Mixed Bag #20: Eisuke Sakakibara on Language in Psychiatry
“Mixed Bag” is a series where I ask an expert to select 5 items to explore a particular topic: a book, a concept, a person, an article, and a surprise item (at the expert’s discretion). For each item, they have to explain why they selected it and what it signifies. — Awais Aftab
Eisuke Sakakibara, MD, PhD, is a psychiatrist working as a lecturer in the Department of Neuropsychiatry at the University of Tokyo Hospital, Japan. He has worked in the area of philosophy of psychiatry for a decade and has published articles on topics such as delusions, neuroenhancement, and epistemic injustice. He runs a monthly study group in Japan where psychiatrists, philosophers, and psychologists meet to discuss philosophical issues in psychiatry. Since 2017, he has organized a symposium on the philosophy of psychiatry at the annual meeting of the Japanese Society of Psychiatry and Neurology (the US equivalent of the American Psychiatric Association). To learn more about his work, see here.
Article — ”A nice derangement of epitaphs” by Donald Davidson
Before I say something about language in psychiatry, let me give you a personal history of how I became interested in the subject. I have had a deep interest in linguistics and the philosophy of language since before I became a psychiatrist. My first peer-reviewed English paper focused on Donald Davidson's radical interpretations. Davidson developed his philosophy by investigating the situation of radical interpretation, in which an interpreter first encounters people who speak an unknown language.
Davidson argued in his paper “A nice derangement of epitaphs” that communication is possible without the existence of linguistic conventions.
Starting from the argument that radical interpretation is possible as long as rationality can be attributed to the other party, Davidson argued in his paper “A nice derangement of epitaphs” that communication is possible without the existence of linguistic conventions. The phrase used in the title of his paper was uttered by Mrs. Malaprop in the play The Rivals, and assuming that this was intended to be a meaningful utterance, we can correctly assume that she really meant “A nice arrangement of epithets.” In my first paper, I argued that while linguistic conventions are certainly not essential for successful communication, it is precisely when communication fails that conventions become indispensable in determining whether the speaker or the hearer is responsible for the communication failure.
Davidson was a philosopher whose lifelong reflections on language, meaning, and rationality profoundly influenced the philosophy of mind. Davidson showed that the understanding of the human mental state and the meaning of speech are inseparable from rationality, which directed my later interest in language in psychiatry.
Concept — Words and communications
Of all the branches of medicine, verbal interaction with patients has the greatest importance in psychiatry. Other disciplines can diagnose illnesses by performing physical examinations, conducting blood tests and imaging studies, but psychiatry, by and large, diagnoses from the patients’ words and treats them through verbal interaction.
In internal medicine, obtaining the history of a patient’s illness is extremely important. According to one study, 70% of illnesses can be correctly diagnosed using an appropriate medical interview alone. Nevertheless, linguistic interaction is of special importance to psychiatric diagnosis because it involves not only what the patient says but also the way the patient says it and the patient's own attitude toward what is said to have diagnostic value. Whether the patient’s speech is one-sided, emotional, circumlocutory, assertive, or unsure is the most informative criterion for diagnosis in psychiatry.
Classically, mental illness was understood as fundamentally irrational, although a considerable body of literature has challenged this view and explored the nature of rationality in psychopathology. Karl Jaspers was of the view that incomprehensibility in the patient’s language and thought suggests a pathological process is occurring. According to Davidson, the pathology of mental illness lies beyond the limits of rationality. Psychiatric interviews, in this sense, probe the patient through rationality to determine whether their words lie beyond the reach of rationality.
Also, the term “psychiatry” was invented by the German psychiatrist J. C. Reil, who saw psychotherapy as an important modality of medical treatment on par with pharmacotherapy and surgery. However, one wonders how words can be used to cure illness, and what kind of speech act psychotherapy is. Patients with mental illnesses often have difficulty establishing stable interpersonal relationships. Therefore, therapists must carefully choose their words. In addition, the words they provide to patients may have therapeutic significance. I believe that psychotherapy theories clarify how language can be used to maximize therapeutic efficacy.
Person — Aaron Beck
For some time, after becoming a psychiatrist, my interest in the philosophy of language did not connect with my career as a psychiatrist. I became interested in the philosophy of psychiatry when I realized that the way mental illness is described in traditional psychiatry and cognitive behavioral therapy is not just different, but in some ways is the opposite.
The language of traditional psychiatry separates the patient's psychopathology from the patient’s mind and personality and speaks of it as discontinuous with everyday life. The use of the term “a patient with schizophrenia” rather than “a schizophrenic” is related to this separation of pathology from personality. Additionally, traditional psychiatry uses medical terminology to elucidate the mental dysfunction underlying a patient’s life difficulties. By contrast, Aaron Beck, a founder of cognitive behavioral therapy, stated: “By placing emotional disorders within the realm of everyday experience and suggesting familiar problem-solving techniques, the therapist can start to help the patient at the time of their first contact.” (Beck, A. 1976, p.20). In other words, mental disorders should be understood as continuous with, or existing in the same realm as, everyday problems.
