FORUM – PHILOSOPHY OF PSYCHIATRY: KEY RECENT ADVANCES AND FUTURE PERSPECTIVES

Philosophy of psychiatry: theoretical advances and clinical

implications
Dan J. Stein1, Kris Nielsen2, Anna Hartford1, Anne-­Marie Gagné-­Julien3, Shane Glackin4, Karl Friston5, Mario Maj6, Peter Zachar7, Awais Aftab8
1
South African Medical Research Council Unit on Risk and Resilience in Mental Disorders, Department of Psychiatry and Neuroscience Institute, University of Cape Town, Cape
Town, South Africa; 2School of Psychology, Te Herenga Waka-Victoria University of Wellington, Wellington, New Zealand; 3Centre for Research in Ethics, Canada Research Chair in
Epistemic Injustice and Agency, Université du Québec à Montréal, Montreal, Canada; 4Department of Sociology, Philosophy and Anthropology, University of Exeter, Exeter, UK;
5
Wellcome Trust Centre for Neuroimaging, Institute of Neurology, University College London, London, UK; 6Department of Psychiatry, University of Campania “L. Vanvitelli”,
Naples, Italy; 7Department of Psychology, Auburn University Montgomery, Montgomery, AL, USA; 8Department of Psychiatry, School of Medicine, Case Western Reserve Univer­­
sity, Cleveland, OH, USA

Work at the intersection of philosophy and psychiatry has an extensive and influential history, and has received increased attention recently, with the emer­
gence 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 phenom­
enological psychopathology.

Key words: Philosophy of psychiatry, naturalism, normativism, scientism, reductionism, values-­based care, pluralism, mind-­body problem, em­
bodied cognition, enactivism

(World Psychiatry 2024;23:215–232)

Work at the intersection of philosophy and medicine makes an In health care, conceptual competence refers to “the transforma­tive
important contribution by considering key metaphysical issues awareness of the ways by which background conceptual assump­­
(e.g., what is the nature of disease?), epistemological questions tions held by clinicians, patients, and society influence and shape as­­
(e.g., how do we determine the validity of diagnostic concepts?), pects of clinical care”7. These assumptions relate to a range of issues,
and ethical matters (e.g., how does disease impact personhood?). in­­cluding concepts of disease, professional values, causal explana-
Analogous questions arise at the intersection of philosophy and tions, and the mind-­body problem. Here we aim to bring attention to
psychiatry. Since ancient times, implicit and explicit responses and emphasize the importance of conceptual competence for psychi-­­
have had a crucial influence on clinical practice. In the West, for atry.
example, Aristotle’s reply to these questions involved a notion of In the health care sciences, there has been growing attention to
the “golden mean”, while in the East an approach emphasizing evidence-­based approaches, and state-­of-­the-­art reviews are ex­
concepts of yin and yang was developed – these frameworks were pected to synthesize the literature in a rigorous way11. In philoso-
employed to understand disease and deviant behavior, and have phy, there is an ongoing debate not only about the parameters of
influenced clinicians since1,2. good philosophy, but also about whether the field actually makes
Advances in science after the Enlightenment raised new con- progress over time12,13. In this paper, we focus on three areas at the
ceptual questions about medicine and psychiatry. K. Jaspers is a intersection of psychiatry and philosophy, exemplifying a broad
particularly seminal figure in the history of philosophy of psychi- range of conceptual debates in the field, which suggest that some
atry; he not only wrote a key textbook of clinical psychiatry (Gen­ progress has indeed occurred – if not in resolving all conceptual
eral Psychopathology), but also advanced ideas about how best to issues, at least in articulating them clearly – and which have par-
conceptualize and research mental disorders3. His approach has ticular relevance for clinicians.
had an enduring and substantial influence on clinical concepts We begin by considering responses to the key question of the
and practice4. In recent decades, these questions have received nature and boundaries of psychopathology, an issue that has long
increasing attention, with the emergence of professional societies been at the core of philosophy of psychiatry. We then move on to
and conferences, as well as journals, textbooks, and book series consider questions about the nature of psychiatric constructs and
specifically devoted to philosophy and psychiatry5-­9. explanations in general, and about how best to think about the
An influential literature has emphasized the various compe- brain-­mind relationship in particular. In outlining the advances
tences that health care professionals should acquire10. More re- that have been made, and their clinical implications, we argue that
cently, the notion of “conceptual competence” has been proposed. there has been a growing and useful emphasis in the field on soft

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naturalism, on explanatory pluralism, and on embodied cogni- and spurred by the decision to exclude homosexuality as a disor-
tion, concepts that we will explore in more detail. der from the DSM25,26. In philosophy of science, T.S. Kuhn’s notion
of scientific paradigms has been enormously influential27, and in
psychiatry many have proposed paradigm shifts for the field28.
THE NATURE OF “DISORDER” AND THE The clash between different psychiatric models has brought con­
INTERPLAY OF FACTS AND VALUES ceptual conundrums to the fore. The notion put forward by both
neo-­Kraepelinians and translational neuroscientists that mental
In the latter part of the 20th century, a group of thinkers, often disorders are brain disorders, for example, raises a series of inter-­
referred to as neo-­Kraepelinians, saw themselves as ending the related and perennial philosophical issues, including the validity
dominance of psychoanalysis, countering the antipsychiatrists’ of diagnostic concepts, the relationship between different expla-
critique, and re-­orienting psychiatry into the mainstream medi- nations of mental illness, and the mind-­body problem29,30. Each
cal tradition14. In doing so, they looked back to late 19th century of these conceptual issues has important clinical and research im­­
European psychiatry, which became aligned with the rest of plications, as exemplified in vociferous debates between propo-
medicine when E. Kraepelin proposed an influential classifica- ­nents of biologically-­oriented psychiatry vs. psychoanalysis, be­­
tion of mental diseases based on rigorous clinical description tween those who emphasize intrinsic causes vs. social determinants
and natural history. Likewise, the neo-­Kraepelinians claimed that of mental illness, or between supporters and critics of RDoC. Ad-
precisely defined diagnostic criteria could be used to discover dressing these conceptual issues seems increasingly urgent, given
the specific biological causes of psychiatric syndromes and es- the growing recognition of the burden of mental disorders, and the
tablish psychiatry as a branch of medicine15,16. ongoing need for better interventions.
Although the ideas of R. Spitzer, the architect of the DSM-­III, dif­ In this section we focus on the nature of mental disorders, pro-
fered in some respects from those of the neo-­Kraepelinians, this viding a foundation from which to consider other key conceptual
approach helped to undergird the development of that diagnos- debates as the paper proceeds. The nature of mental disorders in
tic manual17,18. Furthermore, advances in psychopharmacology turn raises a series of subsidiary questions, each of which will be
in the 1960s helped support a view that psychiatric disorders are addressed here: What justifies the position that a particular biolog-
discrete entities with specific pathophysiologies, and so respond ical or behavioral state is a disorder? Do psychiatric classifications
differentially to medications. Indeed, D. Klein, a psychopharma- reflect natural features of psychopathology, or do they reflect our
cologist whose work influenced the development of the DSM-­III, clinical and societal interests? Are mental disorders best consid-
put forward the notion of “pharmacological dissection”. He held ered as universal entities that are similar across individuals, or as
that not only did mental disorders respond selectively to particular shaped in particular ways that are unique for each person? What
medications, but so did specific disorder subtypes. For instance, are the implications of psychiatric diagnosis for personal agency?
atypical depression responded preferentially to monoamine oxi-
dase inhibitors19,20.
In the 21st century, however, the relationship between the DSM Disorder status: naturalism and normativism
and biological psychiatry has shifted, with biologically-­oriented
psychiatrists emerging as prominent critics of the manual. T. I­ nsel, In a straightforward binary version of this debate, naturalism
during his tenure as director of the US National Institute of Mental and normativism are opposite and diametrically opposed views
Health (NIMH), exemplified this shift. He emphasized that psy- (see Table 1). The phrase “the disorder wars” comes to mind31.
chiatric disorders are brain circuit disorders, and that descrip- On one end lies strong naturalism, i.e. the view that the concept
tive diagnoses based on symptoms rather than laboratory tests of “disorder” can be described in completely factual and value-­
are not in alignment with the rest of medicine21. He also argued free terms and can best be studied using methodologies continu-
that, because the DSM categories are not biologically-­based, the ous with those used in natural sciences such as chemistry and ge­
use of these categories in research interferes with rather than pro- netics. Many biological psychiatrists of the late 20th century held
moting the discovery of causal mechanisms of psychopathology. this view to the extent that they accepted that psychiatric disorders
Hence Insel supported, in place of the Research Diagnostic Cri- are caused by neurobiological dysfunction and understood abnor-
teria (RDC) that were key to the development of the DSM22, the mal psychology to be the result of objectively deviant brain func-
development of a set of Research Domain Criteria (RDoC) by the tioning15,16.
NIMH23, and foregrounded translational neuroscience as a foun- In the philosophy of medicine, the notion of disorder as objec-
dation for psychiatry21. tive deviation from a state of health is most notably expressed by
Indeed, it might seem that, over the course of its history, psy- C. Boorse. For him, health is a state of normal biological function-
chiatry has lurched from one model to another, in which entirely ing, and functions are normal if they make a causal contribution
different concepts of mental disorder prevail. In the US, it is no- to survival or reproduction that is typical for the species32. Boorse
table that psychoanalytic thought held sway for many decades, has been remarkably persistent in maintaining this view; twenty
before giving way to a more neurobiological perspective24. There years after his original papers, he published a lengthy rebuttal to
has also been considerable debate about the nature and classifi- his critics33, and nearly two decades later, at a symposium on his
cation of mental disorders, as perhaps most notably exemplified work, he again countered his critics34. Indeed, it has been suggest-

