tenure as director of the US National Institute of Mental Health (NIMH), exemplified this shift. He emphasized that psychiatric disorders are brain circuit disorders, and that descriptive diagnoses based on symptoms rather than laboratory tests are not in alignment with the rest of medicine 21 . He also argued that, because the DSM categories are not biologically‐based, the use of these categories in research interferes with rather than promoting the discovery of causal mechanisms of psychopathology. Hence Insel supported, in place of the Research Diagnostic Criteria (RDC) that were key to the development of the DSM 22 , the development of a set of Research Domain Criteria (RDoC) by the NIMH 23 , and foregrounded translational neuroscience as a foundation for psychiatry 21 .
Indeed, it might seem that, over the course of its history, psychiatry has lurched from one model to another, in which entirely different concepts of mental disorder prevail. In the US, it is notable that psychoanalytic thought held sway for many decades, before giving way to a more neurobiological perspective 24 . There has also been considerable debate about the nature and classification of mental disorders, as perhaps most notably exemplified and spurred by the decision to exclude homosexuality as a disorder from the DSM 25 , 26 . In philosophy of science, T.S. Kuhn's notion of scientific paradigms has been enormously influential 27 , and in psychiatry many have proposed paradigm shifts for the field 28 .
The clash between different psychiatric models has brought conceptual conundrums to the fore. The notion put forward by both neo‐Kraepelinians and translational neuroscientists that mental disorders are brain disorders, for example, raises a series of inter‐related and perennial philosophical issues, including the validity of diagnostic concepts, the relationship between different explanations of mental illness, and the mind‐body problem 29 , 30 . Each of these conceptual issues has important clinical and research implications, as exemplified in vociferous debates between proponents of biologically‐oriented psychiatry vs. psychoanalysis, between those who emphasize intrinsic causes vs. social determinants of mental illness, or between supporters and critics of RDoC. Addressing these conceptual issues seems increasingly urgent, given the growing recognition of the burden of mental disorders, and the ongoing need for better interventions.
In this section we focus on the nature of mental disorders, providing a foundation from which to consider other key conceptual debates as the paper proceeds. The nature of mental disorders in turn raises a series of subsidiary questions, each of which will be addressed here: What justifies the position that a particular biological or behavioral state is a disorder? Do psychiatric classifications reflect natural features of psychopathology, or do they reflect our clinical and societal interests? Are mental disorders best considered as universal entities that are similar across individuals, or as shaped in particular ways that are unique for each person? What are the implications of psychiatric diagnosis for personal agency?
Disorder status: naturalism and normativism
In a straightforward binary version of this debate, naturalism and normativism are opposite and diametrically opposed views (see Table 1). The phrase “the disorder wars” comes to mind 31 .
Table 1.
Questions in the naturalist‐normativist debate, and possible alternative responses
| Are there biological and behavioral states that can be characterized as dysfunctional or malfunctional in objective terms independent of human interests? |
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| Is there an essence that is shared by all dysfunctions? |
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| Is “dysfunction” necessary for disorder status? |
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| What are the relevant human interests? |
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On one end lies strong naturalism, i.e. the view that the concept of “disorder” can be described in completely factual and value‐free terms and can best be studied using methodologies continuous with those used in natural sciences such as chemistry and genetics. Many biological psychiatrists of the late 20th century held this view to the extent that they accepted that psychiatric disorders are caused by neurobiological dysfunction and understood abnormal psychology to be the result of objectively deviant brain functioning 15 , 16 .
In the philosophy of medicine, the notion of disorder as objective deviation from a state of health is most notably expressed by C. Boorse. For him, health is a state of normal biological functioning, and functions are normal if they make a causal contribution to survival or reproduction that is typical for the species 32 . Boorse has been remarkably persistent in maintaining this view; twenty years after his original papers, he published a lengthy rebuttal to his critics 33 , and nearly two decades later, at a symposium on his work, he again countered his critics 34 . Indeed, it has been suggested that, after Boorse, philosophers of medicine must either work within his theory or explain why not 35 .
On the other end of the divide, strong normativism holds that there is no natural, objectively describable set of biological processes that we can characterize as “dysfunctional”, and hence disorder attributions are thoroughly value‐laden. Normativists differ, however, on the presumed nature of these value judgments.
For K.W.M. Fulford, disorder is inherently normative because it is grounded in the “illness experience”, the patient's direct experience of something having gone wrong, which is dependent upon social or folk‐psychological intuitions of what is abnormal 36 . For Fulford, the value‐ladenness of the illness experience not only unites medicine and psychiatry, but also humanizes both fields.
T. Szasz, renowned for his critique of psychiatry, provides an entirely different view. For him, disorder judgments in psychiatry are judgments of deviance based on sociocultural norms, with no evidence of the presence of a biological disease. His view of valid disorders arises from a strong naturalist view of physical disease together with a strong normativist view of mental illness. Diseases ought to be described in terms of objective pathological changes, and, as the states we call “mental disorders” are value‐laden and without evidence of such alterations, their characterization as disorders or illnesses is a category error, a myth. For Szasz, value‐ladenness becomes a reason to question the medical legitimacy of psychiatry.
It is crucial to appreciate, however, that those who view disorder concepts as inherently value‐laden do not necessarily deny the biological reality of the afflictions. Naturalists and normativists may agree on the physiological and behavioral facts at hand and yet may disagree on whether the state in question is healthy or disordered 37 . As the philosopher R. Cooper has illustrated using a weeds and daisy metaphor, we can all agree on what a daisy is as a species, but disagree on its status as a weed 38 . Similarly, researchers can agree on the biological mechanisms of premenstrual dysphoric disorder, but disagree on its status as a mental disorder 39 , 40 .
For naturalists, medicine is at its theoretical core a scientific discipline like other natural sciences and subject to a similar sort of interplay of natural facts and human interests 33 . For normativists, disorder concepts are not fundamentally scientific but rather are clinical and practical concepts. They are grounded in the experiences of distress, disability and disruption, which are interpreted to indicate that something has gone wrong and which lead patients to seek professional help for their problems. From a normativist perspective, medicine is at its core a practical activity aimed at reducing human suffering and enhancing well‐being 36 , 41 , 42 .
The naturalist‐normativist debate acquires a particular valence in psychiatry in part because of the way value‐ladenness has been wielded by antipsychiatry figures, such as Szasz, to challenge the notion of mental illness. New critical movements have gone even beyond this approach, by exploring how social and cultural values impact views of the normal and the pathological. Neurodiversity studies, for example, argue that cognitive profiles such as autism may be socially disabling, but are not intrinsically pathological 43 , 44 . Mad studies similarly resist the pathologizing of diversity and emphasize social factors as a cause of distress 45 , 46 .
Binary positions have the advantage of being straightforward. However, one disadvantage is that, when they are understood in opposition to each other, their differences are often accentuated, such that each position may be defined by what the other rejects. Further, an important development in philosophy of science has been an appreciation of the role that values play in science and a recognition that the notion of value‐free science is not only untenable but also undesirable 47 . For example, values influence which scientific problems are prioritized, how they are studied, how uncertainty is managed, how much evidence is considered sufficient, and how scientific evidence is used to inform practical decision‐making. The incorporation of values and human interests into a broader notion of scientific objectivity has enriched our understanding of natural sciences.
Strong naturalism runs the risk of scientism, i.e. over‐reliance on what is currently perceived as factual 48 , 49 , while strong normativism runs the risk of a relativism where any socioculturally disvalued condition could potentially be considered a disorder. In philosophy, a position that has been termed “soft naturalism” attempts to avoid both scientism and relativism, and to acknowledge the importance of both facts and values in science 50 . Analogously, in philosophy of psychiatry, a number of different proposals have been put forward on how best to incorporate both naturalist and normative considerations in conceptualizing mental disorders 51 .
