Intervista di Alessandra Premici a Ivana Markovà, una delle personalità di maggior spicco coinvolta nella formulazione del modello Cambridge della formazione dei sintomi mentali.
1) From where appear the necessity of a new “Model” in the formation of mental symptom?
“Epistemology refers to the theory/study of the origins and legitimacy of knowledge. Our interest in the epistemology of psychiatry meant that by definition we wanted to explore the nature and legitimacy of psychiatric knowledge. In order to do that, questions naturally arise concerning the sources, the origins, the structure, the sources, the stability etc., of psychiatric knowledge. When such questions are posed, then it becomes clear that little has been addressed in this area. Instead, much of research in psychiatry is based on assumptions that mental symptoms (and disorders) are well defined objects – and akin to symptoms and disorders in general medicine. Historical analysis shows that when psychiatry was formed as a medical discipline in the 19th century, it took on the practises, structures and models that were present in medicine. In other words, the assumption was – and continued to be – that psychiatry had an epistemological basis that was similar to the rest of medicine. However, analysis shows clearly this is not the case and that the foundational basis to psychiatry is very different (see the chapter on epistemology of psychiatry in the Kirmayer book and also the paper on epistemology of psychiatry).
An aspect of epistemological exploration in psychiatry is to examine the structures of psychiatric objects (symptoms and disorders). And, in order to explore the structure of mental symptoms, then it becomes essential to try to understand how symptoms are formed. Only by making sense of that, can we then make postulations concerning symptom structure. We could not find models of symptom formation – apart from the psychodynamic perspectives as developed by Freud. The psychoanalytic schools are based on a different epistemological position, one that focuses on hermeneutic understanding. Our own conceptual analysis however, resulted in an epistemology of psychiatry that is based on hybridity (see below) and hence includes both hermeneutics and neurobiology. Hence, we focused on developing a new model of mental symptom formation”.
2) What type of research has been direct in psychiatry and psychological environment before the formulation of the current Cambridge Model?
“I am not entirely clear what you mean by this question. Much of research in psychiatry has been empirical in nature – exploring the relationship between mental disorders/symptoms and other ‘variables’ including psychological and social and organic. The issue is that whilst such research may yield important findings, it tends to be based on assumptions around the nature of mental disorders/symptoms that are often not made explicit nor justified. The Cambridge model is about trying to understand the underlying assumptions on which psychiatry and its objects are based. In other words, it is addressing different sorts of problems. In the chapter on symptoms in the Psychosomatic Medicine book, there is a section (p27) in which we make a distinction between 2 spaces of research, namely, the conceptual and the empirical. The Cambridge model is trying to clarify issues that pertain to the conceptual research space and thus addresses different sorts of questions than the research that is carried out in the empirical space”.
3) In your book “For a new epistemology of Psychiatry” appears the clear necessity of release psychiatry from the strict category of mental symptom and the need of a serious consideration about epistemology. Are we far from this point of view today? Why? (Your personal consideration).
“I think that I have partly addressed this in your first question. In essence, epistemology of psychiatry as a research area, has been and continues to be neglected. The prevailing research drive in psychiatry today is the neurobiological one where mental disorders and mental symptoms are viewed simply as the result of brain/neuronal dysfunction. Hence there is a huge amount of effort and money put into the search for correlations between mental symptoms/disorders and neurobiological markers and increasing use of technologies such as MRI/fMRI etc. to do this. The explicit claims by the RDoC programme (Research Domain Criteria) as developed by the NIMH in the States is a prime example. Without however having a justified epistemological position, such research is not only misleading but may have ethical consequences of the clinical care of patients. The chapter on the epistemology of neuroimaging may help to clarify this. So the answer remains that epistemology is not taken seriously in the psychiatric research arena. Partly, this is historical – the assumption that symptoms are signs of (bodily) pathology comes from borrowing models from medicine. Furthermore, the advances in sophisticated technological procedures which have been so important for the diagnosis of neurological disease, can blind researchers to the fact that these technologies are designed for the capture of organic/physiological processes and that their extension into the ‘mental’ carries important conceptual problems”.
4) What is the relationship between Cambridge Model and the biological perspective in the explanation of mental symptom?
“The crucial difference is that the Cambridge model of symptom formation and structure shows that mental symptoms (and mental disorders) are hybrid in nature. This is meant in a deep, structural and meaningful way. In other words, mental symptoms are constituted by the (deep) integration of ‘meaning’ (in a wide sense of personal, socio-cultural, interactional, etc.) and biology (neuronal signalling). Both elements are crucial to the structure of psychiatric symptoms and disorders and neither is reducible to the other. It may be that these elements ‘meaning/semantic’ and ‘biological/organic’ are likely to have different roles in different symptoms. See the paper ‘the epistemology of psychiatry’ where this is explained more clearly.The biological perspective on the other hand is based on the assumption that mental symptoms/disorders are neurobiological elements.Psychological/stressors/developmental factors/socio-cultural factors etc. may all influence these neurobiological processes but at the heart of it mental disorders are brain disorders”.
Alessandra Premici, settembre 2016