“Shut Up and Treat”
The cost of hermeneutic silence in the clinic
“… it’s worth noting that the scientific deployment of quantum mechanics does not require an interpretation. It may seem strange, but it’s entirely possible to ignore questions about what superpositions, entanglements, and measurement mean and just use the formalism to design and analyze experiments. This “shut up and calculate” approach, so-named by physicist David Mermin, works just fine. In fact, for many years, concern about the “foundations of quantum mechanics” (how to interpret its deeper meaning) was seen as a career killer for young physicists.”
Adam Frank, Marcelo Gleiser, and Evan Thompson (2024). The Blind Spot: Why Science Cannot Ignore Human Experience (p. 95). MIT Press.“Most users don’t worry too much about these puzzles. In the words of the physicist David Mermin of Cornell University, they ‘shut up and calculate’. For many decades quantum theory was regarded primarily as a mathematical description of phenomenal accuracy and reliability… Talking about the interpretation of quantum mechanics was, on the other hand, a parlour game suitable only for grandees in the twilight of their career, or idle discussion over a beer. Or worse: only a few decades ago, professing a serious interest in the topic could be tantamount to career suicide for a young physicist. Only a handful of scientists and philosophers, idiosyncratically if not plain crankily, insisted on caring about the answer. Many researchers would shrug or roll their eyes when the ‘meaning’ of quantum mechanics came up; some still do.”
Philip Ball (2018). Beyond Weird: Why Everything You Thought You Knew about Quantum Physics Is Different (pp. 13-14). The University of Chicago Press.Although there is little in common between quantum mechanics and psychiatric nosology, whether in terms of subject matter or empirical rigor, I have long felt that there is a parallel to be drawn between attitudes towards the interpretation and meaning of quantum mechanics captured by the phrase “shut up and calculate” and attitudes towards the interpretation and meaning of the diagnostic entities and treatment in psychiatry for which I am using the phrase “shut up and treat.”
Deployment of descriptive diagnoses based on symptom report and identification in the clinic does not necessarily require any interpretation. One can diagnose “major depressive disorder” (or “generalized anxiety disorder” or “bipolar disorder,” etc.) without having any clear idea of, or saying a word about, what it means. Similarly, we can proceed with treatment following the standard of care set by various guidelines for any particular diagnosis or condition without any clarity about how treatment should be conceptualized. We can stay at a very superficial level along the lines of, “This medication has been shown to help patients with X, reduces symptoms of X, has been approved for X, or is recommended for in the treatment of X” without any details of how the relationship between the medication, the diagnosis, and the psychopathology is supposed to be understood.
In fact, often times, a specific diagnosis is not even necessary. Many clinicians dwell in the domain of the “unspecified” or use a diagnostic category simply for the purpose of billing and documentation, and it barely even comes up in case conceptualization, treatment formulation, or in discussions with patients. From the patient’s perspective (and sometimes even the clinician’s!), the situation can be even worse in psychotherapy, where patients can spend months and years receiving treatment without any clear sense of what is being treated and how.
What sort of interpretative issues do I have in mind?
The nature of judgments of “disorder” and “psychopathology”
The nature of diagnostic categories
The nature of causal explanation
The relationship between psychopharmacology and psychopathology
There are two different dimensions to this attitude.
The first is a silence around these issues within the profession. Many psychiatric clinicians feel that the issues are so contested and there is so little resolution that spending much time in these waters is almost pointless. Many are content to leave these issues to the philosophers, and what philosophers have to say about these questions often leaves psychiatrists with little appetite for more. And it is so easy to get lost in the thick of it. Every psychiatrist is familiar with some colleagues who start asking these questions and end up in a place of unpalatable skepticism and nihilism.
The temptation to simply ignore these issues and focus on diagnosis and treatment—which goes hand in hand with the desire to be “atheoretical” and just empirical—is a deceptive one, particularly so in the field of psychopathology. There are, for better or worse, no theory-free observations. We always approach human behavior, and the world generally, with preconceived notions and theoretical constructs, whether these are recognized or unrecognized. The question, therefore, is not whether philosophical assumptions are inherent in our frameworks but whether we wish to examine them. The failure to give due importance to philosophical foundations of the field has resulted in widespread confusion and has negatively impacted the historical trajectory of the profession. The reification of diagnostic constructs, the tendency towards explanatory reductionism, and the debates surrounding medicalization are all linked to inadequate conceptual appreciation of the nature of psychiatric diagnoses, the role of causal explanations, and the pragmatic functions served by diagnoses. Addressing this tendency in the context of education and training has been the motivation behind my work on “conceptual competence” with colleagues such as G. Scott Waterman (Aftab & Waterman, 2021; Aftab et al, 2024) and behind preliminary explorations of how professionals think about these things (Aftab, Joshi, & Sewell, 2020; Jerotic et al, 2024).
The second is a willingness to talk about these issues in the clinic. What meaning of diagnosis and treatment is being communicated to patients? How do they understand these things? What narrative have they created, and how does this narrative interact with the clinical course?