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Table 1 Questions in the naturalist-­normativist debate, and possible alter­ disorders arises from a strong naturalist view of physical disease
native responses together with a strong normativist view of mental illness. Diseases
ought to be described in terms of objective pathological changes,
Are there biological and behavioral states that can be characterized as
and, as the states we call “mental disorders” are value-­laden and
dysfunctional or malfunctional in objective terms independent of human
interests? without evidence of such alterations, their characterization as
• Yes, dysfunction can be described in entirely value-­free terms.
dis­­­­­­­­orders or illnesses is a category error, a myth. For Szasz, value-­
• Dysfunction may not be explicitly defined in value-­laden terms, but an ladenness becomes a reason to question the medical legitimacy
evaluative component or human interests will play a role when the concept of psychiatry.
is operationalized in a particular context. It is crucial to appreciate, however, that those who view disorder
• No. There are biological and behavioral processes, but the characterization concepts as inherently value-­laden do not necessarily deny the
of these processes as “dysfunctional” is not an objective fact independent
biological reality of the afflictions. Naturalists and normativists
of human interests.
may agree on the physiological and behavioral facts at hand and
Is there an essence that is shared by all dysfunctions? yet may disagree on whether the state in question is healthy or
• Yes. The malfunctions are grouped together because they share an essence disordered37. As the philosopher R. Cooper has illustrated using a
(e.g., they are all failures of a mechanism to perform a function for which it weeds and daisy metaphor, we can all agree on what a daisy is as a
was naturally selected). species, but disagree on its status as a weed38. Similarly, research-
• No. Dysfunction refers to a family of related concepts, so that there is no ers can agree on the biological mechanisms of premenstrual dys-
one account of it that is uniquely correct or uniquely privileged, and there
is no common characteristic that is shared by all. Some of these concepts
phoric disorder, but disagree on its status as a mental disorder39,40.
may be value-­free and others may be value-­laden. For naturalists, medicine is at its theoretical core a scientific dis-
• Yes. What these processes have in common is a particular social or folk-­ cipline like other natural sciences and subject to a similar sort of
psychological judgment of abnormality. interplay of natural facts and human interests33. For normativists,
disorder concepts are not fundamentally scientific but rather are
Is “dysfunction” necessary for disorder status?
clinical and practical concepts. They are grounded in the experi-
• Yes
ences of distress, disability and disruption, which are interpreted
○ Necessary and sufficient.
to indicate that something has gone wrong and which lead pa-
○ Necessary but not sufficient – a harm component or a human-­interest
component is also necessary.
tients to seek professional help for their problems. From a norma-
• No. Disorder judgments may be legitimately made in the absence of an tivist perspective, medicine is at its core a practical activity aimed
explicit “dysfunction” judgment (e.g., based on considerations of biological at reducing human suffering and enhancing well-­being36,41,42.
or behavioral regularities – “mechanistic property clusters” – and harm). The naturalist-­normativist debate acquires a particular valence
in psychiatry in part because of the way value-­ladenness has been
What are the relevant human interests?
wielded by antipsychiatry figures, such as Szasz, to challenge the
• Diverse considerations of harm (e.g., distress, disability, risk). notion of mental illness. New critical movements have gone even
• Diverse clinical and scientific interests that arise in different contexts.
beyond this approach, by exploring how social and cultural values
• Diverse stakeholders’ interests and values.
impact views of the normal and the pathological. Neurodiversity
• Sociocultural norms (social deviance).
studies, for example, argue that cognitive profiles such as autism
• Functional norms of self-­maintenance and adaptation.
may be socially disabling, but are not intrinsically pathological43,44.
Mad studies similarly resist the pathologizing of diversity and em-
phasize social factors as a cause of distress45,46.
ed that, after Boorse, philosophers of medicine must either work Binary positions have the advantage of being straightforward.
within his theory or explain why not35. However, one disadvantage is that, when they are understood in
On the other end of the divide, strong normativism holds that opposition to each other, their differences are often accentuated,
there is no natural, objectively describable set of biological pro- such that each position may be defined by what the other rejects.
cesses that we can characterize as “dysfunctional”, and hence dis- Further, an important development in philosophy of science has
order attributions are thoroughly value-­laden. Normativists differ, been an appreciation of the role that values play in science and a
however, on the presumed nature of these value judgments. recognition that the notion of value-­free science is not only unten-
For K.W.M. Fulford, disorder is inherently normative because it able but also undesirable47. For example, values influence which
is grounded in the “illness experience”, the patient’s direct experi- scientific problems are prioritized, how they are studied, how un-
ence of something having gone wrong, which is dependent upon certainty is managed, how much evidence is considered sufficient,
social or folk-­psychological intuitions of what is abnormal36. For and how scientific evidence is used to inform practical decision-­
Fulford, the value-­ladenness of the illness experience not only making. The incorporation of values and human interests into a
unites medicine and psychiatry, but also humanizes both fields. broader notion of scientific objectivity has enriched our under-
T. Szasz, renowned for his critique of psychiatry, provides an standing of natural sciences.
entirely different view. For him, disorder judgments in psychiatry Strong naturalism runs the risk of scientism, i.e. over-­reliance
are judgments of deviance based on sociocultural norms, with no on what is currently perceived as factual48,49, while strong nor-
evidence of the presence of a biological disease. His view of valid mativism runs the risk of a relativism where any socioculturally

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disvalued condition could potentially be considered a disorder. judgments about dysfunction are value-­laden but, provided that
In philosophy, a position that has been termed “soft naturalism” appropriate procedures are in place, they can be socially objec-
attempts to avoid both scientism and relativism, and to acknowl- tive64. Nielsen and Ward argue that the key norm violation for dis-
edge the importance of both facts and values in science50. Analo- orders is a breakdown in the norms that support an individual’s
gously, in philosophy of psychiatry, a number of different propos- functioning within his/her social context62. They attempt to “nat-
als have been put forward on how best to incorporate both nat- uralize normativity” by noting that, in the psychiatric domain, dis-
uralist and normative considerations in conceptualizing mental orders entail cognitions and behaviors that run counter to an in-
disorders51. dividual’s self-­maintenance and adaptation needs; disorder status
A particularly influential integrative position, J. Wakefield’s harm­­­­­ is therefore based on the needs of the individual, rather than on
ful dysfunction analysis, is a hybrid view that combines naturalism societal norms.
and normativism in roughly equal measures52,53. One component Strong naturalism can be tempered by acknowledging that val­
of disorder, “dysfunction”, is defined in value-­free, evolutionary ues and human interests play important roles in clinical and sci-
terms. Dysfunction refers to the failure of biological or psychologi- entific contexts. Many would agree that the concept of disorder
cal mechanisms to perform the function which they were naturally invokes value-­laden notions such as disability, harm and suffer­
selected to perform during evolution. The second component of ing65-­67. Authors such as L. Reznek, D. Murphy and R. Cooper con­­
disorder is that the dysfunction is harmful to the individual. Harm- sider disorders to be natural processes that are held together in
fulness is normative and, in Wakefield’s view, largely determined virtue of human interests, akin to categories such as “weed” or
by social standards. Wakefield has applied his harmful dysfunction “vermin”38,68,69. Such weaker forms of naturalist concepts of disor-
analysis to a broad range of psychiatric disorders and, like Boorse, der may be seen as exemplars of a soft naturalism that emphasizes
has engaged widely with critics over several decades54. the complexity and fuzziness of the world, as well as the need to
According to Wakefield, for instance, developing depression in address both the mechanisms underlying disease and the experi-
reaction to a stressor such as loss is an evolutionarily designed adap­ ence of illness70.
tive response to adversity and not a dysfunction. The DSM, there- A view of science as influenced by values can also provide nu­
fore, makes an error by classifying such depressive reactions as dis- ance to strong normativism. This can be tempered by appreciating
orders. It is only when depression occurs out of the blue, or does not that disorder characterizations often require negotiation between
resolve once the stressor is no longer active, or is accompanied by competing values, and arguing that the values which influence our
some specific features (such as suicidal ideation, psychosis, or psy- definition of mental illness can be discussed and critiqued to reach
chomotor retardation), that it becomes reasonable for us to assume a consensus on the type of values that are desirable in psychia-
that mechanisms designed to regulate sadness in response to loss try (e.g., values concerning human flourishing, well-­being, harm
and adversity have failed55,56. reduction, vs. oppressive values such as racism and sexism)71,72.
One recent alternative to Wakefield’s analysis is a hybrid account Notably, Spitzer was open to articulating the values underpinning
offered by J. Tsou. He defines mental disorders as biological kinds DSM-­III73. Further, several authors have advocated for consultative
(value-­free component) with harmful effects (normative compo- decision-­making processes that would include patients’ voices on
nent) and, by doing so, bypasses speculation about what normal psy­­ the question “What is a mental disorder?”, in order to ensure that
chological functions are products of natural selection57. Instead, patients’ interests are represented in psychiatric concepts and clas­­
drawing on the work of R. Boyd on clusters of properties in nature58, sifications39,74-­81.
he argues that valid biological kinds are those that exhibit char- Strong normativism can also be tempered by acknowledging
acteristic regularities due to stable sets of interacting biological that broad scientific agreement can be achieved on the co-­oc­
mechanisms, which allows us to make inferences and predictions cur­rence and co-­variation of signs and symptoms that character-
about diagnostic categories. We can do this because the properties ize the psychiatric conditions regarded as disorders. For example,
that define scientifically valid kinds are produced by similar sets of whether or not people have the symptoms of anorexia nervosa
causal mechanisms. can be seen as an empirical matter, and the decline in functioning
For Tsou, schizophrenia is a disorder because it entails shared associated with these difficulties can be recognized by all observ-
causal mechanisms that result in an identifiable cluster of prop- ers regardless of the value-­laden nature of the standards by which
erties with predictable regularities (i.e., it is a biological kind) and functioning may be judged to be impaired. Furthermore, scientific
because it compromises the capacity of a person to function ad- agreement can also be reached on the involvement of particular
equately as judged by sociocultural standards (i.e., it is harmful). neurobiological processes in specific psychiatric conditions82,
However, Tsou would also include as disorders normal psycholog- even though these processes may not be characterized as “dys-
ical reactions to stress, such as acute depression, which are char- functional” on neuroscientific grounds alone63.
acterized by biological mechanisms that fall in the normal range of Pragmatic considerations have assumed an increasingly prom-
function. Thus, the naturalistic standard of being a biological kind inent role in the conceptualization of mental disorders. Pragmatic
is broad enough to accommodate the range of conditions that accounts, however, tend to focus on clinical and scientific goals
mental health professionals treat. rather than sociocultural norms and values. For instance, in ar-
Additional ways of bridging the naturalist-­normativism divide ticulating the notion of a practical kind, P. Zachar argues that the
have been proposed59-­64. Gagné-­Julien, for example, argues that development of disorder concepts in the DSM and the ICD can be

