Philosophy of Psychiatry and Psychopathology

Psychological and philosophical studies have extended J. J. Gibson’s notion of affordances. Affordances are possibilities for bodily action presented to us by the objects of our perception. Recent work has argued that we should extend the actions afforded by perception to mental action. I argue that we can extend the notion of affordance itself. What I call ‘Introspective Affordances’ are possibilities for mental action presented to us by introspectively accessible states. While there are some prima facie worries concerning the non-perceptual (...) nature of introspection, I will argue that our internal mental lives share enough commonalities with experiences in our environment to warrant this extension. I will demonstrate the value of introspective affordances by showing how they allow us to explain an underexplored aspect of thought insertion. (shrink)

This paper argues that proper functions are proximal functions. In other words, it rejects the notion that there are distal biological functions – strictly speaking, distal functions are not functions at all, but simply beneficial effects normally associated with a trait performing its function. Once we rule out distal functions, two further positions become available: dysfunctions are simply failures of proper function, and pathological conditions are dysfunctions. Although elegant and seemingly intuitive, this simple view has had surprisingly little uptake in (...) the literature. Indeed, our position departs from that of almost every theorist who has engaged with the issue at any depth. We start by presenting three arguments for the position that proper functions are proximal: one from the specificity of functions, one from their relation to intervention, and one from their relation to pathology. We then consider two case studies evidencing the trouble that accepting distal functions causes for philosophical reflection on the nature of pathological conditions. Finally, we anticipate and respond to three objections: that there can be failure of function without dysfunction; that our account is unacceptably revisionary in respect of normal function-talk; and that our thesis over-generalises from a narrow set of cases. (shrink)

The research program Spit For Science was launched at Virginia Commonwealth University (VCU) in 2011. Since then, more than 10,000 freshmen have been enrolled in the program, filling out extensive questionnaires about their drinking, general substance use, and related behaviors, and also contributing saliva for genotyping. The goals of the program, as initially stated by the investigators, were to find the genes underlying the heritability of alcohol use and related behaviors, and in addition to put genetic knowledge to work in (...) ways that might aid university administrators and mental health professionals in the prevention and treatment of substance abuse. We review every empirical paper involving genetic data that has emerged from the program, and reach a surprising conclusion: the study has never identified a single genetic effect of more than trivial magnitude. Although the quantitative results of the studies were reported transparently, the theoretical ramifications of the negligible results have never been acknowledged. To the contrary, most of the papers ignore the tiny effects, reaching optimistic conclusions about the prospects for future genetic explanations of alcohol use. We explore the implications of these results for the broader prospects of applied psychiatric genetics. (shrink)

Psychiatric research is in crisis because of repeated failures to discover new drugs for mental disorders. Lack of measurement validity could partly account for these failures. If researchers do not actually measure the effects of drugs on the disorders they aim to investigate, one should expect suboptimal treatment outcomes. I argue that this is the case, focusing on depression, and fear & anxiety disorders. In doing so, I show how psychiatric research illustrates a more general phenomenon that I call “validity (...) drift.” A validity drift occurs when, in the course of developing new measurement procedures, researchers end up studying something different from what they originally aimed to study. I analyze the different ways in which scientists attempt to validate procedures for measuring mental disorders for the purpose of testing drugs in animal models. I show how those validation efforts might fail, thereby leading to validity drifts. Overall, this analysis highlights the complex interplay between the development of new measurement procedures, their calibration, and scientific theories of the target phenomena. (shrink)

Despite how he begins, suggesting that it is somehow a problem for me that I think "there is such a thing as philosophy, which could then be useful for psychopathology," ultimately it is clear that the possibility of philosophy is not the issue for Ghaemi. Rather, his issue is with academic philosophy of psychiatry, as he sees it, and with my failure to ask what underlying assumptions typically operate in it.I do not dispute that someone like Jaspers would want to (...) ask such a question, nor do I dispute that it is, in general, a perfectly good question. But Ghaemi thinks that my paper is missing out on something by not posing it. The reason he thinks this is because he thinks my paper is an instance of a pattern in the discipline against which he evidently has an axe to grind. In particular, he thinks philosophy in general should be more attendant to the ways in which Diagnostic and Statistical Manual of Mental Disorders (DSM) categories are (problematically) socially constructed. The fact that philosophers have failed to critically point this out allegedly shows philosophy of psychiatry's— and my—unexamined sympathy with the postmodern tendencies—understood as tendencies toward "relativism about truth" and "skepticism about science"—of psychiatry itself. This is odd for a number of reasons, especially in the present context. Firstly, I am not presently in a position to exhaustively defend all of philosophy of psychiatry on the charge of 'postmodernism,' or on the charge of failure to critically engage with the DSM, but it is worth simply stating that I find these to be rather patently unsubstantiated charges. Prominent works that falsify the latter and easily come to mind are by Tsou (2011), Cooper (2004, 2007), Horwitz and Wakefield (2007), Murphy (2006), Poland and von Eckhardt (2013), and Lalumera (2016). Of these, only Lalumera is interested in defending a DSM-style descriptivism (which perhaps Ghaemi would call a kind of "social constructionism"), but even she limits her defense of DSM categories to their role as reference-fixing representations. It is also true that Tsou's paper is an argument that the practical considerations which go into shaping the DSM categories sometimes represent values that permissibly operate in psychiatry. Perhaps this could be construed as a kind of social constructionism as well, and presumably Ghaemi would disagree with it, but no one here is guilty of a failure to engage critically with the DSM and its history. Further, whichever position is taken by these theorists on whether the DSM does, or even one day could, cut nature at its joints, or whether some of the values that shape its construction do so permissibly or impermissibly, one's acceptance or rejection of relativism about truth is an entirely logically independent matter. (shrink)

Is addiction a behavioral pattern, or the underlying cause of a behavioral pattern? Both views are found in prominent accounts of addiction, but theorists generally do not notice that they are taking a controversial position, let alone justify it. A third possibility is that addiction consists in both addictive behavior and its causes, though this view is less obviously present in the literature. I argue that two important considerations favor the "cause view" over the "behavior" and "hybrid" views. The first (...) is that we want to be able to explain addictive behavior with reference to addiction. The second is that addiction seems to persist long after addictive behavior has ceased. Only the cause view can easily accommodate both data points. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:How Narrative Counts in Phenomenological Models of SchizophreniaThe author reports no conflicts of interest.Rosanna Wannberg (2024) offers an intriguing and novel critique of the predominant phenomenological model of schizophrenia, the ipseity disturbance hypothesis. According to this model, which was initially proposed by Sass and Parnas (2003), schizophrenia is best understood as arising from a disturbance or instability of minimal or basic self-hood, the sense of being present to oneself (...) and one's experiences (Henriksen, 2022). This disturbance appears as various experiential anomalies, sometimes termed "anomalous self (or world) experiences" or "self disorders," which include such phenomena as alienation from subjective processes, doubt in the existence of the world or one's own existence, fluidity of boundaries between self and others or self and world, and many other phenomena. Many of these have been captured in the Examination of Anomalous Self Experience (Parnas et al., 2005) and the Examination of Anomalous World Experience (Sass et al., 2017).At the same time, some research reveals the presence of self disorders in nonpsychotic conditions like panic disorder (Madeira et al., 2017) and depersonalization/derealization disorder (Sass et al., 2013). There are also competing phenomenological models that posit schizophrenia instead as a disturbance of dialogical self (Lysaker & Lysaker, 2002) or as a disruption of automatic perceptual processing (Uhlhaas & Mishara, 2007). Such works contain implicit critiques of the ipseity disturbance hypothesis that focus on the specificity of self disorders, or else on the specific nature of the underlying disturbance in schizophrenia.Wannberg's critique is distinct from these others: by considering the validity and function of recovery narratives, she raises crucial epistemological and ethical questions about the phenomenological approach to psychopathology, asking not only whose narrative counts, but how narrative counts. In particular, Wannberg questions a phenomenology that, she suggests, might find any ongoing symptoms as evidence of continued alterations of subjectivity, and that would then be dismissive of recovery narratives—a phenomenology that would prioritize the authority [End Page 71] of consciousness, as Wannberg puts it, over the authority of the person.It is worth stating here that the standard phenomenological response would not be to distrust or dismiss accounts of recovery. Ideally, phenomenological models, along with their ongoing theoretical developments and empirical work, are based on a deep respect for patients' experience and self-descriptions, striving to attend to experiences as they are lived without imposing pre-defined constructs that would limit or alter the experiences in a fundamental way (Nordgaard et al., 2013).Questions about the nature of recovery might be addressed within phenomenology by considering the difference between minimal (or basic) self and narrative (or extended) self, a more complex self-understanding or self-interpretation that is founded on the more basic, pre-reflective sense of being alive in the world (Gallagher, 2000; Parnas, 2007). According to proponents of the ipseity disturbance hypothesis, disturbances of basic self-hood can contribute to disturbances of narrative self, such as confusion about one's future goals or difficulties making sense of one's life history, though it is unlikely for disruptions that originate in the narrative self to trickle down to the minimal self (Henriksen, 2022). Such a view might similarly suggest that it would be unlikely for work on the level of the narrative self to lead to improvements in minimal self. Recovery, according to this approach, might best be viewed as an understanding of and compensation for alterations in basic self-hood, such that a person can develop a relatively solid narrative self that accounts for and manages disturbances of minimal self—while the minimal self may also grow more solid through various therapeutic interventions (Skodlar & Henriksen, 2019).Wannberg finds a more transformative possibility in Wittgenstein's grammatical approach, which is concerned with the function and rules of discourse. According to her grammar of recovery, recovery narratives are not only the product of a process of meaning-making and self-understanding, but they can create meaning and new realities. Furthermore, this process, according to Wannberg, has an inherently social and normative quality to it: the self-work that occurs in recovery and the recovery narrative involves the development of agency, autonomy, and responsibility in a social world... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Social, the Outer and the ReflexiveSome More Dimensions of Subjectivity, Schizophrenia, and Its RecoveryThe author reports no conflicts of interest.First of all, I want to express my gratitude to the Association for the Advancement of Philosophy and Psychiatry, Philosophy, Psychiatry, & Psychology, and the Karl Jaspers Award Committee for their recognition of my paper "Institution or individuality? Some reflections on the lessons to be learned from personal accounts (...) of recovery from schizophrenia" (Wannberg, 2024). I am also very thankful for Dr. Paul B. Lieberman's (2024) and Pr. Elizabeth Pienkos' (2024) stimulating comments on the paper.In the original paper, I used the case of the first person accounts of recovery from schizophrenia as a paradigm to elucidate the components of subjectivity more generally, as well as their logical relations. My main point was that considering the "recovery claim" as potentially endowed with a meaning sufficiently close to the official definition of the "personal" sense of recovery at stake—that is, in brief, having "become oneself" despite recurring or residual symptoms—invites us to question current phenomenological, narrative and constructionist approaches of the self in psychopathology. By contrast to these, I stressed the need of a conception of the self more sensible to its social and interpersonal dimensions, which I attempted to sketch out notably by resorting to Wittgenstein's (1953/1997) idea of "grammar." I am very happy that both Lieberman and Pienkos see the appeal to the social as a welcome move with regard to prevailing approaches to schizophrenia and its recovery. But what does it really mean for the subjective or the individual to be socially and interpersonally constituted, and how are we to account for that? [End Page 75]At a first glance, appealing to the social seems to be in line with current trends in psychopathology, including, as Pienkos points out, in the phenomenological tradition. She elsewhere announces a "shift in emphasis" currently taking place within phenomenological psychopathology, characterized by an increasing interest in the situated and dated aspects of subjectivity (Pienkos et al., 2023). This is a valuable turn. However, I am quite dubious that the well-known distinction between an "experiential" and a "narrative" self to which Pienkos appeals is apt to do all the conceptual work required to attain a satisfactory conception of the self and its social dimensions. In my original paper, I took the "recovery account" to challenge both these notions. As concerns the experiential dimension, I held that this type of account questions the phenomenologist's assumption that subjectivity is ultimately grounded in lived (self-)experience. Provided that typical symptoms of schizophrenia (e.g., thought insertion) are expressions of a disorder situated at this most "fundamental" level of the self and provided that they are stemming, at least according to one of the most widespread phenomenological models, from a trait-like disposition present before the onset of psychosis (e.g., Henriksen et al., 2019), it is quite natural to think that these symptoms persist in some form in the context of recovery (e.g., as intrusive thoughts or as "thoughts spoken out loud"). This is indeed the case for several of the authors "in recovery" in the Schizophrenia Bulletin's archives (e.g., Greenblat, 2000), which provided the main source of my analysis. But if this is so, we cannot see their recovery claim as an expression of a "whole" self, so to speak. So we must either say that "personal" recovery from schizophrenia is an illusion or a contradiction, or else we must revise the foundational status of the experiential dimension (other possible options are left aside for the purposes of this brief comment). I argue for the revisionist option. For the equation between the subjective and the experiential does not only lead to an unwelcomed skepticism about the recovery account. There are also more straightforward philosophical reasons for refusing it. Wittgenstein (1980) made a first important step by inviting us to better take into account the variability of the psychological concepts. He notably made a crucial categorical distinction between "lived experiences" (like sensations and mental images) and "attitudes" (like beliefs and intentions) such that all concepts which, when used in the first person... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Phenomenological Interviews and Tourette'sThe authors report no conflicts of interest.We appreciate the responses from the two clinicians, Efron and Mathieson. We agree with their reminder about the holistic nature of clinician's engagement (mood, sociality, and work life) and with their emphasis on patient-reported outcome measures, although this is not quite what we did in our interviews. As has recently been recognized in section 24 of the Victorian Mental Health (...) and Well-being Act (to provide a local Australian example), patients and caregivers' "lived experience makes them valuable leaders and active partners in the mental health and wellbeing service system."1In this paper, however, our aim was both more modest and immodest: modest, in that we aimed to work with those "leaders and active partners" to generate a more adequate account of lived experience in concert with behavioral symptomatology; immodest, in that we wondered how the lived experience of Tourette syndrome (TS) aligned (or not) with some of the commonly ascribed features of the condition. Although phenomenology as a discipline does not own lived experience, of course, it is more systematically treated in this tradition, starting with elaborations of Erlebnis.Efron and Mathieson note that older patients are more likely to describe urges or premonitory urges (PUs). This raises the priming question: Has greater exposure to and involvement in medical concepts and treatments transformed the nature of their self-report, or has it provided them with more phenomenological skills, enabling them to pick out discrete parts of experience? Or perhaps they have just been exposed more frequently to the experience over time? We address some related issues below, in our reply to Fernandez, where we outline our interview techniques more fully.They end by noting that the aim of comprehensive behavioral intervention for tics is to become attentive to PUs to better block tics. This is complex and understudied. In principle, becoming aware of something cognitively and experientially can foreground or even perhaps induce that experience. Conversely, from the TS scholarship, we know that attending to urges in certain ways (e.g., via acceptance training) can also reduce perceived urge frequency and intensity (see Gev et al., 2016). We would welcome further work on this link between attention and experience in TS. [End Page 49]Response to FernandezBecause our paper was partly framed around Fernandez' own work on phenomenological psychopathology, we welcome his invitation to provide further "inspiration and guidance" for other phenomenological researchers conducting empirical studies, who may also be dealing with the challenge posed by "narrative habits." When an interviewee uses well-worn medicalized terms to describe their experience, it is not clear whether these descriptions genuinely reveal or rather occlude the experience in question. There are sometimes, perhaps often, second-person phenomenological 'tells' regarding interviewees genuinely re-evoking an experience, but for interviewers it still raises the question of how to prompt alternative and potentially more accurate descriptions of experience.Because of this challenge, we purposely did not use the term "urge" or "premonitory urge" (PU) in our interview questions. Instead, we asked about (and used the broader term of) "experiences" that may occur prior, during, or after ticcing, without assuming that there are such experiences in the first place. We guided interviewees to evoke the memory of a specific, singular tic event (a tic token; see Curtis-Wendlandt 2020, 2023). Once a memory of such an event had been identified, we asked interviewees the following three lead questions:1. What, if anything, did you experience during this tic?2. What, if anything, did you experience before this tic?3. What, if anything did you experience after this tic?The temporal framing of these questions counters common trends and assumptions in the scholarship, which has focused heavily on pre-tic experiences, with little attention given to post-tic experiences (reduced to notions of "relief" and barely investigated), and even less to experiential explorations of the tic itself. Our catalogue of supporting questions sought to elicit fine-grained descriptions of evoked/recalled experiences along sensory and cognitive-affective dimensions:•. Did you see anything before, during, or after this tic? If so, what did you see?•. Did you hear anything... (shrink)

Rosanna Wannberg (2024) has given us a dense but helpful introduction to certain philosophical questions raised by the fact that many patients recovering from psychotic illnesses describe their recovery in terms of gaining or regaining a 'sense of self' and a 'sense of agency,' which often involves acceptance of the 'fact' of being mentally ill, for example, of 'having schizophrenia.' She raises two important questions: How should we understand what is going on in these accounts? and What are the implications (...) of these reports for our understanding of what it is to have a 'sense of self' or a 'sense of agency'—of 'subjectivity' generally—which might have, both, clinical and nonclinical implications?What does it mean... Read More. (shrink)

Abstract:In this paper, I argue for a social conception of subjectivity, via a philosophical reading of first-person accounts of recovery from schizophrenia, published in the Schizophrenia Bulletin. Following the hypothesis that these accounts exemplify a more general tension between, on the one hand, normative and social dimensions of the self, and on the other, experiential and psychological dimensions, the first section of the paper formulates the problem from a philosophical perspective inspired by Ludwig Wittgenstein's grammatical approach. The second section explores (...) and rejects different possible readings (sociologistic, phenomenological, or narrativist readings), as conceiving the subject in too passive a relationship with him or herself, and as leading to overly skeptical conclusions about the claims in the first-person accounts insisting on the notion of recovery as a restoration of a sense of self and as empowerment. The third section suggests that a more positive answer can be given via the idea of a certain grammar of recovery governing these narratives, and sketches out how this relates to the more general philosophical question on subjectivity. (shrink)