A particularly influential integrative position, J. Wakefield's harmful dysfunction analysis, is a hybrid view that combines naturalism and normativism in roughly equal measures 52 , 53 . One component of disorder, “dysfunction”, is defined in value‐free, evolutionary terms. Dysfunction refers to the failure of biological or psychological mechanisms to perform the function which they were naturally selected to perform during evolution. The second component of disorder is that the dysfunction is harmful to the individual. Harmfulness is normative and, in Wakefield's view, largely determined by social standards. Wakefield has applied his harmful dysfunction analysis to a broad range of psychiatric disorders and, like Boorse, has engaged widely with critics over several decades 54 .
According to Wakefield, for instance, developing depression in reaction to a stressor such as loss is an evolutionarily designed adaptive response to adversity and not a dysfunction. The DSM, therefore, makes an error by classifying such depressive reactions as disorders. It is only when depression occurs out of the blue, or does not resolve once the stressor is no longer active, or is accompanied by some specific features (such as suicidal ideation, psychosis, or psychomotor retardation), that it becomes reasonable for us to assume that mechanisms designed to regulate sadness in response to loss and adversity have failed 55 , 56 .
One recent alternative to Wakefield's analysis is a hybrid account offered by J. Tsou. He defines mental disorders as biological kinds (value‐free component) with harmful effects (normative component) and, by doing so, bypasses speculation about what normal psychological functions are products of natural selection 57 . Instead, drawing on the work of R. Boyd on clusters of properties in nature 58 , he argues that valid biological kinds are those that exhibit characteristic regularities due to stable sets of interacting biological mechanisms, which allows us to make inferences and predictions about diagnostic categories. We can do this because the properties that define scientifically valid kinds are produced by similar sets of causal mechanisms.
For Tsou, schizophrenia is a disorder because it entails shared causal mechanisms that result in an identifiable cluster of properties with predictable regularities (i.e., it is a biological kind) and because it compromises the capacity of a person to function adequately as judged by sociocultural standards (i.e., it is harmful). However, Tsou would also include as disorders normal psychological reactions to stress, such as acute depression, which are characterized by biological mechanisms that fall in the normal range of function. Thus, the naturalistic standard of being a biological kind is broad enough to accommodate the range of conditions that mental health professionals treat.
Additional ways of bridging the naturalist‐normativism divide have been proposed 59 , 60 , 61 , 62 , 63 , 64 . Gagné‐Julien, for example, argues that judgments about dysfunction are value‐laden but, provided that appropriate procedures are in place, they can be socially objective 64 . Nielsen and Ward argue that the key norm violation for disorders is a breakdown in the norms that support an individual's functioning within his/her social context 62 . They attempt to “naturalize normativity” by noting that, in the psychiatric domain, disorders entail cognitions and behaviors that run counter to an individual's self‐maintenance and adaptation needs; disorder status is therefore based on the needs of the individual, rather than on societal norms.
Strong naturalism can be tempered by acknowledging that values and human interests play important roles in clinical and scientific contexts. Many would agree that the concept of disorder invokes value‐laden notions such as disability, harm and suffering 65 , 66 , 67 . Authors such as L. Reznek, D. Murphy and R. Cooper consider disorders to be natural processes that are held together in virtue of human interests, akin to categories such as “weed” or “vermin” 38 , 68 , 69 . Such weaker forms of naturalist concepts of disorder may be seen as exemplars of a soft naturalism that emphasizes the complexity and fuzziness of the world, as well as the need to address both the mechanisms underlying disease and the experience of illness 70 .
A view of science as influenced by values can also provide nuance to strong normativism. This can be tempered by appreciating that disorder characterizations often require negotiation between competing values, and arguing that the values which influence our definition of mental illness can be discussed and critiqued to reach a consensus on the type of values that are desirable in psychiatry (e.g., values concerning human flourishing, well‐being, harm reduction, vs. oppressive values such as racism and sexism) 71 , 72 . Notably, Spitzer was open to articulating the values underpinning DSM‐III 73 . Further, several authors have advocated for consultative decision‐making processes that would include patients’ voices on the question “What is a mental disorder?”, in order to ensure that patients’ interests are represented in psychiatric concepts and classifications 39 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 .
Strong normativism can also be tempered by acknowledging that broad scientific agreement can be achieved on the co‐occurrence and co‐variation of signs and symptoms that characterize the psychiatric conditions regarded as disorders. For example, whether or not people have the symptoms of anorexia nervosa can be seen as an empirical matter, and the decline in functioning associated with these difficulties can be recognized by all observers regardless of the value‐laden nature of the standards by which functioning may be judged to be impaired. Furthermore, scientific agreement can also be reached on the involvement of particular neurobiological processes in specific psychiatric conditions 82 , even though these processes may not be characterized as “dysfunctional” on neuroscientific grounds alone 63 .
Pragmatic considerations have assumed an increasingly prominent role in the conceptualization of mental disorders. Pragmatic accounts, however, tend to focus on clinical and scientific goals rather than sociocultural norms and values. For instance, in articulating the notion of a practical kind, P. Zachar argues that the development of disorder concepts in the DSM and the ICD can be seen as an attempt to calibrate concepts to multiple goals such as enhancing reliability, supporting etiopathological validity, facilitating communication, guiding treatment, minimizing stigmatization, and promoting research 83 .
The bridging of the naturalist‐normativist divide provides key lessons for clinicians. In particular, such bridging offers an important foundation for complementing evidence‐based care with value‐based care. Evidence‐based care is largely focused on a synthesis of the medical literature, while values‐based health care reminds us of the importance of assessing and addressing patients’ values. Values‐based care is consistent with a model of patient‐centered practice, where the values of individual patients are central to evidence‐based clinical decision‐making. Fulford's model emphasizes that values‐based health care is skills‐based, with the most important skills being awareness (of values), reasoning and knowledge (about values), and communication skills 84 . Each of these skills draws on philosophical sources, but also exemplifies good psychiatric practice.
Psychiatric classification: tackling essentialism
Once we have implicitly or explicitly identified a class of mental disorders, a set of psychopathological states, or a community of psychiatric conditions/mental health problems, we can further ask: How do we map the territory of psychopathology? How do we distinguish between conditions within the class of mental disorders? How do we demarcate disorder from normality?
Philosophy of psychiatry has been helpful in clarifying the metaphysical and methodological assumptions that guide the search for answers to these questions. One common metaphysical assumption in psychiatric classification has been essentialism. This is the notion that categories have essences, identity‐determining properties that all members have in common and that distinguish them from members of other categories. Kinds with essences have been called natural kinds, meaning that they reflect the structure of the natural world. In the context of psychopathology, an essentialist view implies that psychiatric disease entities are discovered through scientific inquiry, similar to the identification of infectious disease entities in medicine, and thus a valid psychiatric classification “carves nature at its joints”, as Plato put it 85 , 86 .
Philosophy of biology and of psychology have recently focused on how causal processes and mechanisms undergird observed phenomena 87 , 88 , 89 . When these processes and mechanisms are well understood, professionals are often able to use them as the basis for classification. This is the case for infectious diseases, in which classification based on identification of the causative pathogen is possible. However, when the processes and mechanisms of an illness are particularly complex, dimensional or multifactorial, knowledge of etiology by itself does not necessarily offer an optimal classification, and we rely on additional considerations – on what we want the classification to accomplish – to draw boundaries and set thresholds. This applies to many areas of medicine, but is an issue that is more pervasive and pronounced in psychiatry 90 , 91 .
From a somewhat simplified metaphysical perspective, we may think of a classification as demarcating natural kinds, practical kinds, or social kinds. If psychiatric classifications such as the DSM and the ICD were demarcating natural kinds, we would expect each diagnosis to correspond to an entity that exists in the structure of the world, independent of human interests 85 , 86 . E. Kraepelin, for instance, believed in the existence of natural disease entities in psychiatry, and in addition held the view that pathological anatomy, etiology, and clinical symptomatology including course of illness, would all coincide in the case of such entities 92 .
The assumption that there are natural disease entities in psychiatry was also adopted by the neo‐Kraepelinians, and implicitly guided the development of the DSM‐III 93 , 94 . Furthermore, the Kraepelinian notion of convergence of validators was also accepted by Robins and Guze 95 , who assumed that their proposed validators of clinical description, laboratory findings, course of illness, and family studies would all point towards the same disease entities. This set the agenda for a research program for the next several decades in which researchers sought to validate the DSM diagnostic constructs.
