 our last talk of the morning. It's my honor and privilege to present to you another pop-up that will give us a talk, present a talk entitled, Mechanism, Activities and Biopsychosocial Cursation. Thank you. So yeah, I'll be talking about mechanisms and activities or some of these topics that have already been discussed earlier in the conference but I'll be looking at a case from medicine. Particularly bringing together biological causes with social and psychological ones. So I'm first going to look at what the biopsychosocial model of health disease is and then basically see where mechanisms fit in. I'm then going to look more specifically at a model of mental disorders that explicitly uses mechanisms. So that's the mechanistic property clusters accounts and try to expand that to broader uses and biopsychosocial causation. And then I will look at one take aspect regarding mechanisms and particularly the activity account and I'll do so by looking at the case study on ideas in football syndrome. So to start with there are different models of health and disease. Now the predominant model is the biomedical one which has been facing several lines. Criticism, despite this, yeah, it's still the standard dominating model when we talk about disease. One of the problems, this model is the fact that when we talk about causes of illness, usually there are multiple causes and these causes are different kinds. And just as an example, if you're trying to find, let's say the causes of heart disease, diet could be one, diet essentially could be explained in terms of biological and physiological processes. However chronic stress is also a cause of heart disease and in that case it's not as straightforward to have a biological explanation of that. Similarly, and maybe even more so when we talk about mental disorders, let's say major depressive disorder, you have the basically chemical imbalance theory that essentially explains depression through chemical processes but depression is also linked to adverse circumstances. Many variables are linked to depression, so this could be unemployment, job insecurity, loneliness, and again it's not as straightforward how these could be part of biological processes and how they could be subject to biomedical science. So yeah, the underlying question is how to account for causality across these different domains and also these different levels because yeah we're talking about multiple levels here, chemical, biological one, psychological, social. And the broader problem in the background here which is relevant but I'm not going to discuss it unless it comes up in the Q&A is how to conceptualize health and illness. Maybe yeah, health and illness are not merely biological or biomedical concepts but they have a broader range. So a bit of background for this, a biopsychosocial model was introduced as a response to the problems that the biomedical model has been facing starting with the 70s but it didn't quite take over. One of the initial objections to it was its vagueness. So you say oh yes, disease is not only biological but there are also these psychological, social aspects with it but you do it in this hand way kind of way without exploring any actual cause of pathways and any approaches. So that has been one of the initial critiques of it but there's more criticism so yeah one of the recent works on the topic, this model was being the slacking content, validity and coherence. Now my starting point is a recent defense of the biopsychosocial model by Walter Mings Gillett and one of the many things that Walter Mings Gillett make in their book, actually some of the insights from the biopsychosocial model have been realized in medical research on social determinants of illness. So the model is not as vague, incoherent as its critics would claim and actually yeah some of these lines of research are present in current medicine but they point out the need to do more philosophical and particularly metaphysical work to ground this model. So Walter Mings Gillett made this claim that for much medical research a reductive physicalism is still the go-to ontology but this doesn't yet quite match the social determinants of illness and biopsychosocial model so we kind of need to move beyond that. Again this is broader than the scope of my talk here what I would like to do today is to focus on the problem of causality causality is obviously connected to this ontological kind of background. So yeah in the book Walter Mings Gillett mentioned both interventionism and mechanisms so these are two of the main contemporary approaches to causation. One benefit of interventionism that has been singled out and again this is in the context of causality and psychiatry is that it can account for causation across domains and levels without looking into how that's possible ontologically speaking. So if you wiggle and say I don't know things like drug and security or unemployment then you have state of mental health of people exposed to these things and so changing with that. So interventionism would not that soak how exactly what this is the pathway from secure employment to better mental health from unemployment to worse mental health prospects. So that has been kind of sold as an advantage of interventionism and in the context of Walter Mings Gillett's book interventionism has also been suggested as a way of avoiding certain metaphysical questions that regard normativity in nature because if you have a normative concept of disease or illness then yeah questions of normativity in nature also arise. Still, despite these kinds of suggestions Walter and Gillett say that the experimental method and this is basically what they mean by interventionism is not enough for theorizing the biological, psychological and socials. So interventionism gives you these variable names but it doesn't tell you exactly what these things are and then how they cause one another. So to answer this how question essentially we need mechanisms. So one of my claims here basically a drawing from Bolton's point is that mechanisms are needed for a biopsychosocial model of health and disease particularly when we're talking about causation. So again in the book the example that Walter and Gillett use is that of stress as a cause again they mention causation but not into as much detail. So what I'm going to do first is try to explain how this works according to the mechanistic model and here's a quotation basically explaining how stress affects health and I've highlighted there things that could be entities and entities in a mechanistic