Psychiatric treatments and most forms of psychotherapy (except family systems therapy) have in common that they are focused on the individual. Even very committed opponents of the DSM or any use of psychotropic medication in psychotherapy[1] remain focused on the individual as the unit of attention and treatment. From that point of view, the opposition against the new DSM-5, against the medicalization of psychotherapy, and against the abuse of psychotropic medications remains stuck within the same epistemological paradigm that is underlying psychiatry and individual psychotherapy.

Psychiatrists focus on the bio-physiological organism of an individual and presume a biological, often also genetic etiology[2] for “mental illnesses”, hypothesize measurable brain dysfunctions, such as chemical imbalances, and rely heavily on psychotropic medications. Psychotherapists focus on the intra-psychic dynamics, conflicts, abnormal behaviors, thought disorders, or cognitive and emotional confusions of an individual and treat the client through the power of one-on-one conversations by providing insight, proposing alternative behaviors, clarifying confusions about moral or practical choices, and bringing hidden strengths to bear on a person’s dilemma.

The disagreements, profound as they may appear to be, between the treatment modalities of psychiatrists and psychotherapists are, nevertheless, based on a similar epistemological thought frame. Epistemologically speaking, both camps remain rooted in the same assumptions about the etiology, symptoms, diagnoses, and cures of mental disorders and illnesses: Psychiatric or psychological treatment of an individual is supposed to resolve and “cure” problems that are located in the individual. In other words, emotional, psychological, intellectual, mood-related symptoms and “abnormal” behaviors are rooted in either brain-based biological disorders or in unresolved intra-psychic conflicts or in cognitive or affective malfunctions of the individual seeking help. Despite profound differences in what is considered effective treatment (use of medication vs. insight-oriented or cognitive-behavioral psychotherapy or therapies based on newer schools), the individual is the focus of treatment in psychiatry and (for the most part) also in psychology.

The core point of this blog post is: Any attempt to establish an alternative diagnostic system to the DSM-5 needs to critically explore how, not only what, we think about health and healing and about mental health, i.e. mental and emotional suffering, about traumatic experiences and injustices, and the multiple forms of pain that seem to be part of our human existence. The broad critique of the DSM-5 by so many national and international organizations and individual colleagues will in the end not be powerful and far reaching enough without this inquiry into the epistemological foundations of our thinking – an endeavor that is fundamentally philosophical in nature.

The epistemological considerations proposed here are an attempt to lay the groundwork for a radical, 2nd order change in our way of thinking, i.e. a shift in the epistemological paradigm that we use (naively or with all the accouterments of science) when we look at certain human phenomena and experiences.

The core of these reflections is the proposal to the community of “mental health” professionals to adopt a “relational epistemological paradigm” that

(1) allows shifting the perspective of the therapist from the individual’s bio-physiological or intra-psychic reality to her or his interpersonal network or contexts and back,

(2) adopts each perspective (the classic, “objective realism” paradigm and the strictly relational/contextual paradigm) as valid, yet as never the entire or objective truth, rather as a “reality edit”, that is accessed through a particular lens, and

(3) includes the “participant observer” (here the mental health professional) into the observed field so that the continuously changing (circular) interactional process between “clients” and someone called “the doctor” is an integral part of the epistemological paradigm.

It is my contention that the efforts to construct an alternative to DSM-5 will ultimately fall short, i.e. fail, without this radical shift in our thought paradigm.

Reflecting on Thinking and Living in Two Worldviews

Image courtesy of KROMKRATHOG /
Image courtesy of KROMKRATHOG /

As denizens of the 21st century, we live and think within two distinctly different, yet legitimate worldviews or “epistemologies” at the same time. What distinguishes them are not only the vastly different vistas that open up from their points of view, just as we may see profoundly diverse landscapes depending whether we stand at the top of a mountain or swim in the middle of an ocean. These two “worldviews” or thought paradigms (epistemologies with a small ‘e’) also qualify their epistemological status in methodological reflections on themselves as paradigms in distinctly different ways. The classic “objective Realism” paradigm holds on to the firm conviction that our thinking about the reality outside of us can arrive at the objective truth about that reality, whereas the relational paradigm allows for the social construction of “reality edits” that are forever linked to how we think as interrelated beings.

The following are philosophical reflections. As is common for philosophy, these reflections may raise many questions and may be short on definitive answers. That makes such reflections on how we think uncomfortable and productive.

1. The Classic, “objective Realism” Paradigm

This is the traditional, perhaps somewhat naïve worldview that is commonly held by most people prior to a systematic and critical review of their own way of thinking.

a) Fundamental to this approach is the presumed to be objective dualism between the (thinking) Subject and the (thought about) objects (including other human beings). In this view, the (human) person, the Subject of cognition and any other interaction with the world of objects is seen as self-sufficient, as complete, and, as such, as separate from other Subjects and from objects. The cognitive comprehension of another Subject, in inter-subjective relationships, and the cognitive comprehension of (subhuman) objects are viewed as essentially the same and remain extrinsic to the thinking Subject. The Subject appears like a Monad (Leibniz), complete within her/himself, yet with, so to speak, “foreign” relationships to other (human) Subjects.

