Review by S. Nassir Ghaemi, M.D., M.A., M.P.H.
In June 2006, a group of psychiatrists and philosophers met in Denmark to converse; though asked to join them, I was unable, but with this book, I can partially mollify my regret at having missed the occasion. Here all readers can have the benefit of being present to listen to wise thinkers think hard about what psychiatry means.
The editors are excellent guides. Kendler is a prominent American psychiatric researcher, perhaps the prime figure in psychiatric genetics, Parnas a well-known European phenomenologist. My regard for them is biased, especially with Kendler: I was once his student during a medical school summer fellowship in psychiatric research. That was two decades ago; in the meantime, as his mainstream research credibility has grown, Kendler has branched out into the field of philosophy and psychiatry, with this being his first book-length explicitly philosophical contribution.
Indeed, though each chapter is full of important content, my favorite parts of the book are the introductory comments by Kendler or Parnas before each chapter. These introductory comments distil the meaning of each chapter, and forever seek to make them presentable in plain English (rather than the language of academic philosophy) and make them relevant to the average psychiatric clinician.
The three themes that are covered are nosology, philosophy of science, and phenomenology, with Kendler overseeing the first two themes, and Parnas the latter one.
In the section on nosology, the work of the psychologist Peter Zachar defends an approach that straddles the middle road between simple positivism (things are real and we have objective truth) and postmodern nihilism (all is blood and power, and nothing is really real); Zachar uses philosophical pragmatism, the attempt to "triangulate to reality" rather than through direct perception, as an antidote to both extremes of positivism and nihilism. His writings, along with Kendler, clarify much that is unnecessarily contentious in the anti-psychiatry/postmodernist debates.
In the long section on philosophy of science, authors go a long way to help us understand what it means to apply concepts of causation to psychiatry, and they explicate the key distinction between causal objective explanation and meaningful subjective understanding. The work of the physician /philosopher Kenneth Schaffner, on the topic of genetics and psychiatry, is especially intriguing, and the comments by the genetic expert Kendler provide a wonderful dialogue between two profound thinkers on an immensely important topic. I especially like how Schaffner critiques excessive reductionisim; for instance, he calls the nematode, C. Elegans, "the reductionist's delight" because of its simple nervous system. It turns out that about 1000 full time researchers in the world completely focus on this worm, and two Nobel Prizes have been delivered as a result. Schaffner argues for a nonreductive approach to genetics, one that focuses on "emergent" properties, as do other authors like John Campbell and Dominic Murphy. Exactly how one can be nonreductive, while also being scientific, is the topic with which these authors struggle, a topic with no simple answers, but one which can only be ignored at the price of the two extremes of overreductionism or eclectic anti-reductionism.
The section on phenomenology brings up the ideas of Karl Jaspers and tries, in the Continental tradition, to defend the importance of subjective experience -- such as the "lived world" -- in psychiatry.
Kendler opens the book with a wonderful introduction in which he notes that "perhaps the most central task for a philosophy of psychiatry" is to "develop a frame of reference in which we can anchor our multiple perspectives, lest our pluralism degenerate into an organized list of facts that could more confuse than enlighten." I fully agree with this view, which has been a theme of my critiques of the conceptual status quo in psychiatry today.
We need to get serious about examining our philosophical assumptions and clarifying our ideas: What do we mean by mental illness and psychiatric diagnosis; what does it signify? How do we know in psychiatry; what do we mean by cause and explanation; what is science as applied to psychiatry? How can we know the subjective experience of another person's mind, and how is it relevant to psychiatry?
These are difficult questions, not been asked enough, for which good answers have not been forthcoming. Without answering them, however, all of our drugs, and all of our research -- even sequencing the whole human genome -- will fail to serve their best purposes.
This book asks the right questions, and sends us in the right direction.