model. So I'll read part of this and highlight the components of the mechanism. So a good way of thinking about stressful person-environment relationship is to examine the relative balance of forces between environmental demands and the person's psychological resources. So these could be the entities that we have here so environmental demands, psychological resources. If the environmental load substantially exceeds the person's resources, the stressful relationship exists, the psychological stress, the comparisons between the power of the environmental demands will harm, threaten or challenge the psychological resources of the person to manage. So these entities basically have these kinds of activities so demands can challenge and harm whereas by using psychological resources one can manage particular demands. In this particular quotation is not mentioned but probably yes, also in the Lazarus book about another more recent research as well, hyperactivity that results from this inability to meet environmental demands is also linked to the inflammation which is basically a pathway from against psychological and social variables to biological ones and some diseases that are linked to inflammation. And yeah, this is my sketch of the causal connection here. So social demands that deplete or challenge psychological resources, this leads to the stealing of uncontrollability, leads to hyperactivity, leads to inflammation which don't likely lead to things such as heart disease, also psychiatric disorders and other health effects. So now, yeah, this was my stage for mechanism but I would like this picture to be a bit more complex. So I'm also going to look at mechanistic property clusters. Mechanistic property clusters weren't used as a way of understanding mental disorders and one of their benefits is that they can encompass multiple kinds of mechanisms that work together in accounting for a complex illness. So again, this would be mental illness but my claim here is that we can move beyond that and use the mechanistic property clusters for other complex kind of illnesses. And here's description from the Candler et al. article. Members of mechanistic property cluster kinds are not similar nearly either superficial properties but because the co-occurrence of these properties from individual to individual is explained by possible mechanisms that regularly ensure these properties are instantiated together, these mechanisms typically span several levels. So we have mechanisms and we also have a multitude of levels here so that's relevant. Here, so the image on the left is the illustration from the Candler et al. article. You can see this causes, some of which have this cyclical kind of mutually reinforcing structure. You see the underlying state, so the underlying state here could be something like major depressive disorder. The causes could be some of these environmental, psychological sort of causes and then you also have the manifestations which would be the symptoms of the disease and again they are self-reinforcing which sort of mutually reinforcing which is something that happens in medical disorders. On the right, I've sketched out the simplified picture of some of the considerations about stress as a challenge to health. So you have this dynamic between increased environmental demands, decreased resources and yes as the resources decrease the demands that one is not able to meet. Also increase and then this fits into uncontrollability generating the underlying stress of chronic stress and then stress further produces these other effects like inflammation, high blood pressure, hyperactivity and as you can see yes, some of these are behavioral, some of these are physiological, some of these are psychological so you have these different levels and domains represented here. So now yes, I'm moving towards the more metaphysical part of the picture here because so we saw we need mechanisms for the biopsychosocial model. We can talk about complex diseases or pathways to disease from this perspective about mechanistic property clusters which helps incorporate multiple levels and domains but what are mechanisms and what exactly are the parts that we put together in these models and yeah, this is just a review from the Stanford Encyclopedia of Philosophy. When we talk about mechanisms, they're the classic kind of salmon dough approaches looking at the quantity, they're the mechanistic accounts, they're the activity-based accounts and the contractual accounts. For my purposes here I'll focus on the activity-based accounts chiefly because I think and yeah, I'll actually discuss this in the Q&A if you disagree but I think this is the more metaphysically rich picture so some of the defenders of mechanisms have dropped the, I'll talk about activities partly because it's too obscure and too metaphysical but I think there is a benefit in keeping them and then exploring this further. So just a brief explanation of what the activities are because the mechanisms consist in what's called productive activities and then productive activities are understood in Anscombe's sense. Yeah, I don't want to go into Anscombe. Scholarship here so briefly she defines causation as the rivativeness of an effect from its causes so the idea is that causes somehow produce their effect and this is basically an activity so it's not something that's passive, it's not something again that you don't really know so you wiggle and see whatever else because that would be the interventionist picture rather it is productive and a process and here is McEvoy definition for instance activities are the happening stats singularly or in Anscombe activities produce changes in or bring into existence other entities and or activities. Activities are ways of acting processes or behaviors they are active rather than passive dynamic rather than static and yeah this is relevant when we talk about health and disease causation because you have also these dynamic processes at play. Now this is not meant without criticism as you can see activities and activities entities but other activities as well so this is getting kind of complicated so yeah one quick tip is that activities have not really been analyzed but you have there is a description then people saying that this is actually vacuous you're not even saying anything and one answer to this is an evidence book on the new mechanistic philosophy explaining activities through lower level mechanisms so here's a notation activities cannot naturally be reduced to properties of or relations between entities so it is