There is an evolving recognition in healthcare that the patient's subjective experience needs to be privileged both in understanding clinical phenomena and also ensuring the salience of outcomes used to evaluate the impact of treatment interventions. This is reflected in the expansion of patient-reported outcome measures to capture a person's perception of their own health, and the increasing requirement of involving people with lived experience in the co-design of research studies (National Health and Medical Research Council, 2016) and care improvement (...) initiatives. In mental health it has been long understood that observable behavioral phenomena can only partially inform clinical understanding of the experience... Read More. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Priming and Narrative Habits in the Phenomenological InterviewReflections on a Study of Tourette SyndromeThe author reports no conflicts of interest.In "Dimensions, Not Types: On the Phenomenology of Premonitory Urges in Tourette Syndrome," Lisa Curtis-Wendlandt and Jack Reynolds provide new insights into some of the experiences characteristic of Tourette syndrome (TS). Their study is an excellent example of applied phenomenology (Burch, 2021), combining philosophy and qualitative research methods to illuminate (...) experiences that have often been mischaracterized in the existing literature. In their study, they focus on what is commonly referred to as a "premonitory urge" (PU): the "anticipatory urge that is often thought to precede the onset of the motor and phonic tics that are part of Tourette Syndrome" (Curtis-Wendlandt & Reynolds, 2024, p. 26). They ask not only whether PU is a necessary feature of TS, but also whether the very concept of PU accurately portrays the experiences and behaviors that it's intended to refer to. They point out that existing scales used to assess PU, for example, seem to implicitly narrow the relevant experiences by assuming that they are a) always negative and b) always internal, or inwardly focused (Curtis-Wendlandt & Reynolds, 2024, 26). Curtis-Wendlandt and Reynolds question these in-built assumptions about PU, suggesting that they may provide an overly narrow depiction that misses the genuine diversity of experiences that precede the onset of a motor or phonic tic.To explore these phenomena in more detail, they conducted a study intended to elicit fresh descriptions of these experiences. They interviewed 12 teenagers with a diagnosis of TS about their experiences of ticcing and tic suppression. Using the micro-phenomenological method (Petitmengin, 2006), they asked participants to reflect on a specific tic or tic suppression event and to recall the event in detail. Throughout the interview, [End Page 43] they asked open-ended questions about sensory, cognitive, or affective experiences surrounding the event. Through these interviews, they were able to generate rich descriptions of these experiences and investigate how these descriptions differed from standard accounts in the existing literature.Curtis-Wendlandt and Reynolds provide a detailed account of how they designed their phenomenological study, both philosophically and empirically. However, there is an important aspect of their method that they discuss only in a cursory or implicit way, which is what I want to focus on here. Throughout their study, they were concerned that participants might simply parrot back well-worn medicalized characterizations of PU. Such characterizations risk simplifying or even occluding key aspects of the participants' experiences that might be difficult to reflect upon or describe. However, despite stressing the importance of eliciting fresh descriptions, Curtis-Wendlandt and Reynolds provide only glimpses of how the interviews actually unfolded and what kinds of techniques they used to elicit these descriptions.In my experience, it is quite common to hear phenomenological psychologists and psychiatrists express concern that people may simply repeat common psychiatric or medicalized characterizations of their condition, rather than genuinely reflect upon and describe their first-person experiences. The philosophical assumption is that we all fall back on culturally sedimented language and terminology when describing our experiences. Someone who has spent extended periods of time interacting with psychiatrists and other healthcare professionals, for example, is likely to have picked up common ways of describing their condition—ways that may have helped them receive a diagnosis or obtain treatment. There is nothing inherently wrong with falling into these culturally sedimented characterizations. They facilitate everyday communication through a shared language and terminology. But phenomenologists are often concerned that this kind of culturally sedimented language covers over or obscures the phenomenon or experience they are trying to investigate. For example, if a psychiatrist has often described their patient's depressed mood as "sadness," then that patient may be likely to self-describe their mood as sadness in an interview setting. It might, in fact, be the case that their mood is best described as sadness. But it could also be the case that their mood would be more accurately described as, for instance, a sense of emptiness or feeling deep despair. The challenge is therefore to know whether someone's self-description is... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Postmodern Assumptions of Philosophy of PsychiatryThe author reports no conflicts of interest.This paper makes claims for relevance of philosophy to psychopathology, as inspired in part by the work of Karl Jaspers. Yet there is no such thing as philosophy, in a general sense; there are philosophies, or as Jaspers would prefer, there is philosophizing (Ehrlich & George, 1994; Jaspers, 1951). Jaspers' approach to philosophy was akin to Freud's approach (...) to psychology: the goal was to make unconscious assumptions conscious. The unconscious assumption in the present paper is that there is such a thing as philosophy, which could then be useful for psychopathology. In effect, the author is probably meaning academic philosophy, or mainstream thinking in current philosophy of psychiatry. If that is the meaning, then Jaspers' question would be: What are the unconscious underlying assumptions of modern academic philosophy of psychiatry? The author's paper does not ask that question. But if we do, my answer would be that current mainstream philosophy of psychiatry has a basic worldview, another concept very central to Jaspers' thinking (Rindermann, 2021). Its worldview is postmodernist relativism about truth and skepticism about science, especially biology as applied to psychiatry. This unconscious assumption in modern philosophy of psychiatry is a major impediment in any benefits it might provide to psychiatry and psychopathology, as will be explained in the rest of this commentary.The paper refers to major depressive disorder (MDD) without appreciating that the term itself makes assumptions which the paper wishes to argue should be in the province of philosophy to analyze. The term MDD is not the same as depression, although the paper synonymizes the two. This synonym is an unanalyzed assumption, namely, that the Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnostic system validly defines psychopathology. It clearly does not, for reasons that modern philosophy of psychiatry has not accurately analyzed (Ghaemi, 2014).About a decade ago, when DSM-5 was being developed, colleagues in the field of philosophy of psychiatry had worked for decades on psychiatric diagnosis, and there was initial hope that the time had come for an impact (Kendler et al., 2008). The leader of the prior edition of DSM was unhappy [End Page 17] with the fifth revision. A set of essays were published where philosophers and psychiatrists engaged the former DSM leader about psychiatric diagnosis (Frances, 2013). His response, with a somewhat derisive reference to "philosophyland," was eye opening to me. He explicitly stated that DSM revisions were not based on science or facts, but on "pragmatism," on the beliefs of DSM leaders about what was best for the profession or society. In short, it was admitted that DSM was a social construction, just as postmodern thinking had said about psychiatric diagnosis since Foucault. Yet this admission was made unconsciously; DSM leadership does not use that phrase, nor does it understand its conceptual foundations. Surprisingly to me, colleagues in the world of philosophy and psychiatry also failed to make the obvious connection, or if they did, they seemed to have little problem with it (Phillips et al., 2012). Social constructionism was their worldview too.In effect, philosophy of psychiatry had nothing to provide; it did not analyze or critique the philosophical worldview of DSM leadership; it shared that worldview and participated in it (Kendler, 2013).The result, in my view, is that mainstream philosophy of psychiatry has failed in the role which it could have played, the role of making the unconscious postmodern assumptions of psychiatry conscious, and criticizing those assumptions. Instead, it applauded them.My broader critique of mainstream philosophy of psychiatry gets played out in papers such as this one in relation to the DSM term MDD, which should be dropped because it is not a scientifically sound term; it has many conceptual and scientific falsehoods within it, which both a philosophical analysis and a scientific analysis would demonstrate.The term MDD was invented in the DSM-III process in the late 1970s to get votes for passage of that third revision by the American Psychiatric Association in 1980 (Decker, 2013). It literally was a social construction. To the extent that it had any scientific basis, it had its roots in the... (shrink)

Research in the philosophy of addiction commonly explores how agency is impacted in addiction by focusing on moments of apparent loss of control over addictive behavior and seeking to explain how such moments result from the effects of psychoactive substance use on cognition and volition. Recently, Glackin et al. (2021) have suggested that agency in addiction can be helpfully analyzed using the concept of affordances. They argue that addicted agents experience addiction-related affordances, such as action possibilities relating to drugs, drug (...) paraphernalia, and drug-related activities, as aberrantly salient motivations for action. Building on this approach, we present a novel two-tiered affordance model of addiction. In doing so, we suggest that what is significant about the addicted person’s world is not simply what affordances are experienced as salient, but also the way in which the addicted person’s world is shaped by a dominant concern. It is not only that addiction-related affordances become more prominent as addiction progresses but that one’s plurality of concerns become monopolized by and funneled through addiction. Our model endorses Glackin et al.’s idea that addiction-related affordances become aberrantly salient, while proposing why they become and remain so. This way of viewing agency in addiction also brings to light important implications for recovery and treatment. For, if an addicted person adopts a new, even “socially approved”, dominant concern, there is a risk that the shape of addiction is preserved, even though the content changes, leaving an individual at the risk of addiction substitution or relapse. (shrink)