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seen as an attempt to calibrate concepts to multiple goals such as From a somewhat simplified metaphysical perspective, we may
enhancing reliability, supporting etiopathological validity, facili- think of a classification as demarcating natural kinds, practical
tating communication, guiding treatment, minimizing stigmatiza- kinds, or social kinds. If psychiatric classifications such as the DSM
tion, and promoting research83. and the ICD were demarcating natural kinds, we would expect
The bridging of the naturalist-­normativist divide provides key each diagnosis to correspond to an entity that exists in the struc-
lessons for clinicians. In particular, such bridging offers an impor­ ture of the world, independent of human interests85,86. E. Kraepe-
tant foundation for complementing evidence-­based care with val­ lin, for instance, believed in the existence of natural disease enti-
ue-­​based care. Evidence-­based care is largely focused on a syn- ties in psychiatry, and in addition held the view that pathological
thesis of the medical literature, while values-­based health care anatomy, etiology, and clinical symptomatology including course
reminds us of the importance of assessing and addressing patients’ of illness, would all coincide in the case of such entities92.
values. Values-­based care is consistent with a model of patient-­ The assumption that there are natural disease entities in psy-
centered practice, where the values of individual patients are cen- chiatry was also adopted by the neo-­Kraepelinians, and implic-
tral to evidence-­based clinical decision-­making. Fulford’s model itly guided the development of the DSM-­III93,94. Furthermore,
emphasizes that values-­based health care is skills-­based, with the the Kraepelinian notion of convergence of validators was also ac-
most important skills being awareness (of values), reasoning and cepted by Robins and Guze95, who assumed that their proposed
knowledge (about values), and communication skills84. Each of validators of clinical description, laboratory findings, course of ill-
these skills draws on philosophical sources, but also exemplifies ness, and family studies would all point towards the same disease
good psychiatric practice. entities. This set the agenda for a research program for the next
several decades in which researchers sought to validate the DSM
diagnostic constructs.
Psychiatric classification: tackling essentialism By the 1990s, however, there was growing recognition that dif-
ferent validators might not inevitably align to offer a single privi-
Once we have implicitly or explicitly identified a class of men- leged classification, in a way that amounts to a psychiatric version
tal disorders, a set of psychopathological states, or a community of the periodic table of elements96. Rather, different validators sug-
of psychiatric conditions/mental health problems, we can fur- gest alternative mappings of the space of psychopathology97. For
ther ask: How do we map the territory of psychopathology? How example, in the study of schizophrenia, shared family history sug-
do we distinguish between conditions within the class of mental gests a broad mapping (schizophrenia spectrum), whereas poor
disorders? How do we demarcate disorder from normality? outcome indicates a narrower mapping (schizophrenia). In such
Philosophy of psychiatry has been helpful in clarifying the meta­ a scenario, empirical facts alone do not determine which valida-
physical and methodological assumptions that guide the search for tors we ought to use. Our choice of validators depends also on our
answers to these questions. One common metaphysical assump- assumptions and goals, which may differ from practitioner to prac­
tion in psychiatric classification has been essentialism. This is the titioner and from context to context.
notion that categories have essences, identity-­determining prop- In contrast to the natural kind view is the skeptical view that
erties that all members have in common and that distinguish them the categories of psychiatric classifications are social kinds, almost
from members of other categories. Kinds with essences have been entirely constructed by social processes (i.e., strong social construc­
called natural kinds, meaning that they reflect the structure of the tionism). This view appeals to many critics of psychiatry, who point
natural world. In the context of psychopathology, an essential- towards the obvious influence of sociocultural factors on the pre-
ist view implies that psychiatric disease entities are discovered sentation of psychiatric conditions, and the inability of psychiat-
through scientific inquiry, similar to the identification of infectious ric research to identify diagnostically valid biomarkers. The social
disease entities in medicine, and thus a valid psychiatric classifica- kind perspective is further supported by examples such as “hys-
tion “carves nature at its joints”, as Plato put it85,86. teria” and “multiple personality disorder”, whose popularity among
Philosophy of biology and of psychology have recently focused clini­cians at various points in history has resembled the rise and
on how causal processes and mechanisms undergird observed fall of fashions. There is also increasing awareness that psycho-
phenomena87-­89. When these processes and mechanisms are well pathological phenomena are subject to “looping effects”, such that
understood, professionals are often able to use them as the basis the very act of classification modifies the behavior of the indi­
for classification. This is the case for infectious diseases, in which vidual classified, further supporting the social constructionist
classification based on identification of the causative pathogen view98.
is possible. However, when the processes and mechanisms of an However, this view in its strong articulation seems untenable,
illness are particularly complex, dimensional or multifactorial, as it fails to take into account that scientific research has discovered
knowledge of etiology by itself does not necessarily offer an opti- relationships between neurobiological processes and psychiatric
mal classification, and we rely on additional considerations – on symptom clusters, albeit these relationships do not necessarily
what we want the classification to accomplish – to draw bound- correspond to specific DSM or ICD categories. For instance, psy-
aries and set thresholds. This applies to many areas of medicine, chiatric research has identified hundreds of genetic variations that
but is an issue that is more pervasive and pronounced in psychi- are associated with a range of psychiatric disorders, so that genetic
atry90,91. influences on psychopathology often cut across DSM diagnostic