clear that activities are in a way metaphysically basic in this account of mechanisms and they are causes in the sense that it is entities engaging in activities that are the producers of change so again activities are necessary for causation and David also talks about mechanism dependence namely that the systems activity is constituted by a set of acting and interacting parts so you can basically break down the activity and look at its parts and that kind of explains this at least addresses partly just worry that activities are not further analyzed and that they may be vacuous and not vacuous if you're interested you can look into what goes on there and you can explain it in terms of interacting parts so now let's look at this in relation to case study so interval bowel syndrome or IDS is a symptom based diagnosis it has certain requirements that the ones that are listed here are chronic abnormal discomfort or pain and abnormal function but other gastrointestinal symptoms are also common now I got this model of how the nervous system is involved in IDS and essentially what you have here is a complex kind of mechanism and you have two pathways one that involves basically top down stress that affects the central nervous system the HPA axis and then it leads to an immune response to the end direct nervous system which feeds back into the central nervous system so you have this mutually reinforcing kind of network yeah this is the image this is the explanation of these processes of chronic stress effects amygdalen hepocampus function which affect the HPA axis resulting in low grade inflammation and immune response so that's the top down mechanism and the bottom up mechanism is inflammation in the entire nervous system that leads to changes in the function of the central nervous system and yeah breaking this down as entities here we have the components of the central nervous system and as activities we have this response and regulation that happen for the bottom up mechanism there the components of the end direct nervous system and then for activities we have inflammation function and again these two so the top down and bottom up are mutually reinforcing so they feed into one another generating basically this kind of underlying state so I did not draw a diagram for this so essentially you can see this part here as one of the components here essentially because yes so this looks at the neural pathways whereas here you would need the two mechanisms that are both immune stress here may be other things that are going on in the organism at the same time so yes this would be a part of this so you can essentially view it as a mechanistic property cluster because you have this underlying state so the symptoms that I mentioned like pain, discomfort, decreased function but then you have yes so top down stress and then response to inflammation and immune response so essentially you could frame this as a mechanistic property cluster so trying to zoom in now on how to understand these mechanisms at least in the model that I've been using the activities here are neural so you have yes so essentially a response from the central nervous system and from the indirect nervous system and this mutually reinforcing pattern but yeah we want to think about this in a biopsychosocial model the question here is how about psychological or social causes and there is work basically suggesting that for instance psychological interventions such as cognitive behavioural therapy is more effective than IBS than in other gastrointestinal illnesses and this is explained basically because it's very optimal orbit with psychiatric conditions and stress response is one of its symptoms so given that yes there are psychological interventions available there is a connection when we talk about symptoms and causation with regard to psychological variables so we talk about them as entities and maybe have the same kind of activities like neural kind of activities or we talk of activities at the psychological and social level as well if so what does this say about the mechanisms that are involved so yes so the only lower level parts that we have in this model are neural but we need more complexity here one thing to stress is that this is compatible with the mechanisms of dependence claims because you can have yes so this activity technically yeah this top down mechanisms could be explained through these activities that are neural but then can we also speak of other activities for instance cognitive activities that link social demands to resources so if one is under excessive cognitive load because of environmental demands does that again change behaviour does that lead to physiological changes as well and yeah the broader pattern here is the top down this regulation which has been pointed out with regard to chronic stress but perhaps other social and psychological processes as well but yes it's the best documented with regard to stress and then the further question here is if we have mechanism property clusters to explain these pathways to disease we could have just as we have different mechanisms we take top down and bottom up we can have mechanisms that involve different kinds of activities so neural but also psychological social maybe others so the other main question again is how to integrate them so even if we bring them together in this complex kind of picture so yeah this is basically the question so this is work in progress to conclude the biopsychosocial model and causal explanations featuring social determinants have implications for causality and among others I have argued that mechanisms are needed for this model then the activity account of mechanistic causation can explain health effects such as dose of chronic stress and then if we use mechanistic property cluster we can bring together different types of variables and different types of mechanisms and with respect to the case of IBS in particular top down and bottom up mechanisms can be explained through neural activities but there are questions about how they would relate to different types of activities and how they would be integrated with them thank you for your attention I have the references here plenty of time for questions comment thanks a lot for the talk I think it's an excellent idea you're working out here I wonder if you could say a bit more about what such if I understand it correctly there are biopsychosocial mechanisms right and they include components or activities from various levels and as it were crossing disciplinary boundaries I wonder if you could say