Implicit assumptions in psychiatry

Implicit assumptions play a fundamental role in shaping our understandings of the world,^{Reference Andersen, Anjum and Rocca3} including psychiatric conditions and psychological suffering. These assumptions are part of the philosophical underpinnings of our scientific and clinical practices.^{Reference Aftab and Waterman2,Reference Bringmann, Elmer and Eronen4} They relate to matters such as what we find desirable and preferable (values), our beliefs about the fundamental natures of psychiatric conditions and psychological suffering (ontology), and about the sorts of knowledge we can obtain about psychiatric phenomena and how it can be obtained (epistemology). These philosophical assumptions are so deeply ingrained that we rely on them implicitly to guide and justify our scientific and clinical work. Although it is not possible or even desirable to eliminate these assumptions completely – all empirical observations are theory-laden, as philosophers of science often point out^{Reference Reiss, Sprenger and EN Zalta5} – we can make conscious efforts to bring them to light and make them explicit.

By making implicit assumptions explicit, we open the door to scrutiny, allowing us to challenge and, if necessary, replace our assumptions.^{Reference Aftab, Joshi and Sewell6,Reference Aftab7} Philosophical assumptions and biases are acquired from a variety of sources, including folk intuitions, education, professional training and practice, and disciplinary traditions. All of these factors contribute to the establishment of scientific paradigms that influence and justify our scientific and clinical practices.

A prominent example comes from the history of psychiatric descriptive classifications, where even purportedly ‘atheoretical’ frameworks such as DSM-III were deeply embedded in neo-Kraepelinian assumptions.^{Reference Aftab and Ryznar8,Reference Zachar, Banicki, Aftab, Kruger and Blaney9} Those assumptions included the existence of discrete disease entities and the expectation that external validators identified through research would ‘converge’ on the characterisation of those entities.^{Reference Klerman and Shershow10} Such beliefs shaped the trajectory of psychiatric research over the course of subsequent decades, even if the DSM project later disavowed such inferences.

To address the potential confusion arising from these implicit assumptions – an example of which is cited above, but which are likely to differ across individuals and across time – it is essential to encourage critical reflection within our scientific and clinical communities. By fostering open dialogue and acknowledging the influences of these philosophical assumptions, we can strive for more comprehensive and accurate ways of understanding and addressing psychiatric conditions. This self-awareness and willingness to reevaluate our assumptions will, one hopes, lead to advances in the field and ultimately to improved patient care and outcomes.

We contend that a neglect of conceptual competence has led to a state of conceptual impoverishment of mainstream psychiatric practice. We do not mean this to imply that psychiatry as a subject lacks conceptual richness but rather it is our view that many practitioners have lost sight of that. Such a view has been echoed by many prominent psychiatric leaders, including Nancy Andreasen, who has lamented the ‘death of phenomenology’ in America.^{Reference Andreasen11} The reification of DSM and ICD constructs, including the misconception that diagnostic criteria constitute rather than index psychiatric conditions,^{Reference Kendler12} has limited the potential richness and flexibility of psychiatric understanding that is offered to us by approaches that take neuroscientific, phenomenological and narrative perspectives seriously.^{Reference Kendler and Parnas13} Additionally, a tendency towards biological reductionism has narrowed the scope of psychiatric research, often overlooking the multifaceted nature of psychiatric phenomena. The biopsychosocial model, although well-intentioned and clinically useful, has been said to lack a philosophical account of causal interactions^{Reference Bolton and Gillett14} and to have generated confusion about the meaning and goals of holism in medicine.^{Reference Ghaemi15–Reference O'Leary18} Diagnostic inflation has resulted in a steady expansion of the domain of mental illness, raising questions about when difference and distress become disorders,^{Reference Aftab and Rashed19} and has led to a common grievance that aspects of ordinary life have been unnecessarily medicalised or pathologised.^{Reference Frances20} Equally concerning is the lack of sufficient representation of patient and ex-patient perspectives in psychiatric practice and science, resulting in inadequate understandings of their complex needs and preferences.^{Reference Kalathil and Jones21} This has been driven in part by a neglect of philosophical frameworks, such as standpoint epistemology and social objectivity, that justify the inclusion of lived experience in science.^{Reference Friesen and Goldstein22,Reference Tekin23}

The conceptual impoverishment of psychiatric practice and training has taken place despite the existence of a rich and growing body of conceptual and philosophical work. The key to rebuilding a culture of inquiry lies in recognising and cultivating conceptual competence within healthcare.^{Reference Aftab and Waterman2} As noted above, conceptual competence involves the transformative awareness of how background philosophical assumptions – held by clinicians, patients and members of society at large – shape various aspects of clinical practice, research and education.