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boundaries99,100. The relationship between genetic variants and ogy61.
psychopathology is therefore complex and transdiagnostic, but Another strand of philosophical inquiry has focused on the use
not absent or chaotic101. of operational definitions employed by the DSM. In an effort to im­­­
The notion of practical kinds offers a different contrast to the prove inter-­rater reliability and to facilitate psychiatric research, the
essentialist perspective on natural kinds, and aligns with the soft DSM from its third edition on has offered operationalized criteria
naturalist view that psychiatric science is both a scientific and so- for each disorder that specify details such as a list of (relatively spe-
cial process. There may be no “natural joints” in psychopathology, cific) symptoms, number of symptoms that must be present, and
but there are scientific facts in the form of symptom patterns and the duration for which they must be present. How should the rela-
co-­variation that constrain any scientific attempts at nosology102. tionship between the criteria and the disorder be conceptualized?
Within these constraints, the boundaries that we draw will often Lack of clarity in this regard leads to another form of confusion,
reflect our pragmatic goals, and diagnostic thresholds will be influ- in which operational criteria are thought to constitute the disorder
enced by both facts and values. Practical kinds are useful heuristic itself.
constructs that categorize the neurophysiological and psychologi- Operational definitions are partial definitions that do not spec-
cal space in ways that serve our scientific and clinical goals. The ify all the details of the phenomena being studied112. They have an
pragmatic nature of psychiatric classification is also supported by element of vagueness that becomes evident when new scientific
considering the history of psychiatric nosology, which shows the questions force us to articulate concepts with greater precision.
contingent nature of our contemporary diagnostic constructs, The DSM excluded non-­specific symptoms (such as anxiety in
and how our classifications would have looked quite different had depression) from operational criteria, but these symptoms as still
certain key historical figures in psychiatry not existed or had they part of the syndrome being described (e.g., depression). Moreover,
made different choices103,104. the polythetic nature of DSM criteria allows for many different
Distancing ourselves from essentialist assumptions about natu- symptom configurations to meet disorder threshold, but these dif-
ral kinds in psychopathology allows us to appreciate the complex- ferent symptom configurations are not seen to constitute different
ity of mental disorders, and makes it possible for us to map and disorders. Instead, they are better understood as different ways in
model psychiatric phenomena using different approaches. For which we can identify a disorder.
example, idiographic approaches focus on the uniqueness of the K.S. Kendler has elaborated on the distinction between diag-
individual psychiatric patient – how his/her mental health prob- nostic criteria as indexical and constitutive113. When diagnostic cri­­­
lems arise from a specific combination of predisposing factors, de- teria are regarded as indexical, they are understood to be fallible
velopmental history, life experiences, behavioral adaptations, and ways to identify a disorder; when they are regarded as constitutive,
psychological defense mechanisms. Such an approach utilizes the symptom criteria are the disorder. According to Kendler, the
broad principles of psychobiological functioning to formulate a DSM criteria are intended to be indexical, and viewing them as
narrative specific to a patient. The aim of classification, then, is to constitutive is a conceptual error. Thus, for example, there are 227
aid the development of a clinical formulation. ways to meet DSM criteria for major depression, but these are dif-
The failure to identify etiologically-­based disease categories has ferent ways of indexing major depression, not 227 types of major
also spurred psychometric efforts to model psychopathology. Psy- depression114. There is no single and privileged correct operation-
chometric analysis goes beyond manifest variables, which can be alization; rather, different operational definitions can be refined
directly measured or observed, to mathematically model latent and optimized for different purposes.
or hidden variables, which cannot be observed directly and only Taken together, an emerging contemporary view of psychiatric
emerge through statistical analysis. This quantitative statistics re- taxonomy incorporates the dimensionality of psychopathology
search program is exemplified by the Hierarchical Taxonomy of (there are few discrete entities), insights from complex dynamic
Psychopathology (HiTOP) consortium105. This attempts to com- systems (relatively stable symptom patterns can emerge from ir-
bine signs and symptoms of psychopathology into homogeneous reducible interactions between multiple factors), and perspectives
traits, to assemble such traits into empirically-­derived syndromes, from embodied cognition (causal mechanisms traverse the brain,
and then to group these syndromes into spectra (e.g., “internaliz- body and environment). Such a view of psychopathology does not
ing” and “externalizing”)106. render categorical diagnostic systems such as the DSM and the
The psychometric approach of HiTOP has generated consid- ICD invalid or useless, but it encourages us to give up an essen-
erable debate107-­109. First, in clinical practice there do seem to tialist bias that has led us to reify them – to attribute them a corre-
be some discrete entities, which respond to specific treatments; spondence to objective reality that they do not possess115,116.
narcolepsy, for example, can be diagnosed using an accurate bio- How is this view of taxonomy relevant to clinical practice? Cli-
marker, and can be effectively managed using particular medica- nicians need to be aware of the work that has gone into, and the
tions. Second, dimensions and categories are not necessarily mu- value of our nosology, while also being mindful of its tentative
tually exclusive; for example, on the dimension of extraversion, a nature and significant limitations117. In particular, although the
particular cut-­point can be used to define an extrovert110,111. Third, DSM has clinical utility, it has often been criticized for facilitating
of particular relevance to positions that emphasize the importance a checkbox approach to psychiatric assessment and evaluation.
of causal mechanisms for classification, psychometric approaches Clinicians ought to be aware that important features of mental dis-
emphasize descriptive features and may elide underlying etiol- orders may well have been described in the psychiatric literature,

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and yet may not be listed in the DSM118. Further, while diagnosis the interpersonal and social costs of perceived diminished agen-
may begin with the DSM or the ICD, a comprehensive evaluation cy, which, while sometimes decreasing perceived responsibility,
needs to assess a range of domains, including clinical subtypes, might simultaneously increase other forms of aversion. Indeed,
symptom severity and staging, cognitive schemas, environmental empirical research has suggested that in some contexts biological
stressors, and protective factors119. Finally, clinical formulations conceptions may ultimately be more stigmatizing for affected in-
need to supplement our growing knowledge of the characteristics dividuals129.
of psychiatric disorders with an idiographic understanding of each The awareness of the impact of psychiatric diagnoses on the
individual patient120. self-­conception and self-­understanding of those diagnosed has
supported the view that people with lived experience might use-
fully contribute to the development of psychiatric classifications.
Psychiatric diagnosis and personal agency They may be better situated to assess the impact of changing di-
agnostic criteria on access to care or the potential risk of stigma
Debates concerning psychiatric taxonomy may have impor­ associated with certain nomenclature issues, or be better able
tant implications for individual self-­conception and self-­under­ to identify mismatch between diagnostic criteria and subjective
standing121. As noted, the DSM criteria should not be taken literally experiences39,74-­81.
as being fully constitutive of disorders, but they are nevertheless The clinical implications of different conceptual approaches
often taken as such, and the influence of the DSM on how men- to personal agency and moral responsibility have been debated
tal disorders are perceived has been profound. Concern has been by philosophers, and this area deserves further attention and re-
raised about the undue extent of this influence, especially given search125,126.
the inevitable neglect of person-­and context-­specific factors in di-
agnostic criteria121.
More broadly, debates about the nature and classification of dis­­ PLURALISM IN PSYCHIATRY
orders are also implicated in the effort of patients to understand
the boundaries of their selves in relation to their disorders. Given In philosophy of science, Kuhn’s notions of dominant scientific
that both psychiatric conditions and psychiatric medications can paradigms that are incommensurable, and of revolutionary shifts
affect deep aspects of self-­experience (such as perceptions, desires in such paradigms27, have become very influential. Arguably psy-
and feelings), ambiguity and uncertainty can arise with regard to chiatry provides a useful exemplar of how different paradigms
where the “self” begins and ends, and how the self is impacted (or dominate over the course of time. In fact, critics of psychiatry have
compromised) by both illness and treatment122,123. The experience argued that the replacement of one psychiatric paradigm by an-
of ambiguity at the phenomenological level can be further com- other may entail neither scientific progress nor clinical advance-
pounded when patients are “confronted with the vagueness and ment130,131.
uncertainty associated with the issue of ‘what is a psychiatric dis- At the same time, Kuhn has been criticized for his relativism132.
order’”123. After all, scientific models can be reasonably compared, and there
Questions concerning the interplay of agency and mental disor- may be justifiable grounds for replacing one model with another.
ders have also been central to debates concerning the relevance of In psychiatry, although there have certainly been important shifts
these disorders to assessments of moral responsibility. While psy- in theoretical frameworks, it might also be argued that current
chopathology has often been treated as paradigmatically exempt- clinical research and practice incorporate valid aspects of both
ing or mitigating in the literature on moral responsibility, there psychodynamic and neurobiological approaches, as well as con-
has been a growing shift to more nuanced assessments and an in­ cepts and data from a range of other models of psychopathology.
creasing emphasis on the need for case-­by-­case evaluation124. Different models may be able to engage usefully, as evidenced by
These trends reflect the larger recognition of person-­specific and the emergence of neuro-­psychoanalysis, or by work on how psy-
situation-­specific factors that affect the manifestation of psycho- chotherapy impacts on neuroimaging. Psychiatry has arguably
pathology in any particular individual. In many cases, the rele- advanced precisely by incremental integration of a range of valid
vant agential capacities are diminished or deeply compromised, models28.
but nevertheless present. In addiction, for example, it is often im- Psychopathology seems to involve multiple causes, and it is pos­­
plausible to speak of blanket incapacitation, given that aspects of sible that different psychiatric models shed light on different causes.
choice and deliberation are often involved. A useful body of philo- Philosophers, starting from Aristotle, have long emphasized the
sophical work has explored the question of responsibility in the importance of multi-­causality in both biology and pathology1,133.
context of mental disorder125-­127. Be­havioral scientists have similarly emphasized the need to expli-
More broadly, the question arises of how different ways of con- cate different kinds of causes of behavior and psychopathology134,​
135
ceptualizing psychiatric disorders influence our attitudes towards . Jaspers, a philosopher-­psychiatrist well known for distinguishing
affected individuals. While it was presumed that more biological between knowledge of causal explanations and understanding of
conceptions of disorders would reduce stigmatizing attitudes in meaningful connections3, can be regarded as a methodological plu-
general, empirical research points to far more complex interac- ralist, with his pluralism influencing a range of subsequent authors
tions128. These findings align with theoretical concerns regarding in philosophy of psychiatry136.