more about what such a biopsychosocial mechanism actually explains does it explain the occurrence specific occurrences of a disease or what exactly do they explain so what is the phenomenon phenomenon here I think occurrence yes it could be but I would say rather the persistence of the disease because I think this is what happens with disease that look basically chronic and involve these kinds of pathways and then I mean I'm also interested in interventions on these diseases because at least with CBT one thing that when it's successful that it does is that it gets falling in a different way framing the kind of situations there is so if you view it as this mechanistic plaster kind of thing move that and then somehow the underlying state will change but it's difficult to tell because yes maybe other things are at play but I'm interested yes or not on the occurrence of disease but persistence of disease and then making implications for treatment and explaining how psychological or social interventions can help address some of these diseases also because yeah this has been a lot of psychiatry but I think it could be expanded since there are social determinants but I think this is thank you other than yet yeah thank you this is I have this really really interesting but maybe but I wonder if I could maybe open up a bigger conversation it occurs to me that when that the philosophy that you're deploying because the philosophy that you're deploying feels very familiar to me as an outsider so it's like stuff I hear all the time in philosophy and biology but also as I hear you laying out your case study it occurs to me like boy in the historians of medicine who will talk about diagnostics pathology and therapeutics in ways that are totally alien to anything that I talk about as a historian of biology and so I'm wondering if you could give me some help in assessing where do the philosophy of biology and the philosophy of medicine for you in these cases where are they incompatible is there a reason you prefer to be working with the set of tools that philosophers of biology are really comfortable with this is a pretty big question I'm just wondering about the landscape of philosophy the landscape of philosophy why you're some some ideas about where you're positioning yourself ok so just to kind of try to specify this a bit so you're referring to mechanisms as tools of philosophers of biology I do have that intuition but I don't know if that's that's because I don't hang out with other philosophers no I think there is something there but I think mechanisms are becoming increasingly popular with philosophers of medicine because I mean yes if you press biology with medicine when you talk about health and illness and then that does bring up questions of normativity in nature functions in biology as well so I think there are a lot of common topics I think mechanisms work well for medicine if you talk about you also want to explain how a certain disease comes about and then what to intervene on again you need but then of course you have to so randomized control trials that are used in drug testing and so on that involves interventionist consequences but that is maybe not so much if you look at doctors and scientists and so on but if you look at philosophers working on this that's under heavy effect so I think the way to go is some version of pluralism people don't agree on what kind of pluralism but in my view mechanisms should definitely be there I know I hope I'm somewhat clear with this talk but I have other arguments in my favor mechanisms so we have a causation in a way that goes beyond these kind of statistical factors that you can notice a lot of so when you think about causation that goes beyond and on the intervention is kind of invariance so you also need to see what's going on so what kinds of variables you have if you want entities and activities relations if you can involve with this position there is I think an emerging strand of literature also talking about these positions Levin in his book mentions it but he says obviously because I read there I'm not really taking a stance on that but I think you need something along those lines that goes beyond interventionist kind of concept but I'm not sure if I because I don't I think interventionism is like an ask people is the big thing in biology as well really interesting this might be slightly unrelated but I was wondering if you think that is there room in your account for evolutionary explanations of disease for example involving a mismatch between our current environment and our evolutionary environment all the kinds of stress that we face now versus the kinds of stress that are stress responsible to do with is that something that could be copyrighted in this part of the account I think it could because yes there are these emerging accounts including again mental illness so the kind of evolutionary processes and people being adapted for certain kinds of environments and those don't work well in other environments but of course there are questions about the evolutionary time so these whole things that are brought against evolutionary accounts maybe because I think there is something to mental illness as with the kind of adaptation and again if you look at PTSD for instance people who have been in traumatic circumstances and then are moved in other circumstances you're not dramatic are going to be adapting and again have some psychological processes there and this doesn't necessarily need to be evolutionary so I would say my account is open to that I don't want to go into the debate about what happens to the brain in this many years and whether we can talk about similar neuro pathways and so on as you did I don't know how many thousands of years ago that's something I don't want to go into but I think this structure of explanation would be available so adaptation to a certain environment and then moving the stressors in a different kind of environment makes sense Thank you Thanks for the really interesting talk and I've been really interested in hearing how you you're playing mechanism and interventionism off of each other and I guess I'm just trying to give a clearer picture of what your goal is for the project do you see yourself as sort of convert like landing on what you think is going to be the right sort of causal account for this and if so I mean you've sort of gestured your pluralism but I wonder if if you think that there is a sort of correct way of catching up causes in biopsychosocial medicine and if there is then what sort of makes that