Contemplative scholarship has recently reoriented attention towards the neuroscientific study of the soteriological ambition of Buddhist practice, 'awakening'. This article evaluates the project of seeking neural correlates for awakening. Key definitional and operational issues are identified demonstrating that: the nature of awakening is highly contested both within and across Buddhist traditions; the meaning of awakening is both context- and concept-dependent; and awakening may be non-conceptual and ineffable. It is demonstrated that operationalized secular conceptions of awakening, divorced from soteriological and cultural (...) factors, have little relationship to traditional Buddhist construct(s) of awakening. This article identifies methodological issues for secular conceptions of awakening concerning introspection and neuroimaging yet demonstrates also the value of recent advancements in empirical first-person phenomenology for attenuating introspective bias. Overall, it is contended that significant problems arise when decontextualizing awakening and placing it within a scientific naturalistic framework. Careful attention to the definitional, operational, and methodological neuroscientific obstacles identified herein is required in the responsible approach to the investigation of awakening states. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Evidence-Based Medicine and EvaluativismTim Thornton (bio)KeywordsPhilosophy, psychiatry, values, causalThe rise of evidence-based medicine (EBM) in psychiatry has brought, in its train, a concentration on the validity of psychiatric taxonomy to augment the previous focus on reliability (in the medical sense of inter-subject agreement). This is not surprising. If EBM is to be a trustworthy guide to future events, such as patient recovery, it must be based on projectible predicates (...) (Goodman 1983). Not all the predicates that apparently fit past observations would produce true predictions for the future. Furthermore, there is reason to think that employing projectible predicates goes a long way to satisfy the (widespread if contested) aim of being based on a nomological science (Papineau 1986). Thus, the successful implementation of EBM within psychiatry requires the successful articulation of a valid psychiatric taxonomy.This connection helps to explain why fears about the application of EBM to psychiatry often turn on fears about the application of the criteriological model of diagnosis to individuals. In her commentary in this issue, Gloria Ayob has examined some of the arguments concerning the application of EBM to individuals. In this brief commentary, I examine a different potential source of disquiet focused on the underlying nature of psychiatric taxonomy.Dimensions for Psychiatric TaxonomyIn their recent paper, Peter Zachar and Kenneth Kendler suggest a number of different dimensions according to which rival conceptions of psychiatric taxonomy can be mapped. These include (1) causalism–descriptivism, (2) essentialism– nominalism, (3) objectivism–evaluativism, (4) internalism–externalism, (5) entities–agents, and (6) categories–continua (2007, 557). At the heart of the objectivism-evaluativism dimension is the question:Is deciding whether or not something is a psychiatric disorder a simple factual matterY (objectivism), or does it inevitably involve a value-laden judgment (evaluativism)?(Zachar and Kendler 2007, 558)Objectivists argue that the concept of disorder is a simple or plain factual matter by contrast with an evaluation. The apparently evaluative connotations of disorder, they argue, can either be reduced to, or explained away in, more basic terms, which are not themselves essentially evaluative. Thus, for example, the attempt to explain disorder in statistical terms is a form of objectivism. The more plausible attempt to explain disorder through the idea of a biological or proper function is also usually presented as a form of objectivism. (The most famous proponent of a biological approach, however, Jerome Wakefield, adds to an objectivist-aspiring core an explicit value in the form of harm [End Page 175] [Wakefield 1999].) Whether or not it can be successful as a form of objectivism, in addition to whether an analysis in biological terms is possible, depends on whether the account of function can fully discharge any initial evaluative or normative assumptions.There seems to be good evidence that current psychiatric taxonomy, at least, contains values. John Sadler, for example, makes a powerful case for this in his substantial work Values and Psychiatric Diagnosis (2005). Sadler, furthermore, addresses in some detail a further set of questions concerning the kinds and nature of the values involved. I outline just one further question about the nature of values involved.Zachar and Kendler contrast the presence of values with objectivism. Objectivity has at least two relevant senses reflecting contrasts with two senses of subjectivity. It—objectivity—might mean requiring no special subject for the conception and framing of relevant judgments. (This mirrors primary, by contrast with secondary qualities, and Williams' idea of an absolute conception [Williams 1978]). Or, it might mean disciplining and providing a contrast between correctness and incorrectness, or truth and falsity, for the relevant judgments. This contrasts with subjective whimsy.Although it seems relatively straight forward that the conception and framing of value judgments requires that subjects have a particular kind of mind, that still leaves open the other issue. Are value judgments disciplined by anything or does the "truth" of a value judgment collapse back into its being sincerely made?Evaluativism in Psychiatric Taxonomy and EBMThis question relates to the application of EBM to psychiatry in this way. On a disciplined account, psychiatric taxonomy can aim to get right the mixture or, better, the compound of simple facts and values... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Recent and Classic References at the Interface of Philosophy, Psychiatry, and Abnormal PsychologyArticlesAggernaes, A. 1972. The expanded reality of hallucinations and other psychological phenomena. Acta Psychiatrica Scandinavica 48: 220–238.Anonymous. 1991. Child sexual abuse and the limits of responsibility. Lancet 337: 890.Anonymous. 1993. Mental incapacity and medical treatment. Lancet 341: 1123–1124.Appelbaum, M. D., and A. Creer. 1993. Confidentiality in group therapy. Hospital and Community Psychiatry 44: 311–312.Beatson, J. A. 1993. (...) The psychiatrist and peer review—a psychodynamic review of the literature. Australia and New Zealand Journal of Psychiatry 27: 311–318.Berrios, G. E. 1987. Dementia during the seventeenth and eighteenth centuries: a conceptual history. Psychological Medicine 17: 829–837.Blackburn, R. 1988. On moral judgments and personality disorders: the myth of psychopathic personality revisited. British Journal of Psychiatry 153: 505–512.Blackmon, W. D. 1993. Are psychoanalytic billing practices ethical? American Journal of Psychotherapy 47: 613–620.Blashfield, R. K., and J. G. Draguns. 1976. Evaluative criteria for psychiatric classification. Journal of Abnormal Psychology 85, no. 2: 140–150.Blashfield, R. K., J. Sprock, and A. K. Fuller. 1990. Suggested guidelines for including or excluding categories in the DSM-IV. Comprehensive Psychiatry 31, no. 1: 15–19.Blashfield, R. K., J. Sprock, D. Haymaker et al. 1989. The family resemblance hypothesis applied to psychiatric classification. Journal of Nervous and Mental Disease 177: 492–497.Borys, D. S. 1994. Maintaining therapeutic boundaries: the motive is therapeutic effectiveness not defensive practice. Ethics and Behavior 4, no. 3: 267–273.Brown, W. M. 1985. On defining disease. Journal of Medicine and Philosophy 10: 311–328.Bub, J. 1994a. Is cognitive neuropsychology possible? Proceedings of the Biennial Meetings of the Philosophy of Science Association 1: 417–427.Bub, J. 1994b. Testing models of cognition through the analysis of brain-damaged performance. British Journal of Philosophy of Science 45, no. 3: 837–855.Buck, C. 1989. Problems with the Popperian approach: A response to Pearce and Crawford-Brown. Journal of Clinical Epidemiology 42: 185–187.Buck, R. 1994. The neuropsychology of communication: spontaneous and symbolic aspects. Journal of Pragmatics 22, no. 3-4: 265–278.Camp, N. M. 1993. The Vietnam war and the ethics of combat psychiatry. American Journal of Psychiatry 150: 1000–1009.Crockett, C. 1961. Ethics, metaphysics, and psychoanalysis. Inquiry 4: 37–52.Dalton, E., K. Hopper, and S. Reiner. 1976. Ethical issues in behavior control. Values and Ethics in Health Care 2: 1–40.Faust, D. 1993a. Use and then prove, or prove and then use? Some thoughts on the ethics of mental health professionals’ courtroom involvement. Ethics and Behavior 3, no. 3-4: 359–380.Fodor, J., and E. Lepore. 1994. What is the connection principle? Philosophy and Phenomenological Research 54: 4.Foss, L. 1994. Putting the mind back into the body: a successor scientific medical model. Theoretical Medicine 15, no. 3: 291–313.Galletly, C. A. 1993. Psychiatrist-patient sexual relationships: the ethical dilemmas. Australia and New Zealand Journal of Psychiatry 27: 133–139.Glymour, C. 1994. On the methods of cognitive neuropsychology. British Journal of Philosophy of Science 45, no. 3: 815–835.Gottlieb, M. C. 1994. Ethical decision making, boundaries, and treatment effectiveness: a reprise. Ethics and Behavior 4, no. 3: 287–293.Gutheil, T. G. 1994. Discussion of Lazarus’s “How certain boundaries and ethics diminish therapeutic effectiveness”. Ethics and Behavior 4, no. 3: 295–298.Helme, T. 1993. A special defence—a psychiatric approach to formalising euthanasia. British Journal of Psychiatry 163: 456–466.Kovel, J. 1976–77. Therapy in late capitalism. Telos 30: 73–92.Lazarus, A. A. 1994a. How certain boundaries and ethics diminish therapeutic effectiveness. Ethics and Behavior 4, no. 3: 255–261.Lazarus, A. A. 1994b. The illusion of the therapist’s power and the patient’s fragility: my rejoinder. Ethics and Behavior 4, no. 3: 299–306.Lehrman, N. S. 1980. Psychiatric power and responsibility: Abuse and abdication, a proposed corrective conference. The Humanist 40: 9–13.Lockhart, T. 1992. Professions, confidentiality, and moral uncertainty. Professional Ethics: A Multidisciplinary Journal 1, no. 3-4: 33–52.Margolin, S. G. 1964. The scientific status of psychoanalytic clinical evidence (II). Inquiry 7: 37... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Excited DeliriumWhat’s Psychiatry Got to do With It?Paul B. Lieberman, MDIf in life we are surrounded by death, so too in the health of our intellect by madness.