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In contemporary philosophy of science, there is an ongoing de­­­­­­- mulating scientific appreciation of psychobiological structures,
bate about whether and how diverse explanations can be inte- processes and mechanisms157.
grated137. In the 1970s, G. Engel, an American internist who had The notion of “soft natural kinds” may be useful in the clinic in a
ex­­­perience working with psychosomatic disorders, argued that the number of ways. Consider the construct of “behavioral addiction”.
dominant model of disease was biomedical, thus neglecting the From a neo-­Kraepelinian perspective, the lumping of substance
psychological and social dimensions of illness138. He therefore pro- use disorders together with gaming and gambling disorders sug-
posed a biopsychosocial model, aiming for a framework that could gests that these conditions have overlapping phenotypic features,
be used in research, teaching and clinical care. Clearly, it is impor- and share key validators, such as clinical course. In fact, however,
tant that we avoid both a brainless psychiatry and a mindless psy- the situation may be much “fuzzier”: the psychobiology of alcohol
chiatry139, steering clear of both scientism and culturalism (which dependence is likely to differ significantly from that of gambling
are overly reductionist about science and culture respectively)49,140. disorder, given that alcohol has direct toxic effects on the brain.
However, the biopsychosocial model has also received stinging However, a key rationale for lumping these conditions may instead
criticism for being overly eclectic and non-­specific141, and for offer­ be a public health perspective158.
ing no particular framework to conceptualize multi-­level causal Consider also the boundaries between disorder and normal-
interactions142 or allow optimal selection of causal mechanisms143. ity159. Current versions of the DSM and the ICD appropriately em­­­­
Further, its practical use in psychiatric formulation has led to an in- phasize that the boundary between disorder and normality is not
advertent reification of “biological”, “psychological” and “social” as hard and fast, but rather can be fuzzy and indeterminate. In some
distinct ontological domains144. Ongoing efforts to understand the other areas of medicine, biomarkers can be helpful in making the
nature of causal explanations in science in general145,146, and in psy- clinical decision as to whether a disorder should be diagnosed,
chiatry in particular147,148, remain therefore crucial. but this is not the case in psychiatry. Critics of psychiatry may con­
An explicit emphasis on pluralism is a relatively recent develop- clude that mental disorders are entirely a matter of convention,
ment in philosophy of science149. Unsurprisingly, for philosophers and that psychiatric diagnosis is merely a matter of “labelling”.
who regard it as important, there is not a single unified approach However, this ignores the complex reality of mental signs and sym­
to pluralism. Instead, from the time of Aristotle, through the work ptoms: psychiatric phenotypes are not elements in a periodic table
of early American pragmatists150,151, and on to contemporary phi- but rather are comprised of overlapping dimensions, and thresh-
losophers152,153, a number of different pluralisms have been delin- olds for disorder reflect a range of considerations160.
eated and developed. We next consider three important notions The second notion to consider is explanatory pluralism. Phi-
of pluralism – ontological pluralism, explanatory pluralism, and losophers have emphasized that science employs multiple partial
value pluralism – as well as some of their clinical implications. 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
Different notions of pluralism of reality, and each of which is useful for a particular purpose. As
noted earlier, in philosophy of psychiatry there is ongoing debate
The first notion to consider is ontological pluralism. As noted about the extent to which the biopsychosocial model, which en-
earlier, the notion of natural kinds reflects the possibility that na­ courages a focus on different dimensions of disease and illness, is
ture can be carved up in an objective way to form discrete enti- merely eclectic, or provides the appropriate scaffolding for consid-
ties85,154. Exemplars of such natural kinds are often found in phys­ ering a range of causal mechanisms.
ics or chemistry; the periodic table of elements is a particularly A major area of debate in philosophy of science regards reduc-
compelling one. Ontological pluralists have, however, argued that tive explanations. It has long been argued that the phenomena of
there are different ways of dividing reality, reflecting different sci- the world can be organized along different levels, ranging from the
entific interests and values, and that a range of different classifica­ physical through the biological and on to the social. A reductionist
tions may be valid. From the time of Aristotle, pluralists have of­­ approach aspires to explain higher level theories (e.g., biological
ten looked to biology. Species can certainly be divided on the basis models) in terms of lower level accounts (e.g., physical models).
of their evo­lutionary history, but there are also alternative ways of Certainly, as science has progressed, such inter-­theoretic reduc-
­clas­­si­­fying organisms155,156. tion seems to have occurred; thus we can account for the prop-
Our earlier discussion emphasized that mental disorders are erties of DNA (which plays such a key role in biology) in terms of
not simply natural kinds that emerge from empirical investiga- its particular structure (that is, in terms of its underlying physico-­
tion. At the same time, our constructs of mental disorders are not chemical properties)161,162.
merely conventional. Instead, they are rigorously informed by sci- Pluralists have emphasized, however, that such successes are
entific research, including work on a range of different validators, only part of the story of science. Science is often concerned with
which reflect the involvement of a range of different underlying phenomena that emerge only at higher levels of organization:
structures and mechanisms. They may be regarded as “soft natural these require models that cannot simply be reduced to lower level
kinds”; although they cannot simply be discovered by carving na- accounts163-­165. Furthermore, as emphasized in the metaphor of
ture at its joints, and although our classifications and descriptions science as cartography, multiple different sorts of models of reality
are value-­laden, these entities nevertheless incorporate an accu- may be useful for different purposes. Focusing on biological sci-

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ence, S. Mitchell concluded: “Given the multiplicity of causal paths ICD-­11, for example, do not necessarily reflect scientific disagree-
and historical contingency of biological phenomena, the type of ment, but rather acknowledgment of differences in their most im-
integration that can occur… will itself be piecemeal and local… portant aims and associated values179.
Pluralism with respect to models can and should coexist with in- Additionally, the argument that natural kinds reflect clusters of
tegration in the generation of explanations of complex and varied properties has been extended to value-­laden constructs. “Healthi-
biological phenomena”166. ness”, for example, may reflect a range of related features, presum-
Discussions of pluralism often refer to the relationships between ably underpinned by relevant biological processes180. However, if
different “levels” of explanation, but “levels” themselves are better we think back to normativist positions on the definition of men-
un­­­derstood as ways of referring to different sorts of organization­ tal disorder, which emphasize the influence of social and cultural
al (part-­whole), spatial and temporal relationships167. Slow vs. fast values, different societies and cultures may have different under-
and large vs. small might carve things up differently than higher standings of mental disorder because they value different concep-
vs. lower, so that a pluralist approach to explanation is required167. tions of human flourishing42.
In philosophy of science and neuroscience, there is an ongoing Philosophical work on value pluralism has long emphasized
exploration of how best to conceptualize causal processes and that, given the plurality of values, choices between them will be
mechanisms, including causality across different levels168-­171. For complex. The philosopher I. Berlin emphasized that different val­
psychiatry, however, it is key to be aware of the complexity of psy­­­­ ues may be incompatible, and this seems consistent with our ex-
chobiological systems, and to avoid overly simplistic neuro-­reduc­­ perience of moral decision-­making181. Nevertheless, this does not
tionism75,172,173. necessarily mean that value-­laden choices cannot be made in
Once again, these philosophical constructs have practical im- a reasonable way. Aristotle emphasized the importance of prac-
port. Psychiatric practice and research ought to involve a broad tical wisdom, arguing that a virtuous person succeeds in making
range of disciplines and methodologies. Applying scientific plu- correct choices182. While practical wisdom may in part involve the
ralism to psychiatry, Kendler has argued that first-­person subjec- application of general principles, Aristotle emphasized the “prior-
tive experiences and sociocultural factors play a vital role in the ity of the particular” in choosing the correct course of action183.
etiology of psychiatric disorders, such that this etiology cannot be Value pluralism again has a number of clinical implications. As
captured by just focusing on the basic biology of the brain174. He noted earlier, the psychiatrist-­philosopher K.W.M. Fulford and his
suggests that a pluralistic psychiatry should aim for “patchy reduc- colleagues have argued that evidence-­based health care needs to
tionism” and “piecemeal integration” as it tries to understand the be complemented by value-­based health care184. A growing litera-
multi-­level causal interactions that give rise to psychopathology ture on shared decision-­making similarly highlights the important
174
. perspectives of those with lived experience of mental illness185,186.
When we think about psychotropic medications, for example, Furthermore, value pluralism emphasizes the importance of a
we often focus on specific receptor effects. While important, this range of epistemic virtues, including epistemic and cultural humil-
downplays how these agents exert a cascade of effects, impact- ity187.
ing 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 Conceptual tools for psychiatric explanation: beyond
explanations involving a range of mediating processes are needed reductionism
to explain higher-­level phenomena such as placebo and nocebo
effects, and to account for molecular-­social interactions such as Three important and interrelated concepts may be useful for
how antidepressants acting on serotonergic pathways may impact psychiatric explanation: dynamical constitution, downward cau­
social hierarchy. While the focus of much psychopharmacology sality, and dual aspectivity188-­191. They are employed in several
has been on lower-­level mechanisms, such as receptor actions, a recent pluralistic approaches, and are important aspects of the
pluralistic approach emphasizes that cognitive and phenomeno- embodied approach explored later.
logical processes can also be important psychopharmacological Dynamical constitution is the notion that objects and processes
targets175. Analogously, a pluralistic approach may be useful in at smaller scales of enquiry can interact over time in ways that pro-
exploring the causes of change during psychotherapy176, and in duce objects, systems or processes at larger scales of enquiry, and
developing integrative models of psychotherapy177,178. that qualities of the larger objects can emerge from the interaction
The third notion to consider is value pluralism. This notion, between the component objects and processes188,190. Downward
which emphasizes that there are many different moral values, is causality is the idea that these emerging objects, systems and
typically considered as a position in moral philosophy. However, processes at larger scales of inquiry can entrain, constrain or oth-
value pluralism is also relevant to science in general, and psy- erwise have causal influence over objects at smaller scales. Dual
chiatry in particular, in a number of ways. In particular, choices aspectivity refers to the idea that, whenever talking about a living
about how best to classify and describe the structures and mecha- system, there are at least two perspectives that one can take: first,
nisms of the world reflect a range of epistemic values, and indeed a body-­as-­object, naturalistic or third-­person perspective; second,
debates about scientific pluralism intersect with debates about a body-­as-­subject, personalistic or first-­person perspective. Both
science and society137. Differences between the DSM-­5 and the perspectives consider the same physical object, but they capture