Although other people or Subjects are understood in this paradigm by the thinking Subject as a special class of Objects, the presumption here is, nevertheless, that they can be examined, analyzed, measured, researched, i.e. fully understood, by the exploring Subject.

b) The only (or the most basic) way a human being can interact with other people or have any kind of knowledge about (non-human) objects is in this view through the same active process of cognition directed at the other Subjects or (sub-human) objects. In fact, this same process of cognitively comprehending a (non-human) object or a (human) Subject is in this paradigm the basis for relating to others. Cognition of other human beings by the reasoning Subject is prior to any interaction with them and is, therefore, in a class logically prior to relationships with other people.

One consequence of this “objective Realism” paradigm is that there is no more mystery: Potentially at least, given enough time and effort, cognition by the thinking and reasoning Subject can fully comprehend, i.e. cognitively conquer the other Subject, thereby transforming the other person into an Object. At least in principle, there is no room left for the ineffable, the mysterious, the incomprehensible in a Subject. A patient, for example, who is exposed to a scientifically rigorous exploration by an examining, comprehending Subject, i.e. medical expert, is reduced in this paradigm to being an Object of this exploration.

Because cognition of other Subjects or objects, i.e. of the world around us, is an activity of the fully constituted Subject, it does not necessarily affect the reasoning Subject or change who the Subject is as a human being. The observing Subject objectively grasps the other objects’ or Subjects’ reality, but stays outside of this process of comprehending.

c) Another fundamental assumption of the “objective Realism” paradigm is the following: When we look, i.e. in the process of cognitively approaching objects distinct from ourselves, including other (human) Subjects, we perceive reality as it is; what we see is the truth (provided, of course, we follow the rules of cognition!). All reality (including all human reality) can be examined, analyzed, manipulated, scientifically researched and understood, conquered, as it were, even the reality of other human beings. The results of ordinary inquisitiveness as well as scientific research describe the true reality. So, normally without much epistemological reflection, we assume it to be true in our exploration of the natural world that there is a reality outside of us that we can observe and study, that there is a linear connection between cause and effect, between an observed phenomenon and the underlying roots, between the physical universe and the laws holding it together.

Yet, here we have to pause and to protest in the name of human dignity and our own inner experience: Human “reality” cannot (and should not) be in the same way an object of scientific research and examination as subhuman entities or objects can. Although human beings partake in the physical world as embodied beings and are exposed to potential “objectification” by another Subject’s inquiring mind, instruments, and explorations, they remain not fully knowable Others, they always also escape the cognitively conquering mind of any comprehending Subject, they remain mysterious.

The classic “objective Realism” paradigm is prominent and predominant in all scientific human endeavors, including medical research and practice. While I acknowledge and emphasize that this is not the only paradigm that influences medical and psychiatric practice, it is nevertheless the dominant paradigm of methodical reflection in medicine and, therefore, profoundly influential. Scientific research and the customary medical practice are closely linked. We speak of “evidence-based practice”. Medical practice focuses on the treatment of diseases and disease pathologies, which appear in the domain of the body. Symptoms are diagnosed and their causes explored. Ever more technologically and chemically complex interventions affect the human body and lead, hopefully, to a cure for the disease.

There is no question, that this epistemological paradigm has enabled enormous scientific and technological achievements in modern medicine. My contention is here solely that this paradigm also led and leads to an unavoidable, but substantial narrowing of focus on physical disease, pathology and brain dysfunctions and, were it not balanced by another epistemological paradigm, would end up “objectifying” the person being treated.

There are other significant consequences from the adoption of the classic realism paradigm by medicine in general and psychiatry in particular:

a) In part because we are embodied beings, physicians focus on the bio-physiological nature of people; the enormous diversity or “otherness” of other people is, therefore, rarely perceived and even less conceptualized. All human beings appear in this mind frame as essentially the same; their diversity appears superficial and negligible from the point of view of the “objective Realism” paradigm. The personal relationships and the enormously complex social networks with which individual people are interconnected are frequently overlooked in healthcare.

Instead, unwittingly, the health care system subsumes people into groupings that the “researchers” or “experts” often saw as real, i.e. superficial differences found in scientific studies can become essential ones. Human history, medical history included, is full of insignificant differences (head circumferences; skin color; height; hair type) constructed as “real” which then define the humanity of another person, group, or nation. Because of the assumption of the essential “sameness” of people these superficial differences among the Objects of human research have been used as evidence to classify people into some who are more and some who are less human! The “reification” of differences among people invariably has led in the general healthcare community to blindness for multi-variant diversity and for social justice issues apparent in a relational and contextual epistemological paradigm.

b) Another consequence of the classic “objective Realism” paradigm is the hierarchical relational definition between someone called the professional expert (doctor) and someone defined as the patient (client or individual in need of professional help). The hierarchical status and power of the expert forces the dehumanization of the one who is on the receiving end of the expertise. The expert’s diagnosis determines the relationship and becomes an instrument of power and control. The language used and all the other trappings of the expert diminish the power of clients to be the experts of themselves and in charge of their own lives.