—WittgensteinDelirium is a medical syndrome defined as “a relatively acute decline in cognition that fluctuates over hours or days” whose primary manifestation is a deficit of attention. It is common, estimated to occur in 10% to more than 50% of hospitalized patients, (...) with higher prevalence rates among people in nursing homes and at the end of life. It is often fatal, with a mortality rate in the hospital estimated to be 25% to 33%. Caused by a wide variety of conditions and frequently difficult to diagnose, it lacks characteristic postmortem pathology (Josephson & Miller 2018)‘Excited delirium,’ as Byju and Friesen forcefully argue (Byju & Friesen, 2023), is, if nothing else, an excuse. The ‘diagnosis’ has not been empirically validated and remains controversial (American Psychiatric Association, 2020). And while delirium is usually treated by internists and emergency medicine physicians, psychiatrists should also be concerned about the misuse of a putative medical diagnosis and join actively in discussion about it. For one thing, patients mis-diagnosed with this condition, as Byju and Friesen’s examples suggest, may actually have another psychiatric condition and, so, be people for whose safety we should advocate. Moreover, the kinds of police interventions which Byju and Friesen document as involving excited delirium also befall patients with other psychiatric problems in whom the issue of delirium does not arise.There are at least two broad ways in which psychiatrists are qualified and obligated to engage with this issue. As physicians, we should join our medical colleagues in carefully but persistently telling the scientific, medical truth. As psychiatrists, we should bring psychiatric knowledge into the discussion, for example, by explaining what can happen when people who do not, apparently, have a diagnosable mental disorder interact under stress with other people who, apparently, do.Delirium is a clinical diagnosis, made when characteristic signs and symptoms are present which should not be made ‘by exclusion’ when, as may happen, other causes are not found. There is no evidence of delirium in any of the three clinical descriptions Byju and Friesen provide. Perhaps such evidence exists which is not in their brief reports, but these three people appear to have had, either, another psychiatric condition, such as psychosis or drug intoxication, or perhaps no [End Page 353] diagnosis at all. Psychiatrists are particularly wellpositioned to make this point since patients with mental health problems are often misdiagnosed when they seek medical attention and are told, and treated as if, “it’s all (“just”!) psychological.”Excited delirium, if it exists, is fatal in 10% of cases (Gonin, Beysard, Hersin, & Carron, 2018) and, although this is lower than the rate for delirium in general, it is still high. Medical personnel must be available to evaluate and ensure the safety of patients in custody.The potential conflict between protecting the patient and protecting the public should not be overstated. Although physical trauma and excessive administration of medications, including ketamine 500 mg IV (Orhurhu, Vashicht, Claus, & Cohen, 2023) can be lethal, mechanical restraint by itself is not (Chieze et al., 2019; Gleerup et al., 2019): something else is necessary, such as asphyxiation (Evans, Wood, & Lambert, 2003). Nor is restraint necessary in many cases in which ‘de-escalation’ techniques can be equally effective (Garriga et al., 2016; Fernández-Costa, 2020). Perhaps these points are best made by law enforcement leaders—and they have been—but psychiatrists can add that safe management of potential violence can be provided for agitated people with psychiatric conditions.Although it is not clear what kind of strength ‘superhuman’ strength might be (certainly not medical), relative imperviousness to pain is clinically described. Its locus classicus is Beecher’s observation, during World War II, that injured soldiers awaiting return home from the front, required lower than usual doses of analgesics (Beecher, 1946). And it’s a common experience, scientifically confirmed, that physical trauma may not become painful until sometime after the injury (Melzack, Wall, & Ty, 1982). But pain is a warning. Its absence is not a license, but a caution... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:“Though This Be Madness, Yet There Is Method in ’T”A Positive Account of MadnessValentina Cardella, PhD (bio)What does it mean to be mad? How can we define mental disorder? The question is still widely discussed among psychiatrists and philosophers, and what exactly distinguishes sanity and insanity remains unclear. Despite this lack of clarity, the common conceptualization of madness is that mental disorders are impairments in rationality: people with mental (...) disorders are generally believed to have impairments in reasoning and logic (Bermúdez, 2001; Edwards, 1981; Harvey, Watkins, Mansell, & Shafran, 2004).Yet, the result of this conception is that we fail to understand madness. We do not understand how, for example, schizophrenic patients can be more logical than healthy people in some reasoning tasks (Mellet et al., 2006; Owen, Cutting, & David, 2007), or delusional patients can be perfectly rational in defending their ideas (Cardella, 2020), or depressive people can be more realistic than non-clinical subjects (Moore & Fresco, 2012). In contrast, if we consider rationality as the core feature of sanity, we fail to understand sanity, too, because normal people exhibit many kinds of biases and heuristics, and thus irrationality is widespread in the general population (Bortolotti, 2020; Johnson-Laird, 2006; Evans, 2002; Kahneman, Tversky, & Slovic, 1982).In his paper, Garson focuses on Late Modern theorists of madness (Locke, Kant, Wigan, and Heinroth) to reframe the problem and provide a positive account of mental disorder. These authors contrast madness to idiocy, rather than sanity, and therefore their conception of madness is very different: “while idiocy is marked by the diminished, or even abolished, functioning of the reasoning power, madness is marked by its perverse functioning. The mad person “has” reason, but deploys it in a perverse, improper, or unseemly manner” (Garson, 2023, p. 286).In his reading of Late Modern authors, Garson provides a new ontology of mental disorder, that goes beyond an absence of reason, and has also political and social implications. Furthermore, he reminds us that every scientific discipline has its philosophical assumptions. In defining madness, [End Page 305] we cannot help but choose a contrasting class, and each choice will have very different consequences. Even if psychiatry is a medical discipline, which aims to endorse a neutral view of mental disorder, it is impossible for it to be unbiased and impartial. All the more so, for it has to deal with human suffering and fragility.But, in this article, there is one crucial question that remains unanswered. In his analysis of Late Modern theorization of madness, Garson comes to the conclusion that madness is marked by a perverse deployment of reason. Yet, who decides when reason is deployed in a perverse manner? While the lack of rationality is something that we can detect easily enough, the task of defining precisely what is an ‘improper’ or ‘perverse’ use of reason is much harder. In other words, it seems to me that, in replacing the ‘lack of rationality’ paradigm with ‘the perverse rationality paradigm,’ the question of what is madness still remains open, and, most important, some normative aspects remain necessary. To recognize when rationality is improperly used, we have to adopt an evaluative stance, which defines what a proper use of reason would be.Valentina [email protected] University of MessinaValentina Cardella Valentina Cardella is Associate Professor of Philosophy of Language at the University of Messina, Italy. Her research interests encompass cognitive sciences, philosophy of language, and psychopathology.The author reports no conflicts of interest.Commentary submitted on June 13, 2023Accepted on June 13, 2023ReferencesBermúdez, J. L. (2001). Normativity and rationality in delusional psychiatric disorders. Mind and Language 16, 457–93. Google ScholarBortolotti, L. (2020). The epistemic innocence of irrational beliefs. Oxford: Oxford University Press. Google ScholarCardella, V. (2020). Rationality in mental disorders: too little or too much? European Journal of Analytic Philosophy 16 (2), 13–36. Google ScholarEdwards, R. B. (1997). Mental health as rational autonomy. In Edwards, R. B. (ed.), Ethics of psychiatry: Insanity, rational autonomy, and mental health care. New York: Prometheus Books. Google ScholarEvans, J. (2002). Logic and human reasoning: an assessment of the deduction paradigm. Psychological Bulletin 128... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:“Though This Be Madness, Yet There Is Method in ’T”A Positive Account of MadnessValentina Cardella, PhD (bio)What does it mean to be mad? How can we define mental disorder? The question is still widely discussed among psychiatrists and philosophers, and what exactly distinguishes sanity and insanity remains unclear. Despite this lack of clarity, the common conceptualization of madness is that mental disorders are impairments in rationality: people with mental (...) disorders are generally believed to have impairments in reasoning and logic (Bermúdez, 2001; Edwards, 1981; Harvey, Watkins, Mansell, & Shafran, 2004).Yet, the result of this conception is that we fail to understand madness. We do not understand how, for example, schizophrenic patients can be more logical than healthy people in some reasoning tasks (Mellet et al., 2006; Owen, Cutting, & David, 2007), or delusional patients can be perfectly rational in defending their ideas (Cardella, 2020), or depressive people can be more realistic than non-clinical subjects (Moore & Fresco, 2012). In contrast, if we consider rationality as the core feature of sanity, we fail to understand sanity, too, because normal people exhibit many kinds of biases and heuristics, and thus irrationality is widespread in the general population (Bortolotti, 2020; Johnson-Laird, 2006; Evans, 2002; Kahneman, Tversky, & Slovic, 1982).In his paper, Garson focuses on Late Modern theorists of madness (Locke, Kant, Wigan, and Heinroth) to reframe the problem and provide a positive account of mental disorder. These authors contrast madness to idiocy, rather than sanity, and therefore their conception of madness is very different: “while idiocy is marked by the diminished, or even abolished, functioning of the reasoning power, madness is marked by its perverse functioning. The mad person “has” reason, but deploys it in a perverse, improper, or unseemly manner” (Garson, 2023, p. 286).In his reading of Late Modern authors, Garson provides a new ontology of mental disorder, that goes beyond an absence of reason, and has also political and social implications. Furthermore, he reminds us that every scientific discipline has its philosophical assumptions. In defining madness, [End Page 305] we cannot help but choose a contrasting class, and each choice will have very different consequences. Even if psychiatry is a medical discipline, which aims to endorse a neutral view of mental disorder, it is impossible for it to be unbiased and impartial. All the more so, for it has to deal with human suffering and fragility.But, in this article, there is one crucial question that remains unanswered. In his analysis of Late Modern theorization of madness, Garson comes to the conclusion that madness is marked by a perverse deployment of reason. Yet, who decides when reason is deployed in a perverse manner? While the lack of rationality is something that we can detect easily enough, the task of defining precisely what is an ‘improper’ or ‘perverse’ use of reason is much harder. In other words, it seems to me that, in replacing the ‘lack of rationality’ paradigm with ‘the perverse rationality paradigm,’ the question of what is madness still remains open, and, most important, some normative aspects remain necessary. To recognize when rationality is improperly used, we have to adopt an evaluative stance, which defines what a proper use of reason would be.Valentina [email protected] University of MessinaValentina Cardella Valentina Cardella is Associate Professor of Philosophy of Language at the University of Messina, Italy. Her research interests encompass cognitive sciences, philosophy of language, and psychopathology.The author reports no conflicts of interest.Commentary submitted on June 13, 2023Accepted on June 13, 2023ReferencesBermúdez, J. L. (2001). Normativity and rationality in delusional psychiatric disorders. Mind and Language 16, 457–93. Google ScholarBortolotti, L. (2020). The epistemic innocence of irrational beliefs. Oxford: Oxford University Press. Google ScholarCardella, V. (2020). Rationality in mental disorders: too little or too much? European Journal of Analytic Philosophy 16 (2), 13–36. Google ScholarEdwards, R. B. (1997). Mental health as rational autonomy. In Edwards, R. B. (ed.), Ethics of psychiatry: Insanity, rational autonomy, and mental health care. New York: Prometheus Books. Google ScholarEvans, J. (2002). Logic and human reasoning: an assessment of the deduction paradigm. Psychological Bulletin 128... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:On the Importance of Conceptual ContrastsMadness, Reason, and Mad PrideAwais Aftab, MD (bio)Garson (2023) offers an engaging historical and philosophical discussion around the importance Late Modern thinkers assigned to the task of differentiating madness from idiocy (or more specifically, to the tripartite distinction of sanity, madness, and idiocy). Based on this analysis, Garson’s identifies the need to offer a positive account of mental illness—one that does not define the (...) essence of mental illness exclusively as the absence, lack, or failure of the power of reasoning. Following the Late Modern thinkers (Locke, Kant, Wigan, and Heinroth), Garson concludes that madness is infused with reason, and what characterizes madness is the presence of reason in an altered and mutated form. This is all worth taking seriously. My own assessment of this historical and philosophical material nonetheless differs from that of Garson. To recognize madness as possessing reason within it in an altered form may be of less profound significance than he thinks it is. Garson’s discussion commendably highlights the importance of making conceptual contrasts explicit in definitional debates, and this should indeed lead us to search for contrasts that are more philosophically illuminating (what is better will depend on the context of inquiry). However, in my view, the recognition of madness as altered reason neither reframes the project of defining “mental disorder” nor does it provide an intellectual scaffolding for mad activism.The significance of “madness contains reason within in but in an altered or perverse form” is difficult to translate into contemporary scientific terms, and the fuzziness and historical baggage around the terms “madness,” “reason,” and “perversion” does not make it easy. “Mental disorder” or “psychopathology” means to us something quite different than what madness meant to Late Modern thinkers, and while “madness” remains a popular term in philosophical literature, there is no clarity on the nature of overlap between the domain of madness and the domain of conditions currently classified by the diagnostic manuals. Mental disorders, as currently conceptualized, include a motley of conditions that were previously characterized using terms such as idiocy, madness, neuroses, and psychopathic personalities. [End Page 297]From our contemporary vantage point, to compare idiocy and madness is to make a distinction within the domain of psychopathology. We are comparing two groups of psychiatric conditions. The lessons we derive from this comparison do not necessarily extrapolate well to a comparison of mental disorders with something outside the domain of psychopathology. To the extent that psychopathology is inclusive of both idiocy and madness, psychiatric disorders both contain and do not contain “reason” within them. The domain is heterogenous in this regard, and broad generalizations about the nature of reason in the mental disorders would be simplistic at best and inaccurate at worst. Other distinctions that we have made within the domain of psychopathology have included organic versus functional, neurosis versus psychosis, categories versus continua, and distinctions used within nosology have included operationalized criteria versus phenomenology, idiographic versus nomothetic, medical versus non-medical, description versus explanation, and so on (Aftab & Ryznar, 2021; Zachar, Banicki, & Aftab, 2023), all of which have the potential to offer a positive account of some aspect of psychopathology.It is worth nothing that the distinction between “absence of reason” versus “perversion of reason” is analogous to the common distinction between absence of function and altered function in patho-physiology. Such a distinction exists for almost every function that exists. Consider vision: absence of vision (blindness) and altered vision (illusions, distortions, hallucinations). Consider hypoesthesia (reduced sense of touch) and paraesthesia (altered sense of touch—tingling, pricking, burning, etc.). Garson alludes to diminished sexual capacity versus paraphilia as an analogy, but he does not seem to appreciate that the analogy applies much more broadly. Is the distinction between absence of reason versus perversion of reason of any greater significance than the distinction between blindness and hallucination? If we were to say, “What distinguishes hallucination from blindness is not the failure, absence, or lack of sight, but its presence—albeit in a perverse and mutated form,” how profound would it really be for our notions of disorder? Or imagine some Late Modern physician saying that a disturbance of speech and... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Lack, Perversion, ShameJustin Garson, PhD (bio)I am extremely grateful to the commentators for giving me so much food for thought. Space considerations prevent me from engaging with all of the interesting points they raise, or responding at the length they warrant. For that reason, I chose to structure my response in terms of three recurring themes or distinctions: lack/perversion, madness/mental illness, and shame/pride. Hopefully, the philosophical richness of the (...) commentaries has already indicated the fruitfulness of returning, anew, to the Late Modern distinction between madness and idiocy.Lack and PerversionSeveral commentators directly challenge my characterization of the distinction between idiocy and madness as one between a lack, and a perversion, of the ordinary powers of reason.On the one hand, commentators point to the extent to which Late Modern theorists of madness still frame madness in terms of a lack, rather than a positive being. Jeppsson points out correctly that the Late Modern theorist still insists that madness stems from a lack of some sort or another: “one lacks proper premises to draw conclusions from, lacks a proper appreciation of reality.” Madness is not merely a different mode of reasoning about the world, but one that issues from a certain absence. Kusters, similarly, points out that the projects of Locke and Heinroth “remain insufficient because they remain focused on the mad as lacking something…a lack that prevents them from being part of the communal,” although he thinks Kant’s Aberwitz comes closest to a genuinely positive account. Tsou minimizes the relevance of the distinction between madness and idiocy by pointing out that both represent deviations from (hence they both “lack”) “normal psychological reason.”On the other hand, Banicki points out that even to construe madness in terms of a “lack” or “failure” (a failure of function, of reason, of action) is to presume, at least indirectly, a positive account of madness: after all, the mad person can only properly be said to “fail” in the exercise of their reason because they are the sort of being that participates in reason. A tree or a stone cannot be said to “fail” in the exercise of its reason (as Gipps puts it, “a baobab cannot jump to conclusions”). These commentators have helped me to clarify and sharpen the distinction between lack and perversion and the way they intersect with the categories of idiocy and madness.To put my view summarily: idiocy is, in its essence, just a way of lacking reason, in the same way that being poor is, in its essence, just a way of lacking wealth. But madness is not, in its essence, [End Page 327] a way of lacking reason. It is a way of exercising reason, but via perversion, where perversion must be understood as having the resonance both of excessive and also of driving toward an unexpected end.As I indicated in the paper, the distinction between lack and perversion is easiest to think about in terms of sexuality. A person may lack sexual desire: They may find themselves for long stretches of time with little to no desire for sex, the absence of sexual fantasies, and the inability to stimulate themselves or be stimulated by others. Crucially, being devoid of sexual desire is not a way of being sexual, any more than being dead is a way of being alive, or being a fish a way of being a mammal. By contrast, having a meager sexual desire is a way of being sexual, but via a lack or diminution: It is a way of not having much of it around.In contrast, one can have what is called a “perverse” sexuality: Sexuality infused with the desire to dominate, or be dominated, or to be watched from afar, or to couple with beasts or machines. This is a way of being sexual; it is even a kind of rampant sexuality. One talks of “harnessing” their sexuality, “restraining” it, “unleashing” it. For some, perversions may be terrifying to contemplate, almost unthinkable, even revolting. For others perversion is ecstatic; it transports one to another world in which one sees everything differently; the one who exercises her perversions morphs into an... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Excited DeliriumFalsifiability, Causality, and the Importance of AdvocacyArjun Byju, MD (bio) and Phoebe Friesen, PhD (bio)We want to begin by thanking both Kathryn Petrozzo and Paul B. Lieberman for taking the time to read and respond to our article, “Making Up Monsters, Redirecting Blame: An Examination of Excited Delirium,” so thoughtfully. They each offered us an opportunity to consider dimensions of excited delirium that we had not encountered as (...) of yet and encouraged us to think more carefully about them. In our response, we consider each of their commentaries in turn, given that, as a philosopher and a psychiatrist, they each speak to different aspects of our argument.First, we turn to Kathryn Petrozzo’s commentary “Excited Delirium: The Self-Fulfilling Prophecy of Police Brutality.” We are grateful for her generous comments and careful engagement with our arguments. While much of the commentary is supportive of our piece, Petrozzo makes three critical and insightful points that we hope to respond to here.The first point Petrozzo makes is that our assertion that excited delirium is non-falsifiable is not supported. She suggests that those “seeking to exonerate the police/first responders responsible for these deaths, are not accepting this evidence leading them to reject the excited delirium diagnosis, but rather, are crafting an incorrect causal narrative. This is deeply problematic, but it does not necessarily render excited delirium as nonfalsifiable.”Although we are intrigued by this challenge, we would like to hear more about what it would look like to falsify the phenomenon of excited delirium. The way that the causal theories related to it are structured are such that if one causal factor is not present (e.g., drug use), then another causal factor can be located (e.g., mental health), and if that is not found, another may be simply made up (e.g., genetic predisposition), making excited delirium multiply realizable in a seemingly endless fashion. This is precisely what took place in the case of Anthany Dawson, who was initially said to have been experiencing a mental health crisis, but was later said to have died from excited delirium related to a genetic condition never identified before (Hon, 2004; Razack, 2015). [End Page 361]In practice, confirmations of excited delirium are found on the basis of various unrelated factors, such that after a death involving police force, there is almost always the option to reach