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different aspects of the living system/person under study, in line body exist as radically different kinds of substances – and clini-
with a pluralist approach189,192. cians are typically encouraged to avoid this position in light of a
Taken together, these concepts provide an approach to under- modern naturalist or scientific understanding. At the same time,
stand constitutionally complex systems such as life forms. Organ- clinicians are generally not encouraged in their training to explore
isms are made up of many parts (e.g., organs, cells, receptors) and recent developments in an area of such philosophical complexity,
derive properties, such as mindedness, from the complex interac- and as a result some implausible assumptions can arise199.
tions between these parts in context. Both the parts and the wider One commonly assumed view is that the mind is a powerless
organism are no less real because of the knowledge that we gain or “supervenient” side effect of the physical processes of the brain.
about the parts and how they manage to dynamically constitute Such a view can support neurocentric assumptions, for example,
a minded creature. Analysis at multiple scales of enquiry – con- within a biological psychiatry which contends that the brain is
sistent with an emphasis on a complex systems framework and a where we need to focus the vast majority of our explanatory and
pluralist approach – is useful for understanding how this creature treatment efforts. As noted earlier, while the brain is clearly im-
functions and how things may go awry. portant for understanding mental functioning and mental health,
From a clinical perspective, these considerations emphasize such an approach may be criticized for its neuro-­reductionism,
the complexity of clinical formulation and intervention. Given where minimal space is made for similarly important aspects of
dynamical constitution, neurobiological mechanisms are key to human functioning such as experience, meaning, culture and con­
shaping behavior, thoughts and emotion. However, given down- text.
ward causality, such mechanisms cannot be assumed to have Another common view, inspired by the development of com-
caus­­­al primacy in our explanations. In contrast to the view of neo-­ puters, is to see the mind as a “software” running on the “hard-
Kraepelinians and overly reductionistic translational neurosci- ware” of the brain. Under such a computationalist and functional­
ence, mental disorders are not merely brain disorders29,30. Con- ist view, cognitive functioning is understood as a form of informa-
versely, interventions such as psychotherapy may impact both tion processing where the brain takes sensory input and computes
brain and mind193. appropriate responses. Such an assumption can be seen in the
The biopsychosocial model remains the most influential for en­­­­­ notions of cognitive biases and core beliefs in cognitive-­behavioral
suring a pluralistic approach to assessment and intervention for therapy, with these biases or beliefs effectively performing the role
mental disorders in the clinical context. Despite criticisms that of “bugs in the software” altering our perception of the veridical
­highlight its shortcomings, including the absence of an explanato­­ world. While this can be a useful metaphor, there are multiple
ry account of causal interactions, this model remains valuable be- issues with this perspective. It is difficult to see how such a view
cause it prompts us to resist simplistic binaries – such as the organic can be integrated with a biological perspective, in which neurons
vs. functional, biological vs. psychological, medical vs. social, and and behaviors are complexly intertwined. Indeed, such a view
disease vs. behavior distinctions – in our explanations of psychi- seems implausible; living creatures are not computers with set
atric etiology194,195, and serves as a powerful reminder that a plu- functions, and this analogy may limit our insight.
ralistic framework which considers a broad range of “difference-­ Moving beyond assumptions of supervenience and compu-
makers” is needed in clinical research and practice75,117,148. tationalism, embodied cognition represents a biologically plausi-
Jaspers’ insistence that both explanations of underlying mech- ble and strongly integrative view of the mind-­body relationship,
anisms and understanding of individual meanings are important whereby factors across the biopsychosocial spectrum are consid-
for a comprehensive account of mental disorders remains relevant ered to have potential explanatory value144. Such an embodied
to contemporary clinical practice. Medical anthropologists have perspective has gained momentum within philosophy of psychi-
usefully distinguished between disease as a biomedical condition, atry in recent years, but is not yet broadly recognized by clinicians
and illness as the subjective experience of those suffering from nor discussed in training programs. Engagement with embodied
that condition196. Relatedly, work on what has been termed “neu- understandings of the connection between mind and body is a key
rophenomenology” attempts to integrate neuroscientific knowl- development in philosophy of psychiatry.
edge with individual experience192,197. Finally, “explanation-­aided Applied to psychopathology, notions of embodiment, along-
understanding” – the idea that knowledge of causal mechanisms side related ideas such as embedment, extension and enactivism,
can enhance our appreciation of first-­person experience – is also a which we will soon unpack, represent one plausible integrative
key consideration for improving clinical practice198. 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
EMBODIED COGNITION AS A PLAUSIBLE in previous sections, while also cohering well with other contem-
INTEGRATIVE APPROACH porary theoretical and methodological developments in a range
of disciplines. In this section, we first define some key terms and
The “mind-­body problem” is a paradigmatic issue at the inter- review the development of embodied cognition. We then go on to
section of psychiatry and philosophy. The philosopher R. Des- discuss the application of this approach to the study and treatment
cartes is often cited for his substance dualism – that mind and of mental disorders.

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What is embodied cognition? tory, a non-­representational and embodied view would suggest
that we engage with simple visual strategies in order to ensure that
Embodied cognition refers to a diverse range of approaches we are in an optimal position to catch it203. This sense of embodi-
across multiple disciplines within cognitive science, including but ment is particularly associated with the position of “radically enac-
not limited to psychology, neuroscience, philosophy, robot­ics, tive cognition”, which attempts to understand cognitive processes
and artificial intelligence. Embodied cognitive science is unit- with no reference to representation204.
ed by a common interest in moving away from a “cognitivist” or When the term “embodied” is used in a conceptualization sense,
“com­­­­putationalist” view, where the brain is seen as an isolated the focus is on psychological concepts and processes, and how
“seat of cognition” that receives sensory information, represents they are shaped by the kinds of bodies and experiences we have.
the world, and computes appropriate responses to it. Instead, The key idea is that the way we conceptualize the world would
embodied approaches variously emphasize the role of the body likely be different if we had different sorts of bodies to navigate
and context both in the moment-­to-­moment constitution of cog- with. For example, consider the idea that we think in terms of “up”
nition and in the shaping of cognition across development, thus as metaphorically connected to positivity and action, and “down”
decentering the ideas of representation in how we seek to under- as connected to depression and inaction, not simply as a cultural
stand the mind200. Instead of understanding the mind through quirk but because of shared associations rooted in our bodily ex-
implicit analogy to computers, embodied approaches seek to periences and actions205. Accumulating behavioral and neurobio-
understand it through analogy to complex living systems adapt- logical evidence supports the related ideas that: a) there is signifi-
ing to the dynamics of their environment. cant overlap in the neural processes involved in sensorimotor co-
Historically, the development of embodied cognition has many ordination and those involved in so-­called “higher” cognitive and
roots. The most commonly recognized of these roots include: a re- social processing, and b) such overlap means that “higher” cogni­
jection of a traditional symbolic-­representational view of cognition tive processes are not siloed in the brain, but are influenced by
where the experienced world is a model/representation of reality; bodily and sensorimotor context such as posture, current action,
an interest in expanding upon the success of minimally repre- and internal physiological state206,207.
sentational “connectionist” understandings of cognition such as When used in a constitutional sense, which is our main focus
exemplified by neural networks; the emphasis of pragmatic phi- here, “embodied” refers to the idea that mental processes are best
losophers such as J. Dewey on how knowledge entails interaction thought of as not constituted by the brain alone, but rather as
with the world; phenomenological insights by authors such as M. emerging from the brain and body acting in concert, i.e., as one
Merleau-­Ponty that the body is an intrinsic part of our experience-­ extended system. The mind does not arise from the efforts of the
of and engagement-­with the world; work in developmental psy- brain to represent the world, but rather is an active process of the
chology by J. Piaget and others who have emphasized interaction entire organism navigating, adapting to, and making sense of the
with the world over time; and inspiration from the success of dy- world197,205,208-­211. In such a view, for example, the release of corti-
namic systems theory in modelling the behavior of complex sys- sol and adrenaline from the adrenal glands in response to an acute
tems201. Such historical antecedents have converged to produce stressor is not simply an event occurring at one level of analysis
understandings of the mind that recognize a broad range of in- with a modulating effect on cognition at a higher level of analysis,
fluences shaping human cognition, from genes and molecules to but rather is part of a single, body-­involving, cognitive-­affective
culture and context. response to threat. Thus, the processes that constitute emotions
Embodied cognitive science is a diverse field. This is true to the weave in and out of the brain, and include a range of interocep-
point that the very word “embodied” can take on subtly differ- tive components207,212. This sense of embodiment incorporates
ent and overlapping meanings in different contexts. It is there- the ideas of dynamical constitution, downward causality and dual
fore important to specify the sense in which we use this term. In aspectivity, discussed earlier.
a summary review of embodied cognition, Shapiro and Spaulding Now that we have outlined what is meant by embodiment, it is
highlight three different yet overlapping themes within the various useful to define some related ideas, specifically those of embed­
usages of the term “embodied”. They refer to these three different ment, extension and enactivism. Together these ideas, alongside
themes of overlapping meaning as constitution, conceptualization embodiment, are often discussed under the umbrella term “4E”.
and replacement202. In this paper, we generally refer to the constitu­ Sometimes “5E” is also used, typically in reference to a focus on
tional understanding of embodiment. It is, however, worth briefly emotion.
explaining all three senses of the term. Embedment is the idea that cognitive functioning involves a
In the replacement sense of “embodied”, emphasis is on the constant interplay with the environment across multiple time-
need to replace our systems of understanding the mind with less scales. Consequently, in order to understand cognition, recogni-
representational and more dynamical ones. In other words, devel- tion of the role of context is vital. When considering human func-
oping ways of understanding the brain, not as generating a mirror-­ tioning, the environment is also regarded not simply to be a physi-
like representation of the world, but rather as resonating with the cal one, but a social-­cultural one, constituted by others, alongside
world directly. A classic example would concern how best to think their artifacts and shared structures of meaning213. Embedment
about the action of catching a fly ball in baseball. Rather than rep- highlights that, across the timescales of evolutionary change,
resenting the entire environment and computing the ball’s trajec- sociocultural development, life-­span learning, and moment-­to-­