Beck encouraged patients to replace the problem of treating their illnesses with solving problems in their daily lives. This approach is opposite to the medical illness narrative, which tells the patient to take time off work and focus on treating the illness and recovering from it. One might argue that the traditional medical perspective seeks to relieve the patient of responsibility, whereas cognitive behavioral therapy attempts to help the patient take responsibility.
If different styles of treatment in psychiatry have different ways of talking about mental illness, traditional psychiatry’s linguistic emphasis on the existence of mental illness as a separate entity from the patient is also a kind of narrative or metaphor.
Flicker's concept of epistemic injustice is helpful when considering communication issues in psychiatry. Epistemic injustice occurs when one’s standing as a knower is undermined. Testimonial injustice, a prime example of epistemic injustice, refers to the unjust deflation of a speaker's credibility owing to the hearer’s prejudice toward the speaker.
The concept of epistemic injustice has attracted considerable attention in philosophy and ethics. In addition to testimonial injustice and hermeneutical injustice proposed by Fricker, other types of epistemic injustice, such as “testimonial smothering” proposed by Kristie Dotson and “participant injustice” proposed by Christopher Hookway were proposed to describe various kinds of communication failures that occur in relationships where prejudice and authority gradients exist. Flicker uses the example of discrimination against women and ethnic minorities in her discussion of epistemic injustice. I believe that the notion of epistemic injustice is also useful for conceptualizing the issues of communication between psychiatrists and psychiatric patients.
In my recent publication, “Epistemic injustice in the therapeutic relationship in psychiatry” I emphasize that the psychiatrist–psychiatric patient relationship (or the doctor-patient relationship) is a subtype of the professional–client relationship. Professional work involves helping clients solve problems through paid consultations. This problem-solving process requires good epistemic collaboration, shared understanding, and exploration of the problem between the professional and the client. However, a professional might unintentionally dismiss certain issues important to the client as irrelevant from a professional perspective.
The doctor-patient relationship is unique among professional-client relationships in that it seeks to solve the client’s bodily problems. Thus, the client experiences the duality of being both the problem solver and the problem itself—both the informant and the source of information. This is where the epistemic injustice inherent in medicine can arise, since in today’s medicine, objective findings from the patient's body, such as CT scans and blood tests, tend to be more prioritized than the patient’s verbal complaints.
The client experiences the duality of being both the problem solver and the problem itself—both the informant and the source of information.
Finally, psychiatry deals with illnesses that may impair a patient’s rational capacity, which creates additional difficulties in epistemic collaboration. If a patient is delusional, the psychiatrist may have to accept the patient’s utterances not as testimonials but as sources of information that reflect the patient’s illness.
Fricker's discussion of epistemic injustice is considered an area in which epistemology and ethics intersect, but her argument can also be seen in the ethics of communication. Hence, the epistemic injustice argument is helpful in conceptualizing the communication problems that arise between psychiatrists and patients with mental illnesses.
Surprise item — Kintsugi
Kintsugi is a traditional Japanese craft for mending broken tableware. The Kintsugi craftsmen glue broken pieces of vessels together using Japanese lacquer. Gold powder is then sprinkled on the lacquer to give the glued surfaces a golden color. The tableware repaired by the Kintsugi technique is more beautiful than before it was broken. For this reason, Kintsugi has often been used as a metaphor for recovery from mental illness. Psychiatric clinical practice is rich in metaphors and concepts. Other examples of metaphors and concepts include “burnout,” “(psychological) trauma,” “brain fog,” “expert by experience,” and “chemical imbalance.” Speech about mental illness in parallel with physical illness might also be a metaphor.
David Cooper argued that when certain members of a family are scapegoated and given contradictory instructions, called “double binds,” that person will exhibit madness, creating schizophrenia out of nothing. While this assertion is false, the insight that language has strong power in psychiatry is one that we should embrace.
David Cooper, who once led the anti-psychiatry movement, argued that when certain members of a family are scapegoated and given contradictory instructions, called “double binds,” that person will exhibit madness, to which the psychiatrist will apply the diagnostic label of schizophrenia, creating schizophrenia out of nothing. While this assertion is false, the insight that language has strong power in psychiatry is one that we should embrace. Modified labeling theory has led to the study of stigma against mental illness—by the way, the word “stigma” is another example of metaphor. However, sometimes, as in Kintsugi’s example, words can have positive power. Metaphors can change a person's mindset, and concepts have the power to move people. This is why I think that good use of the power of words facilitates patient recovery.
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