the right way of catching them up Thank you I think I can say I don't think there is one way one right way of catching up causes so it's not in this talk but in another talk I've given like a month ago you have these questions of causal models how to choose models, how to choose variables which again has been partly discussed in relation to objectivity and so on by views yes such as Woodward for instance but I don't think it's been discussed at the length that it deserves because I think yes the kind of causal model you use and the kind of variable that you use does depend on your purposes and then we need to think of what we want medicine to do and my motivation for this is especially because yes so the biopsychosocial model has been brought forward to counter the neglect of social and psychological causes of illness the promotion of environmental interventions only this has social, ethical, political kind of implications and I think you think about causation of causal models in a way that you want to address some of these shortcomings then if you're clear about the goals and then again if you're saying I want to improve overall health and there is this big social determinant that if it gets neglected so maybe we should address that then yes we do use a model that will involve that in the right way and then and yes this brings me to the question of evidence that I mentioned before because if you focus only on RCPs then certainly the bill kind of treatments are always going to be ranked higher because you can do the blood trials and so on you cannot do a truly blood trial for psychotherapy or exercise so if you end up with this evidence hierarchy that privileges RCPs then you're going to miss some of these social technical implications so that's kind of my motivation I would resist the current evidence hierarchy saying that's the right way to think about causation in medicine but what the right picture would look like would be far more complex so it wouldn't be one no we can just talk I have one which is provocative voluntary what do you think what is this in philosophy of medicine now they are talking about mechanism because scientists began to model with boxes and arrows because and if you model with boxes and arrows you get too mechanism and why it's coming from because I I work with economists to teach causality in economy we don't use for example basian networks mathematics which is completely applicable to them because they dislike graph with bubble and that's what the economists said to me yeah there's something fishy with these models with arrows and boxes did you see in the historical that these kind of graphs appear because they appear a long time in biology boxes and arrows and you know stuff but maybe it's more recent in medicine I was very struck by the IDE Irritable Bower S that's a graph that you know seen that I didn't know philosophy of medicine people in medicine was doing about disease not about metabolism these are the different factors that could be important for that kind of disease and that's completely stress stuff not just metabolic pathways or something thank you I didn't think about that so that's something that I cannot say historically when they started becoming a thing I can say so when the causality started to be more like this invariance under intervention so that's with the evidence based medicine movement not that far away so sometime in the 90s but that's the direct implication of different types of evidence and the ones that you rank the highest involves these kinds of causal models before that because you have for instance expert opinion and then your expert opinion that you as a doctor could be based on some graphic mechanism but would you draw it like that or lab studies and so all these things that are ranked lower so that's something that I should look up historically because I think maybe yeah I think there is something there so where did this kinds of graphs if that would be connected certain practices push you towards certain conceptual framework yeah just a response to this a lot to this hasn't physiology been using boxes and arrows for a long time which is sort of an integral part of medicine I don't know about these those graphs I don't know anything about medicine so this is where I one of the reasons why I had my question was because yes physiology is integral to medicine but it is one part of medicine when we're talking about therapeutics you know if I as a physician have a patient with irritable bowels I a good physician is going to say do this and this and this possibly with incremental commensurable reasoning I mean this is what a good this is what a good physician living even if I think your right to insist on this point about biomedicine being a particular paradigm of medicine that holds physiological reasoning to be more important and at the same time less pluralistic than what is possible typically in their lives so this is one of the reasons why I'm interested in the way you're framing this as one biomedical package because there's something sorry I only have unorganized thoughts about this but this point about boxes and diagrams actually if you do like in certain sub fields about in space medicine the boxes and diagrams are decision-making processes in therapeutics which is tracking how different kinds of experts are passing patients along in these chains and where certain kinds of diagnostic practices get used where they're misused where assumptions about mechanisms lead to unhealthy outcomes or stuff like this I think this is a huge sorry so you want more conceptual clarity because I mean it's there but it's been there before certain diseases have been reconceptualized because certain treatments have been found so it's been there before this kind of messiness when you talk about treatment explanation of disease causation of disease I think this package has been there so this is not I think there is something in multiple ways of doing that and until we can treat that with antibiotics so it must be this kind of disease we can treat it with this but perhaps more than that in medicine interventionism or intervention means different things like there's an intervention in the experimental context and there's intervention in therapeutic context and they just they're fundamentally I think they're fundamentally different from the mice control trial of course if you're in the control group this can be fundamentally different from receiving medication but if you have control group we will continue this discussion with a sandwich in our hand