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moment cognition, human beings are both deeply influenced by, to solving the “integration problem” in psychiatry; i.e., the fact that
and in turn influence, their surrounding environments. Even the we have identified causal factors across the brain, body and en-
most abstract and intellectual activities, such as mathematics, en- vironment, but struggle to conceptualize how these causes come
tail a thoroughly embodied and embedded skill set192,205. together to shape patterns of disorder220.
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 be- Clinical applications of embodied/4E cognition
yond the body and looping through the world213. To continue the
mathematics example, rather than merely understanding a calcu- Several conceptual frameworks grounded in the embodied/​​4E
lator as supporting the cognitive processes of an individual, an ex- perspective have been applied to mental disorders as a whole189,​
191,220,221
tended view of mind would hold that the calculator becomes part . These frameworks view mental disorders as representing
of the cognitive process. In a well-­known thought-­experiment, disruptions to sense-­making, a view that is consistent with attempts
Clark and Chalmers contrast Inga, who navigates from memory, to bridge the naturalist-­normativist divide, with an emphasis on
with Otto, who has Alzheimer’s disease and relies on written direc- the adaptive fit between individual and context that aligns with
tions in a notebook. Given that the only difference between the soft naturalism62,222. They also share a vision that embodied/4E cog­
two cases is that the process of navigation takes place wholly inside nition serves as an integrative framework for the conceptualization,
the brain in Inga’s case and partly outside it in Otto’s, they argue study and treatment of these conditions, consistent with an empha-
that it is arbitrary to limit cognition to what occurs within the con- sis on multi-­disciplinary and pluralist approaches. Additionally,
fines of the skull214. there have been several efforts to develop descriptive and explana-
Enactivism is an idea that subsumes and builds upon those tory models of particular mental disorders from an embodied/4E
of embodiment and embedment. It may be explained in differ- perspective223-­228.
ent ways and with different points of emphasis, but here we focus A focus on embodied cognition leads to a view of mental dis-
on autopoietic enactivism215. “Autopoietic” simply means “self-­ orders as constitutionally complex, involving biological, cognitive-­
creating”. Accordingly, within autopoietic enactivism, the focus is emotional, environmental and sociocultural aspects. This per-
on the notion that mindedness is brought forth, or rather enacted, spective emphasizes both biology and agency, acknowledging
through the organizational structure of life forms and their efforts biological scales of enquiry as relevant without reducing the ex-
to constantly maintain themselves within the context of their envi- planatory importance of experience and choice. It also incorpo-
ronment. An enactive perspective holds that life forms are shaped rates ideas of dynamical constitution and downward causality to
through evolution to try to survive, and that this inherent purpose break down the received mind-­body divide, and aligns well with
sets up the necessary groundwork for the emergence of relational the notion of mental disorders as fuzzy mechanistic property clus-
meaning. In order to survive, organisms have to learn how to seek ters229.
food, avoid predators, and so on – that is, to respond differentially Through the notion of embedment, these frameworks empha-
to affordances in the world216. Cognition is sense-­making – a con- size the active and historical role of the physical and sociocultural
stantly unfolding process, one that involves body and action, is environment. All organisms, particularly humans, are deeply his-
relational, and is inherently affective/meaning-­laden. Thus, cog- torical and ecologically informed creatures. Shaped by our evolu-
nition is not a linear process of sensation-­perception-­cognition-­ tionary, sociocultural and developmental pasts, we are understood
action, but rather a circular process of sensory-­motor engage- to strive to adapt to the present context and predicted future207,212.
ment. The brain, rather than taking in information and represent- Applied to psychiatry, this allows integration with perspectives
ing a model of the world, as in the neurocentric view, is instead an such as evolutionary psychiatry230, cultural psychiatry196,231, and
organ of coordination, learning and mediation within this sensori- developmental psychopathology232.
motor loop, so allowing for more complex ways of making sense of In the embedded view, however, culture is not seen only as a
and acting in the world189,217. historical force having influence across development, but also as
Overall, the embodied/4E model of cognition presents a non-­​ a living context. In this “constitutional view”, culture is seen as a
dualistic understanding of the mind that appears biologically plau- “shared world” or structure of knowledge, meaning and artifact,
sible and does not fall prey to reductionistic temptation. Human constituted by ongoing engagement212. Such a shared world rep-
functioning is understood from this perspective in a way that pre­ resents a historical context for the development of individuals and
serves a sense of agency, while also recognizing the diverse array of the way they make sense of the world, but also continues to play
influences that shape and influence human health and behavior, out in the moment-­to-­moment interaction of individuals, includ-
from genes to culture. It is therefore an integrative view, demand- ing in the clinical encounter. Embeddedness therefore pushes cli­­
ing both current and historical analysis of the entire brain-­body-­ nicians to actively consider the role of culture in the lives and his-
environment system if we are to understand patterns in human tories of their patients, and in the clinician-­patient interaction.
behavior and cognition. This approach is consistent with a coor- Via the notion of enactivism, these frameworks subscribe to
dinated pluralism218, and arguably even with an integrative plural- a process orientation, with mental disorders not viewed as static
ism219, and has led to the suggestion that accounts of mental dis- problems/dysfunctions in the brain or psyche, but rather as con-
order grounded in embodied/4E cognition may represent a path stantly unfolding patterns of how we make sense of and engage