By the 1990s, however, there was growing recognition that different validators might not inevitably align to offer a single privileged classification, in a way that amounts to a psychiatric version of the periodic table of elements 96 . Rather, different validators suggest alternative mappings of the space of psychopathology 97 . For example, in the study of schizophrenia, shared family history suggests a broad mapping (schizophrenia spectrum), whereas poor outcome indicates a narrower mapping (schizophrenia). In such a scenario, empirical facts alone do not determine which validators we ought to use. Our choice of validators depends also on our assumptions and goals, which may differ from practitioner to practitioner and from context to context.
In contrast to the natural kind view is the skeptical view that the categories of psychiatric classifications are social kinds, almost entirely constructed by social processes (i.e., strong social constructionism). This view appeals to many critics of psychiatry, who point towards the obvious influence of sociocultural factors on the presentation of psychiatric conditions, and the inability of psychiatric research to identify diagnostically valid biomarkers. The social kind perspective is further supported by examples such as “hysteria” and “multiple personality disorder”, whose popularity among clinicians at various points in history has resembled the rise and fall of fashions. There is also increasing awareness that psychopathological phenomena are subject to “looping effects”, such that the very act of classification modifies the behavior of the individual classified, further supporting the social constructionist view 98 .
However, this view in its strong articulation seems untenable, as it fails to take into account that scientific research has discovered relationships between neurobiological processes and psychiatric symptom clusters, albeit these relationships do not necessarily correspond to specific DSM or ICD categories. For instance, psychiatric research has identified hundreds of genetic variations that are associated with a range of psychiatric disorders, so that genetic influences on psychopathology often cut across DSM diagnostic boundaries 99 , 100 . The relationship between genetic variants and psychopathology is therefore complex and transdiagnostic, but not absent or chaotic 101 .
The notion of practical kinds offers a different contrast to the essentialist perspective on natural kinds, and aligns with the soft naturalist view that psychiatric science is both a scientific and social process. There may be no “natural joints” in psychopathology, but there are scientific facts in the form of symptom patterns and co‐variation that constrain any scientific attempts at nosology 102 . Within these constraints, the boundaries that we draw will often reflect our pragmatic goals, and diagnostic thresholds will be influenced by both facts and values. Practical kinds are useful heuristic constructs that categorize the neurophysiological and psychological space in ways that serve our scientific and clinical goals. The pragmatic nature of psychiatric classification is also supported by considering the history of psychiatric nosology, which shows the contingent nature of our contemporary diagnostic constructs, and how our classifications would have looked quite different had certain key historical figures in psychiatry not existed or had they made different choices 103 , 104 .
Distancing ourselves from essentialist assumptions about natural kinds in psychopathology allows us to appreciate the complexity of mental disorders, and makes it possible for us to map and model psychiatric phenomena using different approaches. For example, idiographic approaches focus on the uniqueness of the individual psychiatric patient – how his/her mental health problems arise from a specific combination of predisposing factors, developmental history, life experiences, behavioral adaptations, and psychological defense mechanisms. Such an approach utilizes broad principles of psychobiological functioning to formulate a narrative specific to a patient. The aim of classification, then, is to aid the development of a clinical formulation.
The failure to identify etiologically‐based disease categories has also spurred psychometric efforts to model psychopathology. Psychometric analysis goes beyond manifest variables, which can be directly measured or observed, to mathematically model latent or hidden variables, which cannot be observed directly and only emerge through statistical analysis. This quantitative statistics research program is exemplified by the Hierarchical Taxonomy of Psychopathology (HiTOP) consortium 105 . This attempts to combine signs and symptoms of psychopathology into homogeneous traits, to assemble such traits into empirically‐derived syndromes, and then to group these syndromes into spectra (e.g., “internalizing” and “externalizing”) 106 .
The psychometric approach of HiTOP has generated considerable debate 107 , 108 , 109 . First, in clinical practice there do seem to be some discrete entities, which respond to specific treatments; narcolepsy, for example, can be diagnosed using an accurate biomarker, and can be effectively managed using particular medications. Second, dimensions and categories are not necessarily mutually exclusive; for example, on the dimension of extraversion, a particular cut‐point can be used to define an extrovert 110 , 111 . Third, of particular relevance to positions that emphasize the importance of causal mechanisms for classification, psychometric approaches emphasize descriptive features and may elide underlying etiology 61 .
Another strand of philosophical inquiry has focused on the use of operational definitions employed by the DSM. In an effort to improve inter‐rater reliability and to facilitate psychiatric research, the DSM from its third edition on has offered operationalized criteria for each disorder that specify details such as a list of (relatively specific) symptoms, number of symptoms that must be present, and the duration for which they must be present. How should the relationship between the criteria and the disorder be conceptualized? Lack of clarity in this regard leads to another form of confusion, in which operational criteria are thought to constitute the disorder itself.
Operational definitions are partial definitions that do not specify all the details of the phenomena being studied 112 . They have an element of vagueness that becomes evident when new scientific questions force us to articulate concepts with greater precision. The DSM excluded non‐specific symptoms (such as anxiety in depression) from operational criteria, but these symptoms as still part of the syndrome being described (e.g., depression). Moreover, the polythetic nature of DSM criteria allows for many different symptom configurations to meet disorder threshold, but these different symptom configurations are not seen to constitute different disorders. Instead, they are better understood as different ways in which we can identify a disorder.
K.S. Kendler has elaborated on the distinction between diagnostic criteria as indexical and constitutive 113 . When diagnostic criteria are regarded as indexical, they are understood to be fallible ways to identify a disorder; when they are regarded as constitutive, the symptom criteria are the disorder. According to Kendler, the DSM criteria are intended to be indexical, and viewing them as constitutive is a conceptual error. Thus, for example, there are 227 ways to meet DSM criteria for major depression, but these are different ways of indexing major depression, not 227 types of major depression 114 . There is no single and privileged correct operationalization; rather, different operational definitions can be refined and optimized for different purposes.
Taken together, an emerging contemporary view of psychiatric taxonomy incorporates the dimensionality of psychopathology (there are few discrete entities), insights from complex dynamic systems (relatively stable symptom patterns can emerge from irreducible interactions between multiple factors), and perspectives from embodied cognition (causal mechanisms traverse the brain, body and environment). Such a view of psychopathology does not render categorical diagnostic systems such as the DSM and the ICD invalid or useless, but it encourages us to give up an essentialist bias that has led us to reify them – to attribute them a correspondence to objective reality that they do not possess 115 , 116 .
How is this view of taxonomy relevant to clinical practice? Clinicians need to be aware of the work that has gone into, and the value of our nosology, while also being mindful of its tentative nature and significant limitations 117 . In particular, although the DSM has clinical utility, it has often been criticized for facilitating a checkbox approach to psychiatric assessment and evaluation. Clinicians ought to be aware that important features of mental disorders may well have been described in the psychiatric literature, and yet may not be listed in the DSM 118 . Further, while diagnosis may begin with the DSM or the ICD, a comprehensive evaluation needs to assess a range of domains, including clinical subtypes, symptom severity and staging, cognitive schemas, environmental stressors, and protective factors 119 . Finally, clinical formulations need to supplement our growing knowledge of the characteristics of psychiatric disorders with an idiographic understanding of each individual patient 120 .
Psychiatric diagnosis and personal agency
Debates concerning psychiatric taxonomy may have important implications for individual self‐conception and self‐understanding 121 . As noted, the DSM criteria should not be taken literally as being fully constitutive of disorders, but they are nevertheless often taken as such, and the influence of the DSM on how mental disorders are perceived has been profound. Concern has been raised about the undue extent of this influence, especially given the inevitable neglect of person‐ and context‐specific factors in diagnostic criteria 121 .