2. The Relational, “Perspective Realism” Paradigm

Underneath every doctor-patient or psychotherapist-client relationship is a process that becomes more visible and accessible to philosophical reflection when we directly focus on it. While often hidden, the relational process is accessible when we use an epistemological paradigm that I call the “relational, perspective Realism paradigm”.

a) Let’s start with our own inner experience. As our consciousness develops we experience ourselves not as self sufficient, but rather as deeply oriented by need and desire towards relationships and other human beings. Relational openness and inter-subjective connectedness with others define our humanity. In other words, the individual Subject is constituted as such by “inter-subjectivity”, i.e. by the relational process, by inter-dependence with other (human) Subjects. The existential inter-relatedness between (human) Subjects, between people bridges the (dualistic) distance between Subjects, enables individuality and, therefore, our humanity.

b) Finding myself in a network of relationships with Others, i.e. human Subjects like myself, is in the view of the relational, “perspective Realism” paradigm in a class logically prior to the process of cognition of Others, of other Subjects like myself. In a radical epistemological departure from the Cartesian Dualism of Subject and Object, the “perspective Realism” paradigm posits that the human Subject’s relational openness first and foremost enables and constitutes cognition of other Subjects, not: cognition of Others leads to a relationship with them.

Adopting the “perspective Realism” paradigm we discover significant consequences:

c) Existing as ‘Beings-in-Relationships-to-Others’ prior to cognition, prior to ‘going-out-into-the-world’ to “objectively” know the world outside of us translates to: Our relational interconnectedness with Others determines what we can see, how the human world and the world of sub-human objects appears to us. How we look (which is dependent on our unique web of relationships) governs our view of (especially human) reality. Together with others we construct from our perspective a “reality edit”, i.e. we see the Others, not as objects, but as who they want to appear to us according to our relationship with each other. And, vice versa, we “are” who the Others see us to be according to who we want to be in relation to these Others.

It is not the comprehending Subject who gains knowledge and expertise studying the Others, it is the Others who have to reveal themselves to us in order to start the relational process of mutual recognition and understanding.

d) The “perspective Realism” epistemological paradigm with its priority of relationship over cognition is (or should be) prevalent in all (non-exploitative) personal and “therapeutic” relationships. It is powerfully present in doctor – patient relationships, whether explicit or implicit. In any medical or psychiatric context the energy rooted in the doctor – patient relationship is indispensible for healing.

In the psychotherapeutic context the emerging powerful relationship between therapist and client is explicitly examined and studied. And, as numerous studies have shown, it is the very quality of the doctor – client relationship, not the particular theoretical model the therapist may apply, that constitutes the most essential ingredient of the healing process. I call this “(relational) practice based evidence”.

From here other consequences become visible:

e) Diversity defines our very humanity. What makes us essentially the “same” as human beings is our, is every single individual’s unique “otherness” according to so many essential, contextual, and relationship dependent perspectives, such as social class; race, ethnicity, culture; gender identity; sexual identity; age; religion; health; ability; the sum of personal experiences in relationships and social networks etc. It is relational interdependence according to these and many other perspective categories that creates unique people in unique relationships that are characterized by surprise in new relational discoveries, by interruption during traumatic events, and by the infinite richness of human relational life.

f) Professional hierarchies are faced with the process of deconstruction once we conceive of medical treatment, psychiatric interview or clinical psychotherapy as encounters between two or (in the case of family therapy) more people who are others for each other. The helping professional forfeits expert status and power, becomes vulnerable to the Other, is being taught by the Other, the patient or client. The expertise of the Others seeking assistance is privileged and met with curiosity by the examining and treating professional. In face-to-face conversations and collaboratively they not only explore bio-physiological facts or intra-psychic processes, but also construct together hypotheses guiding treatment, the meaning of health and illness or, broader even, all that has happened to the Other(s).

Thinking, Living and Practicing in Two Worldviews

The presented epistemological reflections are intended to contribute to a deepening of the process of constructing alternatives to the DSM 5. I hope that it is also evident from these reflections that the relational and contextual epistemological paradigm can highlight how much human suffering and existential pain is profoundly related to traumatic injustices inflicted upon individuals and families by the unjust societal structures surrounding them. I will address the issue of social justice in medical and clinical practice in a later post.

I am taking the courage of concluding with a sentence by the Roman slave and poet Terrentius (in Immanuel Kant’s late work on Ethics):

I am a human being. Everything that occurs to other human beings occurs also to me.

© Norbert A. Wetzel 2014

The Center for Family, Community, and Social Justice, Inc.,
[1] Such as the proponents of psychoanalytic treatment of schizophrenia and other “mental illnesses” or organizations like ISEPP.

[2] See for instance the website: “A mental illness is a medical condition that disrupts a person’s thinking, feeling, mood, ability to relate to others and daily functioning. Just as diabetes is a disorder of the pancreas, mental illnesses are medical conditions that often result in a diminished capacity for coping with the ordinary demands of life.”