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with the world. Through interactions with their specific environ- deeply altered in a way that often works against his/her values,
ment and its particular affordances, thinking beings create and and the person enacts a particular and inflexible way of trying to
discover meaning for themselves. Rather than stemming from meet his/her needs. In this framework, a merely neural model is
some underlying “cognitive error” or “psychic disturbance”, men- replaced by a view of addiction as simultaneously neuronally-­and-­
tal disorders emerge within the circular relationships between externally constituted, and there is an account of how drug-­taking
patient and world – as a maladaptive pattern of sense-­making191. transforms the world of the individual – altering his/her personal
This process orientation accords well with the focus of neuro- agency and lived experience.
science and computational psychiatry on active inference, where- There are several advantages of such a view. First, this perspec-
by predictive processing frameworks formally model how organ- tive allows an integration of neurobiological accounts of addic-
isms develop probabilistic assessments of their environment so as tion with accounts of lived experience. Second, the binary choice
to adapt optimally. Indeed, several authors have considered how of seeing addiction as a medical disease vs. a personal choice – a
best to integrate such frameworks with embodied/4E approaches, key issue in the philosophy of this condition241,242 – can be seen
noting that the brain-­mind, including interoceptive components, to be an overly simplistic false dichotomy. Third, this p
­ erspective
engages in embodied predictive processing in order to main- enables us to reconsider strategies for recovery; in particular, it
tain enactive engagement with the environment206,233,234. In their provides an account of how the person with addiction may be
embodied/4E account, Friston and colleagues suggest the term able to change his/her lived experience by manipulating the envi-
enactive inference235. Their framework bridges representational ronment and altering its affordances – so that there is a change in
and non-­representational approaches236, providing a pluralistic, the dynamic interaction of brain biology, interoception, and sur-
yet formal and mechanistic, account of a range of psychiatric con- rounding context.
ditions, often with a particular focus on interoception and bodily
states237,238.
In the clinical setting, given the central role of affordances and DISCUSSION
affectivity within the enactive view, a process orientation accords
with psychotherapies that draw patients’ attention to early mal- Psychiatry is, inherently, a conceptually laden and conceptu-
adaptive schemas and current emotional dynamics in order to ally complex field. Yet the opportunity to reflect on the concepts
better learn to navigate them239,240 – an exercise in sense-­making implicit in psychiatric practice arises infrequently for both clini-
about sense-­making191. Further, from the enactive perspective, cians and trainees. Instead, a range of tacit assumptions – about
therapeutic interventions in psychiatry seek to improve the fit be- the nature of mental disorders, diagnostic categories, causal ex­
tween the individual and his/her environment. This can in turn be pla­­nations, and the mind – influence daily engagements with psy­­
achieved either by altering the sense-­making and behavior of the chiatric taxonomy, clinical assessment and diagnosis, and the dis­
individual, or by changing the world around him/her. This entails cussion of conditions and treatments with patients. These tacit as­
integration with notions of social psychiatry and environmentally sumptions have, however, been carefully addressed by philosophy
focused mental health interventions. of psychiatry, and here we have reviewed key advances in this field
One instructive example of the clinical utility of an embodied/​ and their clinical implications.
4E perspective is the work of Tschacher and colleagues on schizo- In conceptualizing and categorizing mental disorder, both nat-
phrenia225. These authors point out that sensorimotor dysfunc- uralist and normativist considerations have emerged as important
tions are closely associated with psychotic symptoms, leading to – the field increasingly accepts that such work entails a consid­er­
altered timing in the processing of stimuli and to disordered ap- ation of both facts and values. At a conceptual level, this encour­­
praisals of the environment. They argue, therefore, that problems ages moving away from strict scientism to soft naturalism – a position
of social cognition can be viewed as disordered embodied com- that embraces both psychobiological mechanisms and personal
munication. Finally, on the basis of this account, they suggest novel agency. In clinical practice, the bridging of naturalism and norma-
treatment strategies through body-­oriented interventions. Again, tivism facilitates moving away from an approach in which disor-
an embodied/4E approach is theoretically able to integrate bio- ders are reified, and towards appropriately comprehensive and in-
logical and phenomenological perspectives, and also has practical dividualized evaluations of patients. Awareness of the importance
implications for the clinical context. of facts as well as values can also facilitate a mental health care that
As a final clinical example, consider an embodied/4E approach is both evidence-­based and values-­based.
to addiction227. Addiction is embodied insofar as the impact of In considering the nature of psychiatric science, there is now in-
substances on neurobiological mechanisms alters mental activ- creasing emphasis on a pluralist approach, including ontological,
ity, the body itself is altered in unhealthy and use-­supportive ways, explanatory and value pluralism. Conceptually, this acknowledges
and habitual actions play important roles in substance-­related the multi-­level causal interactions that give rise to psychopathol-
behavior. Addiction is embedded/extended insofar as addiction-­ ogy, and is consonant with Jaspers’ early pluralist approach, en-
related behavior is both influenced by and often alters the envi- compassing both explanatory accounts of behavior and an un-
ronments within which it unfolds, and is shaped by individual derstanding of the individual person – an approach espoused by
learning histories. Finally, addiction is enacted insofar as an af- a wide range of philosophers50. Clinically, this view emphasizes
fected person’s experience of and engagement with the world is the importance of a broad range of causal “difference-­makers” as

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well as considerations of “lived experience” in both research and between work on cognitive-­affective neuroscience and phenome-
practice. nological psychopathology192,253.
In addressing a range of questions about the brain-­mind, and Third, we have been selective in our focus on progress in the
how both somatic and psychic factors are key in mental disorders, field, omitting large swaths of work in philosophy of psychiatry –
conceptual and empirical work on embodied cognition provides not the least being ethics (which will be the topic of another forth-
an increasingly valuable approach. Viewing the brain-­mind as coming Forum in this journal) – and potentially downplaying a
embodied, embedded and enactive facilitates the integration of range of authors and advances. Similarly, we have not covered
advances in both cognitive-­affective neuroscience and phenom- the philosophy of any particular psychiatric symptom or disorder
enological psychopathology, as well as in a range of other disci- in detail, despite a large literature addressing a range of mental
plines. Work on embodied cognition is having an increasing im- conditions. The breadth and depth of work by both ancient and
pact on rethinking mental health and mental disorders189,191,220,221. modern philosophers who have considered the questions raised
Conceptual competence has various elements, including mak- in this paper is extraordinary, and we would encourage readers to
ing explicit conceptual assumptions, developing a philosophical explore further.
vocabulary, acquiring familiarity with relevant frameworks, and An important meta-­question is the extent to which there has
maintaining a degree of “conceptual humility”7. These elements been work on the cognitive science of philosophy and psychiatry.
have been exemplified in this paper, but at this point we would An embodied cognition perspective suggests, for instance, that,
like to emphasize in particular the virtue of epistemic humility. For when we think about categories such as mental disorders, rather
example, philosophy of nosology has taught us that, despite the than being aware of how deeply reliant we are on the use of em-
enor­mous amount of work that has been done to improve our clas- bodied metaphors, we are instead prone to essentialize our con-
sifications, these remain tentative, and reification of putative entities cepts60,254. We may therefore have particular difficulty in avoiding
must be strenuously avoided. the traps of reductionism and reification, and in articulating and
Similar considerations would apply to our attempts here to ad- working with fuzzy constructs such as the bridging of naturalism
vance philosophy of psychiatry. We began by noting that progress and normativism.
in philosophy has been disputed, and we are wary of claiming too A number of key themes have emerged from the different parts
much. Some of the issues in philosophy of psychiatry date back to of this paper. Here we highlight three. First, a key theme has been
ancient times, and some of the constructs employed seem to be “es­­­ that of integration. We have discussed the integration of elements
sentially contested”: there are a range of competing views, and there of naturalism and normativism, of evidence-­based care with val­
deserves to be ongoing discussion and debate243. This ap­plies in ues-­based care, of knowledge of science with the understanding
particular to the concept of disease, which may be intractably messy of experience, and of psychobiological mechanisms with per­so­­
31,244
. Still, the purpose of philosophy is not neces­sarily to resolve nal agency. Further, we have emphasized the potential value of the
every dispute or to eradicate disagreement, but rather to properly embodied/4E approach in integrating a range of disciplines con-
articulate and understand debated issues. To the extent that the cerned with the brain-­mind, including cognitive-­affective neu­ro­
issues considered here have been more rigorously articulated in s­cience, developmental psychopathology, and social psychiatry.
theoretical work, and more thoughtfully considered in the clinical A related theme has been that of “balance”. Our notions of men-
context, some progress may be claimed. tal disorders need to avoid the poles of scientism and relativism;
Several limitations of the approach taken here deserve partic­ our explanations need to avoid both neuro-­reductionism and cul-
ular emphasis. First, we have summarized arguments and con­ turalism; and our approach to the mind-­brain problem should be
clu­­­­sions from the literature, rather than attempting to rigorously one that avoids both a brainless and a mindless psychiatry139. Our
defend any particular stance. Relatedly, we have not had space introduction mentioned Aristotle’s notion of the “golden mean”,
to address ongoing work and key variants of some positions that and the emphasis in Chinese philosophy on the balance of yin and
have been put forward here, nor important critiques of these posi­ yang; a balanced perspective that is able to judiciously weigh up a
tions50,245-­248. Key constructs employed here – including soft nat­­­­ range of principles and particulars surely lies at the heart of good
uralism, pluralism, and embodied cognition – all deserve much clinical work255.
deeper consideration. A final theme has been that of complexity. We have argued that
Second, while we have drawn some links between these par- it is important to avoid essentialism and reductionism in psychi­­
ticular constructs – soft naturalism, pluralism, and embodied cog- atry, and that clinical assessments need to go far beyond our di-­
nition – our view is that much further work along these lines is pos- agnostic criteria to assess a range of domains, and to understand
sible. At the broadest level, some work on these constructs seems each patient as a unique individual. While monocausal models of
to allow for a degree of rapprochement between analytic and con­ disease entities (e.g., Treponema pallidum causing neurosyphilis)
tinental philosophy249. At a more specific level, it seems to us have been useful, contemporary psychiatry requires a coordinat­­
that further linkages can be made between key philosophers who ed218 or integrative pluralism. The embodied/4E perspective em­­
have spoken to these issues (including J. Dewey – who prefigured phasizes the complexity of the living being’s dynamic engagement
notions of embodied cognition250, W. Sellars – who contrasted the with his/her environments over time. The complexity of the brain-­
scientific and manifest image251, and H. Putnam – who contrib- mind and of clinical conditions is a key reason why calls for sim-
uted to work on collapsing the fact/value distinction252), as well as plistic paradigm shifts in psychiatry are unlikely to succeed. In-

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