More broadly, debates about the nature and classification of disorders are also implicated in the effort of patients to understand the boundaries of their selves in relation to their disorders. Given that both psychiatric conditions and psychiatric medications can affect deep aspects of self‐experience (such as perceptions, desires and feelings), ambiguity and uncertainty can arise with regard to where the “self” begins and ends, and how the self is impacted (or compromised) by both illness and treatment 122 , 123 . The experience of ambiguity at the phenomenological level can be further compounded when patients are “confronted with the vagueness and uncertainty associated with the issue of ‘what is a psychiatric disorder’” 123 .
Questions concerning the interplay of agency and mental disorders have also been central to debates concerning the relevance of these disorders to assessments of moral responsibility. While psychopathology has often been treated as paradigmatically exempting or mitigating in the literature on moral responsibility, there has been a growing shift to more nuanced assessments and an increasing emphasis on the need for case‐by‐case evaluation 124 . These trends reflect the larger recognition of person‐specific and situation‐specific factors that affect the manifestation of psychopathology in any particular individual. In many cases, the relevant agential capacities are diminished or deeply compromised, but nevertheless present. In addiction, for example, it is often implausible to speak of blanket incapacitation, given that aspects of choice and deliberation are often involved. A useful body of philosophical work has explored the question of responsibility in the context of mental disorder 125 , 126 , 127 .
More broadly, the question arises of how different ways of conceptualizing psychiatric disorders influence our attitudes towards affected individuals. While it was presumed that more biological conceptions of disorders would reduce stigmatizing attitudes in general, empirical research points to far more complex interactions 128 . These findings align with theoretical concerns regarding the interpersonal and social costs of perceived diminished agency, which, while sometimes decreasing perceived responsibility, might simultaneously increase other forms of aversion. Indeed, empirical research has suggested that in some contexts biological conceptions may ultimately be more stigmatizing for affected individuals 129 .
The awareness of the impact of psychiatric diagnoses on the self‐conception and self‐understanding of those diagnosed has supported the view that people with lived experience might usefully contribute to the development of psychiatric classifications. They may be better situated to assess the impact of changing diagnostic criteria on access to care or the potential risk of stigma associated with certain nomenclature issues, or be better able to identify mismatch between diagnostic criteria and subjective experiences 39 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 .
The clinical implications of different conceptual approaches to personal agency and moral responsibility have been debated by philosophers, and this area deserves further attention and research 125 , 126 .
PLURALISM IN PSYCHIATRY
In philosophy of science, Kuhn's notions of dominant scientific paradigms that are incommensurable, and of revolutionary shifts in such paradigms 27 , have become very influential. Arguably psychiatry provides a useful exemplar of how different paradigms dominate over the course of time. In fact, critics of psychiatry have argued that the replacement of one psychiatric paradigm by another may entail neither scientific progress nor clinical advancement 130 , 131 .
At the same time, Kuhn has been criticized for his relativism 132 . After all, scientific models can be reasonably compared, and there may be justifiable grounds for replacing one model with another. In psychiatry, although there have certainly been important shifts in theoretical frameworks, it might also be argued that current clinical research and practice incorporate valid aspects of both psychodynamic and neurobiological approaches, as well as concepts and data from a range of other models of psychopathology. Different models may be able to engage usefully, as evidenced by the emergence of neuro‐psychoanalysis, or by work on how psychotherapy impacts on neuroimaging. Psychiatry has arguably advanced precisely by incremental integration of a range of valid models 28 .
Psychopathology seems to involve multiple causes, and it is possible that different psychiatric models shed light on different causes. Philosophers, starting from Aristotle, have long emphasized the importance of multi‐causality in both biology and pathology 1 , 133 . Behavioral scientists have similarly emphasized the need to explicate different kinds of causes of behavior and psychopathology 134 , 135 . Jaspers, a philosopher‐psychiatrist well known for distinguishing between knowledge of causal explanations and understanding of meaningful connections 3 , can be regarded as a methodological pluralist, with his pluralism influencing a range of subsequent authors in philosophy of psychiatry 136 .
In contemporary philosophy of science, there is an ongoing debate about whether and how diverse explanations can be integrated 137 . In the 1970s, G. Engel, an American internist who had experience working with psychosomatic disorders, argued that the dominant model of disease was biomedical, thus neglecting the psychological and social dimensions of illness 138 . He therefore proposed a biopsychosocial model, aiming for a framework that could be used in research, teaching and clinical care. Clearly, it is important that we avoid both a brainless psychiatry and a mindless psychiatry 139 , steering clear of both scientism and culturalism (which are overly reductionist about science and culture respectively) 49 , 140 .
However, the biopsychosocial model has also received stinging criticism for being overly eclectic and non‐specific 141 , and for offering no particular framework to conceptualize multi‐level causal interactions 142 or allow optimal selection of causal mechanisms 143 . Further, its practical use in psychiatric formulation has led to an inadvertent reification of “biological”, “psychological” and “social” as distinct ontological domains 144 . Ongoing efforts to understand the nature of causal explanations in science in general 145 , 146 , and in psychiatry in particular 147 , 148 , remain therefore crucial.
An explicit emphasis on pluralism is a relatively recent development in philosophy of science 149 . Unsurprisingly, for philosophers who regard it as important, there is not a single unified approach to pluralism. Instead, from the time of Aristotle, through the work of early American pragmatists 150 , 151 , and on to contemporary philosophers 152 , 153 , a number of different pluralisms have been delineated and developed. We next consider three important notions of pluralism – ontological pluralism, explanatory pluralism, and value pluralism – as well as some of their clinical implications.
Different notions of pluralism
The first notion to consider is ontological pluralism. As noted earlier, the notion of natural kinds reflects the possibility that nature can be carved up in an objective way to form discrete entities 85 , 154 . Exemplars of such natural kinds are often found in physics or chemistry; the periodic table of elements is a particularly compelling one. Ontological pluralists have, however, argued that there are different ways of dividing reality, reflecting different scientific interests and values, and that a range of different classifications may be valid. From the time of Aristotle, pluralists have often looked to biology. Species can certainly be divided on the basis of their evolutionary history, but there are also alternative ways of classifying organisms 155 , 156 .
Our earlier discussion emphasized that mental disorders are not simply natural kinds that emerge from empirical investigation. At the same time, our constructs of mental disorders are not merely conventional. Instead, they are rigorously informed by scientific research, including work on a range of different validators, which reflect the involvement of a range of different underlying structures and mechanisms. They may be regarded as “soft natural kinds”; although they cannot simply be discovered by carving nature at its joints, and although our classifications and descriptions are value‐laden, these entities nevertheless incorporate an accumulating scientific appreciation of psychobiological structures, processes and mechanisms 157 .
The notion of “soft natural kinds” may be useful in the clinic in a number of ways. Consider the construct of “behavioral addiction”. From a neo‐Kraepelinian perspective, the lumping of substance use disorders together with gaming and gambling disorders suggests that these conditions have overlapping phenotypic features, and share key validators, such as clinical course. In fact, however, the situation may be much “fuzzier”: the psychobiology of alcohol dependence is likely to differ significantly from that of gambling disorder, given that alcohol has direct toxic effects on the brain. However, a key rationale for lumping these conditions may instead be a public health perspective 158 .
Consider also the boundaries between disorder and normality 159 . Current versions of the DSM and the ICD appropriately emphasize that the boundary between disorder and normality is not hard and fast, but rather can be fuzzy and indeterminate. In some other areas of medicine, biomarkers can be helpful in making the clinical decision as to whether a disorder should be diagnosed, but this is not the case in psychiatry. Critics of psychiatry may conclude that mental disorders are entirely a matter of convention, and that psychiatric diagnosis is merely a matter of “labelling”. However, this ignores the complex reality of mental signs and symptoms: psychiatric phenotypes are not elements in a periodic table but rather are comprised of overlapping dimensions, and thresholds for disorder reflect a range of considerations 160 .
The second notion to consider is explanatory pluralism. Philosophers have emphasized that science employs multiple partial models. Indeed, the model or metaphor of maps may be useful in describing such pluralism; a cartographer may employ multiple different maps of the world, each accounting for different features of reality, and each of which is useful for a particular purpose. As noted earlier, in philosophy of psychiatry there is ongoing debate about the extent to which the biopsychosocial model, which encourages a focus on different dimensions of disease and illness, is merely eclectic, or provides the appropriate scaffolding for considering a range of causal mechanisms.