Development of conceptual competence entails four essential elements. First is identification and articulation of otherwise-implicit conceptual assumptions and corresponding questions that underpin clinical interactions and diagnostic practices. Second is acquisition of a philosophical vocabulary and familiarity with relevant arguments and frameworks by which to examine, rigorously and systematically, those conceptual assumptions. Third is engagement in organised philosophical discourse to evaluate the merits of different responses to conceptual questions relevant to psychiatric practices. And finally comes cultivation of conceptual humility, recognition of the tentative nature of scientific and philosophical formulations, and appreciation of the value of pluralism in our explanatory thinking.

Teaching conceptual competence requires active, dynamic exchanges of ideas. Conceptual discourse is not a matter of passive acquisition of knowledge. Rather, it demands critical engagement and practice. Trainees must be equipped to apply conceptual tools and examine responses to conceptual questions in their training environments. Conversations and debates found in the academic literature can serve as valuable aids in teaching philosophical discourse.

It is essential to acknowledge that conceptual problems are seldom definitively solved or settled. Developing conceptual humility involves recognition of the complexity of the topics involved and acknowledgement that even with our best efforts, some questions are likely to remain unresolved. Understanding that all philosophical frameworks have inherent limitations is integral to cultivating this virtue.

Several elements of the 2022 core psychiatry training curriculum by the Royal College of Psychiatrists (accessible at www.rcpsych.ac.uk/training/curricula-and-guidance/curricula-implementation/curricula-documents-and-resources) are relevant to conceptual competence. Understanding of the development of diagnostic concepts, the development of the profession, historical relationships between psychiatry and society, and a person-centred holistic approach to mental disorders are noted in the curriculum as key capabilities. These are all domains in which understanding requires grappling with implicit as well as explicit conceptual assumptions. The core curriculum also expects trainees to demonstrate an understanding of factors that contribute to complexity and uncertainty in psychiatric practice. This is again relevant to conceptual competence, in particular to the element of ‘conceptual humility’. The framework of conceptual competence can therefore be of value to educators in developing these key capabilities.

In the UK and global contexts, values-based practice (VBP)^{Reference Fulford24} is an admirable example where we can see elements of conceptual competence in action. VBP is a clinical skills-based approach to working with complex and conflicting values in healthcare. VBP encourages the development of skills that identify implicit values at play in any clinical interaction. It offers a rigorous and scholarly framework by which to consider these values in clinical and academic contexts. VBP emphasises the necessity of interdisciplinary dialogue and recognises the humility needed to navigate complex and conflicting values. (The Collaborating Centre for Values-based Practice in Health and Social Care at St Catherine's College, Oxford (valuesbasedpractice.org), is an exceptional resource for learning more about this approach.)

Entry points in teaching conceptual competence

This section considers some examples of teaching conceptual competence in common psychiatric training settings. As introduced above, the first element of teaching conceptual competence (TCC) is developing trainees’ awareness of philosophical assumptions, which frequently entail unrecognised questions, ambiguities and conflicts.

TCC requires a shift in the educator's awareness. One element of that involves movement away from the diagnosis–treatment mode of clinical reasoning and towards use of clinical problems as basic units of clinical reasoning.^{Reference Sadler and Hulgus25} Educators must also recognise the core concept of ‘reduction’ in clinical science and practice. Reduction is the notion that every framework we use requires us to pay attention to some aspects of phenomena and to neglect other aspects. This means that as we shift our frameworks (e.g. aetiopathogenesis framed in neurobiological terms, psychotherapeutic theories, cultural contexts of human distress, etc.), the observational data themselves change.^{Reference Sadler and Hulgus26} Viewing cases through different ‘lenses’ entails conceptual humility, as introduced above. Educators must also recognise that conceptual matters are often tacit, or taken for granted, and that attentional shifts towards making them explicit contribute to improved practice through making such issues teachable.

We identify and outline briefly below four broad categories of opportunity for TCC suitable to different training and clinical settings: (a) ambiguities in meaning; (b) conflicts between imperatives; (c) inexplicit intuitions; and (d) faulty clinical reasoning.