for excited delirium as an explanation/exoneration. According to proponents, there is no factor that could be present that could rule out the diagnosis of excited delirium as it is currently constructed. Indeed, even in the presence of video evidence showing police officers choking an individual until they stop breathing, these deaths are still attributed to excited delirium. This seems like a clear instance of non-falsifiability.Although Petrozzo might maintain that this is simply “an incorrect causal narrative,” it is a causal narrative that aligns with the current theoretical scaffolding surrounding excited delirium.The second point Petrozzo makes is regarding widespread criticisms of Popper’s demarcation criterion of falsifiability. Indeed, this criterion has been called too inclusive, in that any empirical claim can be called falsifiable in principle—even if it refers to a future apocalypse or a UFO landing. It has also been criticized for being too exclusive, in that it ignores the “remarkable tenacity of scientific theories,” as Lakatos puts it (2009, p. 516). In practice, scientists do not merely abandon a theory if it is not supported by facts; they tend to find other explanations (e.g., the measurement was faulty) rather than accept an instance of falsification.Despite this, we believe it is still worth discussing falsifiability in the context of excited delirium for two reasons. First, while falsifiability may not be successful as a criterion that draws a line between science and pseudoscience, in this case, we argue, it still works well as a signifier of pseudoscience. Recently, many interested in the demarcation question have turned towards pluralism as a way to identify pseudoscientific practices (Pigliucci & Boudry, 2013). And excited delirium offers an excellent example of a phenomenon that bumps up against many of the features that might indicate a pseudoscientific practice... (shrink)

This paper examines the controversial diagnosis of excited delirium, which is often employed after individuals die during an encounter with the police. Rather than asking the important, and widely explored, question of whether the diagnosis is real or not, here, we consider how it operates in the world and why it seems to stick around, despite growing controversy and resistance to its use. First, we consider the question of what kinds of people are made up through the diagnosis of excited (...) delirium, exploring how racial stereotypes are exploited and certain behaviors are engendered through the illness script offered by excited delirium. Next, we ask what work excited delirium doing is doing in the world, unpacking how it tends to justify force and redirect responsibility, as well as who is it serving, and who is it not benefitting. Finally, we interrogate the slippery logic of excited delirium, examining how the way it is employed renders it non-falsifiable, and therefore impossible to uncover as real or unreal. (shrink)

The conceptual landscape connected with such notions as mental disease, mental disorder, or, considerably broader, madness is not only complex and internally heterogeneous, but also somewhat obscure. Even the very nature of complexity and heterogeneity at place, what is more, seems to be unclear, which is reflected in the numerous (and heated) debates philosophers of psychiatry engage in and, respectively, in the variety of fundamentally incompatible, if not incommensurable, high-level models of psychopathology they develop (Fulford & Colombo, 2004).The paper by (...) Justin Garson (2023) can be understood as a successful attempt at helping us to find our bearings in such a troublesome conceptual domain. As such, it can... Read More. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Excited DeliriumWhat’s Psychiatry Got to do With It?Paul B. Lieberman, MDIf in life we are surrounded by death, so too in the health of our intellect by madness.—WittgensteinDelirium is a medical syndrome defined as “a relatively acute decline in cognition that fluctuates over hours or days” whose primary manifestation is a deficit of attention. It is common, estimated to occur in 10% to more than 50% of hospitalized patients, (...) with higher prevalence rates among people in nursing homes and at the end of life. It is often fatal, with a mortality rate in the hospital estimated to be 25% to 33%. Caused by a wide variety of conditions and frequently difficult to diagnose, it lacks characteristic postmortem pathology (Josephson & Miller 2018)‘Excited delirium,’ as Byju and Friesen forcefully argue (Byju & Friesen, 2023), is, if nothing else, an excuse. The ‘diagnosis’ has not been empirically validated and remains controversial (American Psychiatric Association, 2020). And while delirium is usually treated by internists and emergency medicine physicians, psychiatrists should also be concerned about the misuse of a putative medical diagnosis and join actively in discussion about it. For one thing, patients mis-diagnosed with this condition, as Byju and Friesen’s examples suggest, may actually have another psychiatric condition and, so, be people for whose safety we should advocate. Moreover, the kinds of police interventions which Byju and Friesen document as involving excited delirium also befall patients with other psychiatric problems in whom the issue of delirium does not arise.There are at least two broad ways in which psychiatrists are qualified and obligated to engage with this issue. As physicians, we should join our medical colleagues in carefully but persistently telling the scientific, medical truth. As psychiatrists, we should bring psychiatric knowledge into the discussion, for example, by explaining what can happen when people who do not, apparently, have a diagnosable mental disorder interact under stress with other people who, apparently, do.Delirium is a clinical diagnosis, made when characteristic signs and symptoms are present which should not be made ‘by exclusion’ when, as may happen, other causes are not found. There is no evidence of delirium in any of the three clinical descriptions Byju and Friesen provide. Perhaps such evidence exists which is not in their brief reports, but these three people appear to have had, either, another psychiatric condition, such as psychosis or drug intoxication, or perhaps no [End Page 353] diagnosis at all. Psychiatrists are particularly wellpositioned to make this point since patients with mental health problems are often misdiagnosed when they seek medical attention and are told, and treated as if, “it’s all (“just”!) psychological.”Excited delirium, if it exists, is fatal in 10% of cases (Gonin, Beysard, Hersin, & Carron, 2018) and, although this is lower than the rate for delirium in general, it is still high. Medical personnel must be available to evaluate and ensure the safety of patients in custody.The potential conflict between protecting the patient and protecting the public should not be overstated. Although physical trauma and excessive administration of medications, including ketamine 500 mg IV (Orhurhu, Vashicht, Claus, & Cohen, 2023) can be lethal, mechanical restraint by itself is not (Chieze et al., 2019; Gleerup et al., 2019): something else is necessary, such as asphyxiation (Evans, Wood, & Lambert, 2003). Nor is restraint necessary in many cases in which ‘de-escalation’ techniques can be equally effective (Garriga et al., 2016; Fernández-Costa, 2020). Perhaps these points are best made by law enforcement leaders—and they have been—but psychiatrists can add that safe management of potential violence can be provided for agitated people with psychiatric conditions.Although it is not clear what kind of strength ‘superhuman’ strength might be (certainly not medical), relative imperviousness to pain is clinically described. Its locus classicus is Beecher’s observation, during World War II, that injured soldiers awaiting return home from the front, required lower than usual doses of analgesics (Beecher, 1946). And it’s a common experience, scientifically confirmed, that physical trauma may not become painful until sometime after the injury (Melzack, Wall, & Ty, 1982). But pain is a warning. Its absence is not a license, but a caution... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:How to Reason Beyond Reason? Toward a Philosophical Understanding of MadnessWouter Kusters, PhD (bio)To analyze the situation of madness on the ground, we need a grounded perspective, close to the situation at hand. The closer we come to the subject under scrutiny, the clearer its outlines, fine-grained details, and its dynamics, and the better we reach an explanation and understanding. The closer the approach, however, the higher the chances (...) are of becoming myopic and losing the connections with broader—or higher—perspectives: the view from above. It has been due to philosophical and historical approaches from above to the practices of philosophically inspired psychiatry that we may gain new insights into what is going on on the ground—and underground. This article by Garson provides such a view that may lead to a change in perspective, a new way to draw boundaries on the ground, to discover similarities and dissimilarities through space and time, without thereby losing the lived connection to the problematic ground.Garson proposes to replace a binary opposition of madness (in the sense of sick or insane) versus sanity (in the sense of healthy), with a triad of concepts, sanity, madness, and idiocy, taken from the work of philosophers of psychiatry avant la lettre in the early modern times, Locke, Kant, Wigan, and Heinroth. This triad is to be understood in terms of reason, where idiocy consists of the diminishment of some aspects of reason, while madness would be characterized by a perversion of reason. By examining how this perversion—or more neutrally said, this change—of reason was conceived by the four thinkers, Garson sheds a new light on research and theory within the philosophy of madness and the philosophy of psychiatry today. He examines the question of “how is it that the mad person “has” reason, but is still not reasonable?” with the help of the four authors mentioned above (of which I discuss three).In answering this question, Garson refers specifically to my work as an example of “exactly the kind of ontology we need for rethinking madness in a positive manner—not necessarily ‘positive’ in the sense of good, helpful, or ennobling, but in the sense of going beyond a mere lack, absence, or failure.” I wholeheartedly agree with this assessment, [End Page 317] and Garson’s proposal of this tripartite schema is helpful and valuable for thinking through how we can further nourish a positive view of madness, especially with reference to Mad Pride.Locke and HeinrothGarson discusses some fragments from Locke and concludes that according to Locke “the mad person, in contrast to the idiot, possesses reason by virtue of possessing an intact inferential capacity. What ultimately makes them mad, and not reasonable, is that their premises are flawed by the unhinged power of association.” So, with Locke the capacity for inferential logic is not disturbed, and in that sense reason is intact. The unreasonable behavior would be due, according to Locke, to an unbridled increase in imagination and associations, which are taken for reality. Instead of reason the capacity to align imagination and reality is afflicted. When we translate this Lockean view into contemporary terms, we could say that it is not their cognition, their way of processing stimuli that is problematic, but their being overwhelmed by impressions or stimuli. This is akin to “bottom-up” theories: Something is wrong with perception or experience, and ‘higher’ capacities of cognition and reasoning remain intact. Reason may seem ‘perverted,’ but at a closer look, this is a result of their being victim to anomalous experience, too many stimuli or too strong imaginations.Heinroth also explicitly distinguishes madness from idiocy, that is, from a diminishment of mental capacities. Instead, he considers madness as a reaction to what Garson calls “a reality that is too awful to bear.” Madness is then “a wholesome desire of nature to cure a perversion through another perversion.” Again, madness is then not in itself a diminishment of reason, but an attempt to cure something that went wrong, in a way that is also only seemingly wrong (perverted reason). Madness then is again within reason, but this core of intact reason is... (shrink)