A major area of debate in philosophy of science regards reductive explanations. It has long been argued that the phenomena of the world can be organized along different levels, ranging from the physical through the biological and on to the social. A reductionist approach aspires to explain higher level theories (e.g., biological models) in terms of lower level accounts (e.g., physical models). Certainly, as science has progressed, such inter‐theoretic reduction seems to have occurred; thus we can account for the properties of DNA (which plays such a key role in biology) in terms of its particular structure (that is, in terms of its underlying physico‐chemical properties) 161 , 162 .
Pluralists have emphasized, however, that such successes are only part of the story of science. Science is often concerned with phenomena that emerge only at higher levels of organization: these require models that cannot simply be reduced to lower level accounts 163 , 164 , 165 . Furthermore, as emphasized in the metaphor of science as cartography, multiple different sorts of models of reality may be useful for different purposes. Focusing on biological science, S. Mitchell concluded: “Given the multiplicity of causal paths and historical contingency of biological phenomena, the type of integration that can occur… will itself be piecemeal and local… Pluralism with respect to models can and should coexist with integration in the generation of explanations of complex and varied biological phenomena” 166 .
Discussions of pluralism often refer to the relationships between different “levels” of explanation, but “levels” themselves are better understood as ways of referring to different sorts of organizational (part‐whole), spatial and temporal relationships 167 . Slow vs. fast and large vs. small might carve things up differently than higher vs. lower, so that a pluralist approach to explanation is required 167 . In philosophy of science and neuroscience, there is an ongoing exploration of how best to conceptualize causal processes and mechanisms, including causality across different levels 168 , 169 , 170 , 171 . For psychiatry, however, it is key to be aware of the complexity of psychobiological systems, and to avoid overly simplistic neuro‐reductionism 75 , 172 , 173 .
Once again, these philosophical constructs have practical import. Psychiatric practice and research ought to involve a broad range of disciplines and methodologies. Applying scientific pluralism to psychiatry, Kendler has argued that first‐person subjective experiences and sociocultural factors play a vital role in the etiology of psychiatric disorders, such that this etiology cannot be captured by just focusing on the basic biology of the brain 174 . He suggests that a pluralistic psychiatry should aim for “patchy reductionism” and “piecemeal integration” as it tries to understand the multi‐level causal interactions that give rise to psychopathology 174 .
When we think about psychotropic medications, for example, we often focus on specific receptor effects. While important, this downplays how these agents exert a cascade of effects, impacting neural networks and ultimately behavior. A pluralistic clinical psychopharmacology is needed in order to flesh out these higher‐level mechanisms in greater detail. Further, complex multilevel explanations involving a range of mediating processes are needed to explain higher‐level phenomena such as placebo and nocebo effects, and to account for molecular‐social interactions such as how antidepressants acting on serotonergic pathways may impact social hierarchy. While the focus of much psychopharmacology has been on lower‐level mechanisms, such as receptor actions, a pluralistic approach emphasizes that cognitive and phenomenological processes can also be important psychopharmacological targets 175 . Analogously, a pluralistic approach may be useful in exploring the causes of change during psychotherapy 176 , and in developing integrative models of psychotherapy 177 , 178 .
The third notion to consider is value pluralism. This notion, which emphasizes that there are many different moral values, is typically considered as a position in moral philosophy. However, value pluralism is also relevant to science in general, and psychiatry in particular, in a number of ways. In particular, choices about how best to classify and describe the structures and mechanisms of the world reflect a range of epistemic values, and indeed debates about scientific pluralism intersect with debates about science and society 137 . Differences between the DSM‐5 and the ICD‐11, for example, do not necessarily reflect scientific disagreement, but rather acknowledgment of differences in their most important aims and associated values 179 .
Additionally, the argument that natural kinds reflect clusters of properties has been extended to value‐laden constructs. “Healthiness”, for example, may reflect a range of related features, presumably underpinned by relevant biological processes 180 . However, if we think back to normativist positions on the definition of mental disorder, which emphasize the influence of social and cultural values, different societies and cultures may have different understandings of mental disorder because they value different conceptions of human flourishing 42 .
Philosophical work on value pluralism has long emphasized that, given the plurality of values, choices between them will be complex. The philosopher I. Berlin emphasized that different values may be incompatible, and this seems consistent with our experience of moral decision‐making 181 . Nevertheless, this does not necessarily mean that value‐laden choices cannot be made in a reasonable way. Aristotle emphasized the importance of practical wisdom, arguing that a virtuous person succeeds in making correct choices 182 . While practical wisdom may in part involve the application of general principles, Aristotle emphasized the “priority of the particular” in choosing the correct course of action 183 .
Value pluralism again has a number of clinical implications. As noted earlier, the psychiatrist‐philosopher K.W.M. Fulford and his colleagues have argued that evidence‐based health care needs to be complemented by value‐based health care 184 . A growing literature on shared decision‐making similarly highlights the important perspectives of those with lived experience of mental illness 185 , 186 . Furthermore, value pluralism emphasizes the importance of a range of epistemic virtues, including epistemic and cultural humility 187 .
Conceptual tools for psychiatric explanation: beyond reductionism
Three important and interrelated concepts may be useful for psychiatric explanation: dynamical constitution, downward causality, and dual aspectivity 188 , 189 , 190 , 191 . They are employed in several recent pluralistic approaches, and are important aspects of the embodied approach explored later.
Dynamical constitution is the notion that objects and processes at smaller scales of enquiry can interact over time in ways that produce objects, systems or processes at larger scales of enquiry, and that qualities of the larger objects can emerge from the interaction between the component objects and processes 188 , 190 . Downward causality is the idea that these emerging objects, systems and processes at larger scales of inquiry can entrain, constrain or otherwise have causal influence over objects at smaller scales. Dual aspectivity refers to the idea that, whenever talking about a living system, there are at least two perspectives that one can take: first, a body‐as‐object, naturalistic or third‐person perspective; second, a body‐as‐subject, personalistic or first‐person perspective. Both perspectives consider the same physical object, but they capture different aspects of the living system/person under study, in line with a pluralist approach 189 , 192 .
Taken together, these concepts provide an approach to understand constitutionally complex systems such as life forms. Organisms are made up of many parts (e.g., organs, cells, receptors) and derive properties, such as mindedness, from the complex interactions between these parts in context. Both the parts and the wider organism are no less real because of the knowledge that we gain about the parts and how they manage to dynamically constitute a minded creature. Analysis at multiple scales of enquiry – consistent with an emphasis on a complex systems framework and a pluralist approach – is useful for understanding how this creature functions and how things may go awry.
From a clinical perspective, these considerations emphasize the complexity of clinical formulation and intervention. Given dynamical constitution, neurobiological mechanisms are key to shaping behavior, thoughts and emotion. However, given downward causality, such mechanisms cannot be assumed to have causal primacy in our explanations. In contrast to the view of neo‐Kraepelinians and overly reductionistic translational neuroscience, mental disorders are not merely brain disorders 29 , 30 . Conversely, interventions such as psychotherapy may impact both brain and mind 193 .
The biopsychosocial model remains the most influential for ensuring a pluralistic approach to assessment and intervention for mental disorders in the clinical context. Despite criticisms that highlight its shortcomings, including the absence of an explanatory account of causal interactions, this model remains valuable because it prompts us to resist simplistic binaries – such as the organic vs. functional, biological vs. psychological, medical vs. social, and disease vs. behavior distinctions – in our explanations of psychiatric etiology 194 , 195 , and serves as a powerful reminder that a pluralistic framework which considers a broad range of “difference‐makers” is needed in clinical research and practice 75 , 117 , 148 .
Jaspers’ insistence that both explanations of underlying mechanisms and understanding of individual meanings are important for a comprehensive account of mental disorders remains relevant to contemporary clinical practice. Medical anthropologists have usefully distinguished between disease as a biomedical condition, and illness as the subjective experience of those suffering from that condition 196 . Relatedly, work on what has been termed “neurophenomenology” attempts to integrate neuroscientific knowledge with individual experience 192 , 197 . Finally, “explanation‐aided understanding” – the idea that knowledge of causal mechanisms can enhance our appreciation of first‐person experience – is also a key consideration for improving clinical practice 198 .