As Rachel Aviv put it memorably in Strangers to Ourselves (2022):
“There are stories that save us, and stories that trap us, and in the midst of an illness it can be very hard to know which is which.
Psychiatrists know remarkably little about why some people with mental illnesses recover and others with the same diagnosis go on to have an illness “career.” Answering the question, I think, requires paying more attention to the distance between the psychiatric models that explain illness and the stories through which people find meaning themselves. Even if questions of interpretation are secondary to finding effective medical treatment, these stories alter people’s lives, sometimes in unpredictable ways, and bear heavily on a person’s sense of self—and the desire to be treated at all.” (p 24)
Nature abhors a vacuum, and humankind abhors a conceptual vacuum.
A lack of meaning or interpretation doesn’t persist. The “atheoretical” DSM-III was already enmeshed with neo-Kraepelinian assumptions before it was even released. The hermeneutic silence in the clinic was filled in the 1990s and 2000s by the narrative of “chemical imbalance”—which offered a concrete image, although wildly off mark, both for the nature of the problem and the nature of treatment—and this narrative currently co-exists with popular narratives of trauma and neurodivergence.
George Engel wrote in 1977, “The historical fact we have to face is that in modern Western society biomedicine not only has provided a basis for the scientific study of disease, it has also become our own culturally specific perspective about disease, that is, our folk model. Indeed the biomedical model is now the dominant folk model of disease in the Western world.”
Arguably, biomedical thinking is even more entrenched now than it was in the 1970s, but we are also in a stage where there is a significant sociocultural backlash to it, a fierce rejection of biomedicine in many segments of society in various forms of “alternative medicine.”
On the treatment side, a problematic interpretative dialectic has emerged between “disease-centered” and “drug-centered” approaches, whereby a psychopharmacological intervention is either remedying a neurobiological dysfunction or it is simply numbing one’s anguish. The reality, of course, is more complicated than that (see also: Aftab & Stein, 2022).
When there is little exploration of the meaning of diagnosis and treatment in the clinical encounter, when we leave patients to their own devices to come up with a narrative of what they are going through, we leave them at the mercy of folk biomedical narratives and folk resistance to such narratives.
We should diagnose, and we should treat, and we should do it well, but to do justice to the clinical process, we cannot “shut up” about its meaning. Even though answers may seem obscure and we are all muddling our way through an interpretative bog, speaking up is better than silence.
One of many differences between "shut up and calculate" in physics and "shut up and treat" in psychiatry, is that (I assume) you can get the calculations reliably right in physics even if you don't do any particular interpretations. In psychiatry, on the other hand, there's no evidence-based treatment that works for every patient with a specific diagnosis or particular symptoms. "Evidence-based" just means that a given treatment gives some measurable improvement to most people with a diagnosis, but it's still gonna be ineffective for lots. And if you refuse to theorize and interpret, all you can do is shrug and continue with your trial-and-error.
I've published and talked a lot about reality doubts. If you don't know what's real or not and this is extremely distressing, you get antipsychotics, and then you should try to "reality-test" as a complement. Whether the meds change your perception of reality to a more stable one or not must be due to brain stuff that a philosopher like me isn't equipped to figure out. But a philosopher CAN tell you at least ONE reason why reality-testing works for some people and not at all for others - every philosophers knows that you gotta take a lot for granted to even begin to prove more specific things about the reality we share. If you doubt too much or if your doubts go too deep, there's nothing you can use as a starting point for your "testing". Also, it's possible that once you have, so to speak, EXPERIENCED the kind of deep doubt that philosophers from Saint Augustine through Descartes to Wittgenstein has treated as intellectual puzzles, the MEMORY of that experience is enough to prevent you from comfortably taking reality for granted again, even if you're on meds that effectively prevents new such experiences from occurring.
Recognizing that someone suffers from this philosophical problem of knowledge and doubt can at least be a starting point for discussing how to handle it. But if you refuse to touch philosophical questions with a ten-foot pole, you're left with "uh okay, this is the evidence-based treatment but unfortunately it didn't work for you ... we'll try other things then, I'm sure we'll find something that works down the line". Or, as one psychiatrist told me when I lectured on these things, "but those are just SICK doubts. They're SUPPOSED to go away when you're on medication and you're well again."
(Btw, I'm fine not having a medical diagnosis beyond "probably somewhere on the schizo-spectrum". But I wouldn't be where I am today without all the philosophical interpretations!)
Thought-provoking piece!
One counter argument is the need to meet patients where they are. Many don't want to have a philosophical discussion about the meaning of their illness (though some do), often they just want to be well enough to get on with their lives.
Similarly, just as clinicians work with patients who hold views completely at odds with modern medicine (fans of homeopathy, natural remedies, reiki, etc), we need to respect our patients interpretation of what their illness means. Especially if this disagrees with our own model of illness/diagnosis.
In these situations a bit of agnosticism can be helpful.