Teaching conceptual competence in addressing ethical dilemmas

In psychiatric ethics, conceptual competence involves the ability to apply complex ethical principles in the approach to clinical cases that represent ethical dilemmas. The US Accreditation Council for Graduate Medical Education's ‘Professionalism’ Milestones for psychiatry recognise five levels of competence in clinical ethics: (1) knowledge of core ethical principles; (2) analysing straightforward situations using ethical principles; (3) analysing complex situations using ethical principles and knowing when help is needed; (4) using appropriate resources for managing and resolving ethical dilemmas as needed, such as ethics and risk management consultations; and (5) identifying and addressing systemic factors that contribute to ethical problems.²⁷ Although these competencies are clearly important, the complexity of ethical dilemmas faced by psychiatrists in training and practice, and the unique problems faced in psychiatry,^{Reference Radden28} demand even greater skills. Psychiatrists and psychiatry residents should be able to recognise that many ethical dilemmas are fundamentally complex, in the sense that they involve competing ethical considerations and perspectives that may be irreconcilable. Approaching such ethical dilemmas involves accepting this complexity while working towards practical responses.^{Reference Bloch and Green29}

In the programme run by one of us (B.M.K.), a case-based approach to ethics education is employed that aims to help fourth-year residents embrace ethical complexity. Through its encouragement of virtuous self-awareness and humility, this method combines recommendations that ethics education should focus on development of virtuous clinicians^{Reference Radden and Sadler30} with claims that it should focus on knowledge and application of ethical principles.^{Reference Forrow, Arnold and Frader31}

For each teaching session, residents provide descriptions of difficult cases in advance, identifying some salient ethical difficulties they involve. Faculty members review the cases, develop learning objectives and provide accessible philosophical readings responsive to those objectives. Within each session, faculty members explain some of the philosophical ideas represented in the readings and then lead case discussions that identify gaps in the residents’ ethical assessments. This promotes recognition of complexity and fosters more sophisticated, nuanced analyses.

This process emphasises that making an ethically good decision might not mean reaching the right conclusion but, rather, following a process that is thoughtful and inclusive, admits multiple competing individual and cultural perspectives, and acknowledges uncertainties at many levels.^{Reference Sinnott-Armstrong32} Residents are encouraged to observe how ethical analysis is sensitive to facts that might be unknown or poorly defined. They are asked to consider how competing moral principles (such as respect for autonomy and beneficence^{Reference Beauchamp and Childress33}) might simultaneously bear on a case and that there might be no guide to balancing them.^{Reference Richardson34} They see how even when a principle is relevant, its correct application is subject to debate, as it depends on concepts that are themselves ambiguous.^{Reference Blumenthal-Barby35} The intended result of this process is that the residents discussing a case identify a reasonable plan of action, while acknowledging its limitations.

For illustration, consider a composite case. The psychiatry consultation team is called by the surgery service to evaluate a man who attempted to castrate himself in prison. He did not succeed but his injuries threaten the viability of the affected tissues. The man was incarcerated for sexual offences and hoped that the castration would demonstrate remorse, make him less likely to reoffend, and promote the possibility of clemency. He wants the surgical team to complete an orchiectomy, but they refuse. The consultation team interviews him and concludes that he has no diagnosable mental illness and has full decision-making capacity.

To help guide the residents’ discussion of the case, philosophical readings are provided that problematise the concept of autonomy.^{Reference Charland36–Reference Kious38} The residents are invited to consider how structural factors like the individual's incarceration can affect autonomy. They are urged to monitor their own responses to him, as the case is likely to produce strong emotional reactions, such as shock at the man's self-injury or disgust at his crime, that could colour ethical judgements.^{Reference Gordon, Gazzillo, Blake, Bornstein, Etzi and Lingiardi39} The residents decide that there is no clear conclusion. Still, they identify positives and negatives for each potential course of action. Following the individual's wishes would respect his autonomy, probably reduce short-term medical risks and conceivably reduce the risk of reoffending. On the other hand, it might make him worse off in the long run, and would involve complicity in an act that seemed coerced and unreasonable.

About the authors

Awais Aftab, MD, is Clinical Assistant Professor of Psychiatry in the School of Medicine at Case Western Reserve University in Cleveland, Ohio, USA. John Z. Sadler, MD, is Professor of Psychiatry and the Daniel W. Foster, MD, Professor of Medical Ethics at the University of Texas Southwestern Medical Center in Dallas, Texas, USA. Brent M. Kious, MD, PhD, is Assistant Professor of Psychiatry, Adjunct Professor in the Center for Bioethics and Health Humanities, and Adjunct Professor in the Department of Philosophy at the University of Utah in Salt Lake City, Utah, USA. G. Scott Waterman, MD, MA, is Professor of Psychiatry Emeritus in the Larner College of Medicine at the University of Vermont in Burlington, Vermont, USA.