EMBODIED COGNITION AS A PLAUSIBLE INTEGRATIVE APPROACH
The “mind‐body problem” is a paradigmatic issue at the intersection of psychiatry and philosophy. The philosopher R. Descartes is often cited for his substance dualism – that mind and body exist as radically different kinds of substances – and clinicians are typically encouraged to avoid this position in light of a modern naturalist or scientific understanding. At the same time, clinicians are generally not encouraged in their training to explore recent developments in an area of such philosophical complexity, and as a result some implausible assumptions can arise 199 .
One commonly assumed view is that the mind is a powerless or “supervenient” side effect of the physical processes of the brain. Such a view can support neurocentric assumptions, for example, within a biological psychiatry which contends that the brain is where we need to focus the vast majority of our explanatory and treatment efforts. As noted earlier, while the brain is clearly important for understanding mental functioning and mental health, such an approach may be criticized for its neuro‐reductionism, where minimal space is made for similarly important aspects of human functioning such as experience, meaning, culture and context.
Another common view, inspired by the development of computers, is to see the mind as a “software” running on the “hardware” of the brain. Under such a computationalist and functionalist view, cognitive functioning is understood as a form of information processing where the brain takes sensory input and computes appropriate responses. Such an assumption can be seen in the notions of cognitive biases and core beliefs in cognitive‐behavioral therapy, with these biases or beliefs effectively performing the role of “bugs in the software” altering our perception of the veridical world. While this can be a useful metaphor, there are multiple issues with this perspective. It is difficult to see how such a view can be integrated with a biological perspective, in which neurons and behaviors are complexly intertwined. Indeed, such a view seems implausible; living creatures are not computers with set functions, and this analogy may limit our insight.
Moving beyond assumptions of supervenience and computationalism, embodied cognition represents a biologically plausible and strongly integrative view of the mind‐body relationship, whereby factors across the biopsychosocial spectrum are considered to have potential explanatory value 144 . Such an embodied perspective has gained momentum within philosophy of psychiatry in recent years, but is not yet broadly recognized by clinicians nor discussed in training programs. Engagement with embodied understandings of the connection between mind and body is a key development in philosophy of psychiatry.
Applied to psychopathology, notions of embodiment, alongside related ideas such as embedment, extension and enactivism, which we will soon unpack, represent one plausible integrative frame for the study and treatment of mental disorders. We argue that an embodied approach has the potential to incorporate and build on many of the recent conceptual developments highlighted in previous sections, while also cohering well with other contemporary theoretical and methodological developments in a range of disciplines. In this section, we first define some key terms and review the development of embodied cognition. We then go on to discuss the application of this approach to the study and treatment of mental disorders.
What is embodied cognition?
Embodied cognition refers to a diverse range of approaches across multiple disciplines within cognitive science, including but not limited to psychology, neuroscience, philosophy, robotics, and artificial intelligence. Embodied cognitive science is united by a common interest in moving away from a “cognitivist” or “computationalist” view, where the brain is seen as an isolated “seat of cognition” that receives sensory information, represents the world, and computes appropriate responses to it. Instead, embodied approaches variously emphasize the role of the body and context both in the moment‐to‐moment constitution of cognition and in the shaping of cognition across development, thus decentering the ideas of representation in how we seek to understand the mind 200 . Instead of understanding the mind through implicit analogy to computers, embodied approaches seek to understand it through analogy to complex living systems adapting to the dynamics of their environment.
Historically, the development of embodied cognition has many roots. The most commonly recognized of these roots include: a rejection of a traditional symbolic‐representational view of cognition where the experienced world is a model/representation of reality; an interest in expanding upon the success of minimally representational “connectionist” understandings of cognition such as exemplified by neural networks; the emphasis of pragmatic philosophers such as J. Dewey on how knowledge entails interaction with the world; phenomenological insights by authors such as M. Merleau‐Ponty that the body is an intrinsic part of our experience‐of and engagement‐with the world; work in developmental psychology by J. Piaget and others who have emphasized interaction with the world over time; and inspiration from the success of dynamic systems theory in modelling the behavior of complex systems 201 . Such historical antecedents have converged to produce understandings of the mind that recognize a broad range of influences shaping human cognition, from genes and molecules to culture and context.
Embodied cognitive science is a diverse field. This is true to the point that the very word “embodied” can take on subtly different and overlapping meanings in different contexts. It is therefore important to specify the sense in which we use this term. In a summary review of embodied cognition, Shapiro and Spaulding highlight three different yet overlapping themes within the various usages of the term “embodied”. They refer to these three different themes of overlapping meaning as constitution, conceptualization and replacement 202 . In this paper, we generally refer to the constitutional understanding of embodiment. It is, however, worth briefly explaining all three senses of the term.
In the replacement sense of “embodied”, emphasis is on the need to replace our systems of understanding the mind with less representational and more dynamical ones. In other words, developing ways of understanding the brain, not as generating a mirror‐like representation of the world, but rather as resonating with the world directly. A classic example would concern how best to think about the action of catching a fly ball in baseball. Rather than representing the entire environment and computing the ball's trajectory, a non‐representational and embodied view would suggest that we engage with simple visual strategies in order to ensure that we are in an optimal position to catch it 203 . This sense of embodiment is particularly associated with the position of “radically enactive cognition”, which attempts to understand cognitive processes with no reference to representation 204 .
When the term “embodied” is used in a conceptualization sense, the focus is on psychological concepts and processes, and how they are shaped by the kinds of bodies and experiences we have. The key idea is that the way we conceptualize the world would likely be different if we had different sorts of bodies to navigate with. For example, consider the idea that we think in terms of “up” as metaphorically connected to positivity and action, and “down” as connected to depression and inaction, not simply as a cultural quirk but because of shared associations rooted in our bodily experiences and actions 205 . Accumulating behavioral and neurobiological evidence supports the related ideas that: a) there is significant overlap in the neural processes involved in sensorimotor coordination and those involved in so‐called “higher” cognitive and social processing, and b) such overlap means that “higher” cognitive processes are not siloed in the brain, but are influenced by bodily and sensorimotor context such as posture, current action, and internal physiological state 206 , 207 .
When used in a constitutional sense, which is our main focus here, “embodied” refers to the idea that mental processes are best thought of as not constituted by the brain alone, but rather as emerging from the brain and body acting in concert, i.e., as one extended system. The mind does not arise from the efforts of the brain to represent the world, but rather is an active process of the entire organism navigating, adapting to, and making sense of the world 197 , 205 , 208 , 209 , 210 , 211 . In such a view, for example, the release of cortisol and adrenaline from the adrenal glands in response to an acute stressor is not simply an event occurring at one level of analysis with a modulating effect on cognition at a higher level of analysis, but rather is part of a single, body‐involving, cognitive‐affective response to threat. Thus, the processes that constitute emotions weave in and out of the brain, and include a range of interoceptive components 207 , 212 . This sense of embodiment incorporates the ideas of dynamical constitution, downward causality and dual aspectivity, discussed earlier.
Now that we have outlined what is meant by embodiment, it is useful to define some related ideas, specifically those of embedment, extension and enactivism. Together these ideas, alongside embodiment, are often discussed under the umbrella term “4E”. Sometimes “5E” is also used, typically in reference to a focus on emotion.
Embedment is the idea that cognitive functioning involves a constant interplay with the environment across multiple timescales. Consequently, in order to understand cognition, recognition of the role of context is vital. When considering human functioning, the environment is also regarded not simply to be a physical one, but a social‐cultural one, constituted by others, alongside their artifacts and shared structures of meaning 213 . Embedment highlights that, across the timescales of evolutionary change, sociocultural development, life‐span learning, and moment‐to‐moment cognition, human beings are both deeply influenced by, and in turn influence, their surrounding environments. Even the most abstract and intellectual activities, such as mathematics, entail a thoroughly embodied and embedded skill set 192 , 205 .
