Conflicting Values and Disparate Epistemologies: The Ethical Necessity of Engagement

I am delighted for the occasion to respond to Verhagen’s insightful commentary and Gupta’s important critique of my paper. In the process, I hope to further clarify my thesis and the proposal that stems from it. I start by attending to Verhagen’s commentary, because in many ways we are in substantial agreement and, if anything, his observations help to further elucidate many of the ideas I propose. After that I turn to Gupta, who disagrees with me on several important points.

Verhagen’s four levels of analysis of psychiatric knowledge bring in to focus the fault lines, or the points in psychiatric practice and theory that require critical attention if we are not to inadvertently bring harm upon patients. It is already at the junction of the first level (experience of the patient as incorporated in to a narrative) and the second level (the clinician’s formulation of the story), as Verhagen observes, that there is a risk of losing the uniqueness of the patient’s story, and with it the values she attaches to her experiences and current predicament. Diagnostic devices like ‘criterion B’ and ‘cultural congruence’ may have been introduced to safe guard against pathologizing normality, but as I have demonstrated throughout section 3 of my paper, that cannot be guaranteed, and these devices may in fact be part of the problem.

The problems between the second and third levels of analysis really start at the second level when the story is reformulated in to a ‘case’ with a specific ‘diagnosis.’ Once that is done, clinicians inevitably appeal to the known explanations for the diagnosed disorder, whether psychological or biological. The problem here is that other possible explanatory frameworks, such as spiritual/ religious, are eliminated as possibilities, partly because the patient’s story has been redescribed in the language of disorder thereby losing the essential characteristics that make it her story. Redescribing the patient’s experiences hampers further attempts at meaning seeking (which includes a search for explanation), especially if that occurs in a coercive context (I address this again in my response to Gupta). Finally, it is the fourth level where the epistemological foundation for psychiatry stands. The psychiatric commitment to a positivist/empiricist approach to experience and belief feeds in to the other two levels; it limits the availability of alternative explanatory models in the third and the legitimacy of subjective narrative in the second.

I am in agreement with Verhagen that psychiatrists “need to understand how they are related to their knowledge,” and they also need to be aware what could go wrong at the fault lines, and how that can be rectified. Gupta’s comments are important, and indeed she agrees that clinicians “need to think more deeply and critically about their epistemological stance” (2010, 207) and should try “harder to understand and accommodate the world views of their patients”(2010, 207). But we need a far more critical attitude toward the psychiatric contribution to these fault lines, and a willingness for mental health professionals to modify their practices, and perhaps their beliefs for a more coherent and ethical psychiatry. Below, I attend in detail to Gupta’s comments, but first a summary of her critique is due.

Gupta questions whether in proposing an open-ended process of communication with patients I have sufficiently taken in to account the values, languages, and epistemologies of mental health practitioners, in the same way that I am “appropriately attuned” to those of the patients. She then questions why it is the case that we must prioritize patients’ languages and epistemologies. Following from that, she makes the more explicit point: why do we have to ‘believe’ patients’ accounts and explanations of their experiences? In opposition to my proposal for an open debate (that includes patients/families and not just professionals) over the epistemologies brought to the clinical encounter, Gupta argues that clinicians must remain committed to their epistemologies and the explanatory frameworks that stem from them for two reasons: the first is that the “the commitment to the explanatory framework informs the clinical...