Extension is an idea in many ways similar to embedment, but which makes a more radical claim. Specifically, it is the idea that cognitive processes are often best understood as extending out beyond the body and looping through the world 213 . To continue the mathematics example, rather than merely understanding a calculator as supporting the cognitive processes of an individual, an extended view of mind would hold that the calculator becomes part of the cognitive process. In a well‐known thought‐experiment, Clark and Chalmers contrast Inga, who navigates from memory, with Otto, who has Alzheimer's disease and relies on written directions in a notebook. Given that the only difference between the two cases is that the process of navigation takes place wholly inside the brain in Inga's case and partly outside it in Otto's, they argue that it is arbitrary to limit cognition to what occurs within the confines of the skull 214 .
Enactivism is an idea that subsumes and builds upon those of embodiment and embedment. It may be explained in different ways and with different points of emphasis, but here we focus on autopoietic enactivism 215 . “Autopoietic” simply means “self‐creating”. Accordingly, within autopoietic enactivism, the focus is on the notion that mindedness is brought forth, or rather enacted, through the organizational structure of life forms and their efforts to constantly maintain themselves within the context of their environment. An enactive perspective holds that life forms are shaped through evolution to try to survive, and that this inherent purpose sets up the necessary groundwork for the emergence of relational meaning. In order to survive, organisms have to learn how to seek food, avoid predators, and so on – that is, to respond differentially to affordances in the world 216 . Cognition is sense‐making – a constantly unfolding process, one that involves body and action, is relational, and is inherently affective/meaning‐laden. Thus, cognition is not a linear process of sensation‐perception‐cognition‐action, but rather a circular process of sensory‐motor engagement. The brain, rather than taking in information and representing a model of the world, as in the neurocentric view, is instead an organ of coordination, learning and mediation within this sensorimotor loop, so allowing for more complex ways of making sense of and acting in the world 189 , 217 .
Overall, the embodied/4E model of cognition presents a non‐dualistic understanding of the mind that appears biologically plausible and does not fall prey to reductionistic temptation. Human functioning is understood from this perspective in a way that preserves a sense of agency, while also recognizing the diverse array of influences that shape and influence human health and behavior, from genes to culture. It is therefore an integrative view, demanding both current and historical analysis of the entire brain‐body‐environment system if we are to understand patterns in human behavior and cognition. This approach is consistent with a coordinated pluralism 218 , and arguably even with an integrative pluralism 219 , and has led to the suggestion that accounts of mental disorder grounded in embodied/4E cognition may represent a path to solving the “integration problem” in psychiatry; i.e., the fact that we have identified causal factors across the brain, body and environment, but struggle to conceptualize how these causes come together to shape patterns of disorder 220 .
Clinical applications of embodied/4E cognition
Several conceptual frameworks grounded in the embodied/4E perspective have been applied to mental disorders as a whole 189 , 191 , 220 , 221 . These frameworks view mental disorders as representing disruptions to sense‐making, a view that is consistent with attempts to bridge the naturalist‐normativist divide, with an emphasis on the adaptive fit between individual and context that aligns with soft naturalism 62 , 222 . They also share a vision that embodied/4E cognition serves as an integrative framework for the conceptualization, study and treatment of these conditions, consistent with an emphasis on multi‐disciplinary and pluralist approaches. Additionally, there have been several efforts to develop descriptive and explanatory models of particular mental disorders from an embodied/4E perspective 223 , 224 , 225 , 226 , 227 , 228 .
A focus on embodied cognition leads to a view of mental disorders as constitutionally complex, involving biological, cognitive‐emotional, environmental and sociocultural aspects. This perspective emphasizes both biology and agency, acknowledging biological scales of enquiry as relevant without reducing the explanatory importance of experience and choice. It also incorporates ideas of dynamical constitution and downward causality to break down the received mind‐body divide, and aligns well with the notion of mental disorders as fuzzy mechanistic property clusters 229 .
Through the notion of embedment, these frameworks emphasize the active and historical role of the physical and sociocultural environment. All organisms, particularly humans, are deeply historical and ecologically informed creatures. Shaped by our evolutionary, sociocultural and developmental pasts, we are understood to strive to adapt to the present context and predicted future 207 , 212 . Applied to psychiatry, this allows integration with perspectives such as evolutionary psychiatry 230 , cultural psychiatry 196 , 231 , and developmental psychopathology 232 .
In the embedded view, however, culture is not seen only as a historical force having influence across development, but also as a living context. In this “constitutional view”, culture is seen as a “shared world” or structure of knowledge, meaning and artifact, constituted by ongoing engagement 212 . Such a shared world represents a historical context for the development of individuals and the way they make sense of the world, but also continues to play out in the moment‐to‐moment interaction of individuals, including in the clinical encounter. Embeddedness therefore pushes clinicians to actively consider the role of culture in the lives and histories of their patients, and in the clinician‐patient interaction.
Via the notion of enactivism, these frameworks subscribe to a process orientation, with mental disorders not viewed as static problems/dysfunctions in the brain or psyche, but rather as constantly unfolding patterns of how we make sense of and engage with the world. Through interactions with their specific environment and its particular affordances, thinking beings create and discover meaning for themselves. Rather than stemming from some underlying “cognitive error” or “psychic disturbance”, mental disorders emerge within the circular relationships between patient and world – as a maladaptive pattern of sense‐making 191 .
This process orientation accords well with the focus of neuroscience and computational psychiatry on active inference, whereby predictive processing frameworks formally model how organisms develop probabilistic assessments of their environment so as to adapt optimally. Indeed, several authors have considered how best to integrate such frameworks with embodied/4E approaches, noting that the brain‐mind, including interoceptive components, engages in embodied predictive processing in order to maintain enactive engagement with the environment 206 , 233 , 234 . In their embodied/4E account, Friston and colleagues suggest the term enactive inference 235 . Their framework bridges representational and non‐representational approaches 236 , providing a pluralistic, yet formal and mechanistic, account of a range of psychiatric conditions, often with a particular focus on interoception and bodily states 237 , 238 .
In the clinical setting, given the central role of affordances and affectivity within the enactive view, a process orientation accords with psychotherapies that draw patients’ attention to early maladaptive schemas and current emotional dynamics in order to better learn to navigate them 239 , 240 – an exercise in sense‐making about sense‐making 191 . Further, from the enactive perspective, therapeutic interventions in psychiatry seek to improve the fit between the individual and his/her environment. This can in turn be achieved either by altering the sense‐making and behavior of the individual, or by changing the world around him/her. This entails integration with notions of social psychiatry and environmentally focused mental health interventions.
One instructive example of the clinical utility of an embodied/4E perspective is the work of Tschacher and colleagues on schizophrenia 225 . These authors point out that sensorimotor dysfunctions are closely associated with psychotic symptoms, leading to altered timing in the processing of stimuli and to disordered appraisals of the environment. They argue, therefore, that problems of social cognition can be viewed as disordered embodied communication. Finally, on the basis of this account, they suggest novel treatment strategies through body‐oriented interventions. Again, an embodied/4E approach is theoretically able to integrate biological and phenomenological perspectives, and also has practical implications for the clinical context.
As a final clinical example, consider an embodied/4E approach to addiction 227 . Addiction is embodied insofar as the impact of substances on neurobiological mechanisms alters mental activity, the body itself is altered in unhealthy and use‐supportive ways, and habitual actions play important roles in substance‐related behavior. Addiction is embedded/extended insofar as addiction‐related behavior is both influenced by and often alters the environments within which it unfolds, and is shaped by individual learning histories. Finally, addiction is enacted insofar as an affected person's experience of and engagement with the world is deeply altered in a way that often works against his/her values, and the person enacts a particular and inflexible way of trying to meet his/her needs. In this framework, a merely neural model is replaced by a view of addiction as simultaneously neuronally‐and‐externally constituted, and there is an account of how drug‐taking transforms the world of the individual – altering his/her personal agency and lived experience.
There are several advantages of such a view. First, this perspective allows an integration of neurobiological accounts of addiction with accounts of lived experience. Second, the binary choice of seeing addiction as a medical disease vs. a personal choice – a key issue in the philosophy of this condition 241 , 242 – can be seen to be an overly simplistic false dichotomy. Third, this perspective enables us to reconsider strategies for recovery; in particular, it provides an account of how the person with addiction may be able to change his/her lived experience by manipulating the environment and altering its affordances – so that there is a change in the dynamic interaction of brain biology, interoception, and surrounding context.
DISCUSSION
Psychiatry is, inherently, a conceptually laden and conceptually complex field. Yet the opportunity to reflect on the concepts implicit in psychiatric practice arises infrequently for both clinicians and trainees. Instead, a range of tacit assumptions – about the nature of mental disorders, diagnostic categories, causal explanations, and the mind – influence daily engagements with psychiatric taxonomy, clinical assessment and diagnosis, and the discussion of conditions and treatments with patients. These tacit assumptions have, however, been carefully addressed by philosophy of psychiatry, and here we have reviewed key advances in this field and their clinical implications.
In conceptualizing and categorizing mental disorder, both naturalist and normativist considerations have emerged as important – the field increasingly accepts that such work entails a consideration of both facts and values. At a conceptual level, this encourages moving away from strict scientism to soft naturalism – a position that embraces both psychobiological mechanisms and personal agency. In clinical practice, the bridging of naturalism and normativism facilitates moving away from an approach in which disorders are reified, and towards appropriately comprehensive and individualized evaluations of patients. Awareness of the importance of facts as well as values can also facilitate a mental health care that is both evidence‐based and values‐based.
In considering the nature of psychiatric science, there is now increasing emphasis on a pluralist approach, including ontological, explanatory and value pluralism. Conceptually, this acknowledges the multi‐level causal interactions that give rise to psychopathology, and is consonant with Jaspers’ early pluralist approach, encompassing both explanatory accounts of behavior and an understanding of the individual person – an approach espoused by a wide range of philosophers 50 . Clinically, this view emphasizes the importance of a broad range of causal “difference‐makers” as well as considerations of “lived experience” in both research and practice.
In addressing a range of questions about the brain‐mind, and how both somatic and psychic factors are key in mental disorders, conceptual and empirical work on embodied cognition provides an increasingly valuable approach. Viewing the brain‐mind as embodied, embedded and enactive facilitates the integration of advances in both cognitive‐affective neuroscience and phenomenological psychopathology, as well as in a range of other disciplines. Work on embodied cognition is having an increasing impact on rethinking mental health and mental disorders 189 , 191 , 220 , 221 .
Conceptual competence has various elements, including making explicit conceptual assumptions, developing a philosophical vocabulary, acquiring familiarity with relevant frameworks, and maintaining a degree of “conceptual humility” 7 . These elements have been exemplified in this paper, but at this point we would like to emphasize in particular the virtue of epistemic humility. For example, philosophy of nosology has taught us that, despite the enormous amount of work that has been done to improve our classifications, these remain tentative, and reification of putative entities must be strenuously avoided.
Similar considerations would apply to our attempts here to advance philosophy of psychiatry. We began by noting that progress in philosophy has been disputed, and we are wary of claiming too much. Some of the issues in philosophy of psychiatry date back to ancient times, and some of the constructs employed seem to be “essentially contested”: there are a range of competing views, and there deserves to be ongoing discussion and debate 243 . This applies in particular to the concept of disease, which may be intractably messy 31 , 244 . Still, the purpose of philosophy is not necessarily to resolve every dispute or to eradicate disagreement, but rather to properly articulate and understand debated issues. To the extent that the issues considered here have been more rigorously articulated in theoretical work, and more thoughtfully considered in the clinical context, some progress may be claimed.
Several limitations of the approach taken here deserve particular emphasis. First, we have summarized arguments and conclusions from the literature, rather than attempting to rigorously defend any particular stance. Relatedly, we have not had space to address ongoing work and key variants of some positions that have been put forward here, nor important critiques of these positions 50 , 245 , 246 , 247 , 248 . Key constructs employed here – including soft naturalism, pluralism, and embodied cognition – all deserve much deeper consideration.
Second, while we have drawn some links between these particular constructs – soft naturalism, pluralism, and embodied cognition – our view is that much further work along these lines is possible. At the broadest level, some work on these constructs seems to allow for a degree of rapprochement between analytic and continental philosophy 249 . At a more specific level, it seems to us that further linkages can be made between key philosophers who have spoken to these issues (including J. Dewey – who prefigured notions of embodied cognition 250 , W. Sellars – who contrasted the scientific and manifest image 251 , and H. Putnam – who contributed to work on collapsing the fact/value distinction 252 ), as well as between work on cognitive‐affective neuroscience and phenomenological psychopathology 192 , 253 .
Third, we have been selective in our focus on progress in the field, omitting large swaths of work in philosophy of psychiatry – not the least being ethics (which will be the topic of another forthcoming Forum in this journal) – and potentially downplaying a range of authors and advances. Similarly, we have not covered the philosophy of any particular psychiatric symptom or disorder in detail, despite a large literature addressing a range of mental conditions. The breadth and depth of work by both ancient and modern philosophers who have considered the questions raised in this paper is extraordinary, and we would encourage readers to explore further.
An important meta‐question is the extent to which there has been work on the cognitive science of philosophy and psychiatry. An embodied cognition perspective suggests, for instance, that, when we think about categories such as mental disorders, rather than being aware of how deeply reliant we are on the use of embodied metaphors, we are instead prone to essentialize our concepts 60 , 254 . We may therefore have particular difficulty in avoiding the traps of reductionism and reification, and in articulating and working with fuzzy constructs such as the bridging of naturalism and normativism.
A number of key themes have emerged from the different parts of this paper. Here we highlight three. First, a key theme has been that of integration. We have discussed the integration of elements of naturalism and normativism, of evidence‐based care with values‐based care, of knowledge of science with the understanding of experience, and of psychobiological mechanisms with personal agency. Further, we have emphasized the potential value of the embodied/4E approach in integrating a range of disciplines concerned with the brain‐mind, including cognitive‐affective neuroscience, developmental psychopathology, and social psychiatry.
A related theme has been that of “balance”. Our notions of mental disorders need to avoid the poles of scientism and relativism; our explanations need to avoid both neuro‐reductionism and culturalism; and our approach to the mind‐brain problem should be one that avoids both a brainless and a mindless psychiatry 139 . Our introduction mentioned Aristotle's notion of the “golden mean”, and the emphasis in Chinese philosophy on the balance of yin and yang; a balanced perspective that is able to judiciously weigh up a range of principles and particulars surely lies at the heart of good clinical work 255 .
A final theme has been that of complexity. We have argued that it is important to avoid essentialism and reductionism in psychiatry, and that clinical assessments need to go far beyond our diagnostic criteria to assess a range of domains, and to understand each patient as a unique individual. While monocausal models of disease entities (e.g., Treponema pallidum causing neurosyphilis) have been useful, contemporary psychiatry requires a coordinated 218 or integrative pluralism. The embodied/4E perspective emphasizes the complexity of the living being's dynamic engagement with his/her environments over time. The complexity of the brain‐mind and of clinical conditions is a key reason why calls for simplistic paradigm shifts in psychiatry are unlikely to succeed. Instead, in keeping with philosophy as the love of wisdom, there is a need for a “wise psychiatry”.
The philosophical resources reviewed here may be useful in considering the extent to which psychiatry has made progress in the past, our current balance of success and failure, and our future aspirations. It seems to us incontrovertible that philosophy has played a key role in psychiatry, whether implicitly or explicitly, and that it will continue to do so into the future. Our immediate hope is that work in philosophy of psychiatry will contribute to the conceptual competence of clinicians. By rendering the implicit explicit, philosophical analysis may help expose the implications, limitations, contradictions and even absurdities that potentially underlie received ideas and prominent positions. Our long‐term hope is that advances in philosophy of psychiatry will in turn have positive clinical impact, contributing to integration, balance and wisdom in psychiatric practice.
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