The paper concerns the essential and permanent place of roles and rules in human life, or what I call ‘the dilemma of compliance.’ The paper begins with previous scholarship warning therapists and psychologists about the danger of unknowingly reinforcing violent and toxic social expectations. A distinction is drawn between conformity and compliance, with the former standing for rote and mindless following of rules, and the latter a self-conscious and flexible way of relating to rules and roles. The paper argues that (...) following rules and filling roles is unavoidable, and, consequently, a human life is always a double-life, divided between pre-existing, generic roles, and our private and unique way of relating to those roles. The crucial difficulty is learning to comply with rules and roles rather than merely conforming to them. Two extreme cases are examined to develop this problem of rules, roles, and living a double-life: schizophrenia and censorship. It is argued that schizophrenia and censorship are cases in which the place of rules and roles become overbearing and urgent. Finally, the paper argues that attention to the dilemma of compliance highlights the significance of trauma-informed care, as trauma is often connected to how one fits or does not fit into a social milieu constituted by roles, rules, and expectations. The arguments are developed primarily in historical, philosophical, and clinical terms. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Excited DeliriumThe Self-Fulfilling Prophecy of Police BrutalityKathryn Petrozzo (bio)In their timely and pressing piece, Arjun Byju and Phoebe Friesen explore the contentious diagnosis of excited delirium; a syndrome characterized by erratic, aggressive, and “delusional” behavior (2023). Overwhelmingly, this term is used when individuals come in contact with police and/or first responders. Although much attention has been given to debating whether or not this is a “real” diagnosis, the authors (...) want to shift the focus to examining the work that excited delirium is doing in the world, as well as the underlying beliefs guiding it that are perpetuating substantial harm. Drawing significantly on the work of Ian Hacking (1998, 2006) and Sherene Razack (2015), Byju and Friesen explore what kinds of people are being made up by the label of “excited delirium” and the subsequent dehumanization that perpetuates violence towards those in this grouping.Despite the lack of an agreed upon definition, excited delirium tends to frequently group together young Black men and other marginalized people of color, who have a psychiatric history, and those who have taken or are suspected to have taken drugs (Byju & Friezen, 2023). As this is “observed” when individuals come into contact with law enforcement and/or first responders, those who are presumed to be suffering from excited delirium are typically met with physical restraints (chokeholds, hogties, etc.), forced injections of sedatives, and/or taser guns. The violent reactions are often justified not only by this “diagnosis,” but the employment of racial stereotypes; notably, the notion that Black bodies as being less susceptible to pain. As the authors aptly put it:This kind of symptom language helps make up the novel category of a person who suffers from excited delirium: a crazed and inhumane monster, a golem that must be met with unrelenting and superordinate force, who is fated, regardless of interventions, to die a spontaneous death. This paradox, that those with excited delirium are supposedly both too strong and too weak, is at the core of the illness narrative.(2023)It is evident that this label is reinforcing the combination of two harmful stereotypes: the notion that those suffering from severe mental illness occupy a space that is “less than fully human,” and racist stereotyping of Black bodies “superseding human strength.” This perpetuates total dehumanization of the individual, where it is then justified to invoke brutal tactics, as well as signal [End Page 357] to the greater community this is how individuals with mental illnesses and/or belonging to a particular racial group (chiefly, Black men), should be treated. This is despite the fact that those suffering from mental illnesses are significantly more likely to be victims of violent crimes, Black Americans are 3.2 times more likely to be murdered by police, and convergence of these factors (being Black and living with a mental illness) increases likelihood of such fatal interactions (Schwartz & Jahn 2020; Shadravan, Edwards, & Vinson 2021; Stuart, 2003).Although I am in wholehearted support of their account, I take issue with the authors’ conceptualization of excited delirium as non-falsifiable, as well as the notion that diseases, generally, are falsifiable. In an attempt to further criticize the utilization of excited delirium, Byju and Friesen call upon Karl Popper’s falsifiability criterion as a measure for what constitutes as scientific; arguing that excited delirium is not a legitimate scientific concept as it is impossible to falsify. First, I am not convinced that excited delirium is in principle non-falsifiable; as the way in which it’s conceptualized actually appears to be falsifiable. The authors point out that external factors, such as tasing and violent restraints, are clearly the causal explanation, which should in fact, lead one to reject the hypothesis of an excited delirium diagnosis. However, in practice, those who are seeking to exonerate the police/first responders responsible for these deaths, are not accepting this evidence leading them to reject the excited delirium diagnosis, but rather, are crafting an incorrect causal narrative. This is deeply problematic, but it does not necessarily render excited delirium as non-falsifiable. More broadly, I am concerned with the reliance on the falsifiability criterion, which has been widely criticized in the... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:What, Exactly, Does the Madperson Lack?Sofie Jeppsson, PhD (bio)Justin garson has already received well-earned recognition for his Madness: A philosophical exploration (2022), in which he distinguishes the view of madness as a dysfunction from madness as a strategy—a distinction that cuts across traditional distinctions between, for example, biological/neurological and psychological/social views. On the dysfunction view, going mad might be comparable to something like having an asthma attack or, more (...) long-term, developing type 1 diabetes. If the trachea closes up and prevents air from passing through, that is a dysfunction in the breathing apparatus. If the islets of Langerhans in the pancreas cease to produce insulin, making the person dependent on insulin shots to stay alive, that is a dysfunction. On the strategy view, going mad is rather like getting a fever when already infected with some pathogen. Given that you have the pathogen reproducing inside you, a rising body temperature provides a strategy (although not, of course, something the ill person chose) to keep the reproduction rate down, thus giving the immune system a better chance at vanquishing the infection. That does not mean that fevers are harmless—if a fever becomes high enough, it might itself do damage to the body. Still, it is a strategy, not a mere dysfunction. Analogously, on the Madness as strategy view, going mad might help a person deal with old traumas or an ongoing terrible situation, even as the madness may also be damaging in itself.In this paper, Garson introduces us to another interesting distinction: between seeing madness as a lack of reason, or as a perversion of or difference in reason. Garson writes that present-day psychiatry tends to see madness as a lack, whereas the late modern thinkers conceived of it as a perversion of reason. The late moderns clearly saw madness as something negative, but if we retain something like their basic view, merely change our evaluation from the negative perversion to the more neutral difference, we have a better basis for regarding Madness as a complicated and problematic but still cherished identity, and for Mad Pride.This is another interesting distinction well worth calling attention to. I’m uncertain how well the J.C.A. Heinroth example works—the text cited seems to show that he had a Madness as strategy view, but is it a Madness as a different kind of reason view?—but the other examples work better. Nevertheless, I want to push back a little against the claim that present-day psychiatry and philosophy of psychiatry tend to regard madness as a lack of something whereas the early moderns saw it as a difference. (Just a friendly little push, mind you, but still.)Arthur Wigan’s description of two brains, one functional and one dysfunctional, still seems to posit a lack of proper function in one of them. Sure, he does not say that the madperson lacks as much as the [End Page 313] idiot, who has two dysfunctional brains whereas the madperson has one functional and one dysfunctional. Still, there’s a lack. This two-brain picture also has its modern analogues: It brings to mind (albeit in a less biologically concrete and reified form) much psycho-educational material on, for example, how to live with bipolar disorder, according to which a supposed sane and rational part of the psychiatric patient’s mind should learn to handle and control the other, mad part (e.g., Miklowitz, 2012).According to John Locke, madpeople reason just fine, but they start from false premises. Is not this, too, something that madpeople are supposed to lack? Correct and realistic premises to start from? Locke writes that madpeople have “taken their fancies for realities,” but “make right deductions from them.” Moreover, Locke’s theory is reminiscent of modern bottom-up theories like Brendan Maher’s (1999)—madpeople have bizarre experiences on the basis of which they form bizarre beliefs, but we need not postulate that they suffer from any problems with, for example, reasoning and drawing inferences to explain why they believe what they do. Theorists who instead argue for a top-down or two-factor account of why madpeople stick... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Madness, Reason, and PrideRichard G.T. Gipps, PhD (bio)MadnessQuestions such as “what’s madness?” or “what’s reason?” carry no singular sense about with them wherever they go—which isn’t to say that, asked out of a particular interest in a particular context, they can’t be perfectly intelligible. Garson (2023) is wise to this when he follows “what is madness?” with “as opposed to what?”, even if this latter question itself hardly enjoys (...) a clear sense in the initial context of his asking. What counts as a satisfactory answer to “what’s x?” varies, so that sometimes we’ll be satisfied with a name, at other times by information about something’s genus, origin, function, or composition. Things get notoriously tricky when in the philosophical context the question is asked with a presumption of intelligibility despite ‘x’ being, say, an abstract noun formed from an adjective (‘consciousness’ out of ‘conscious’; ‘happiness’ out of ‘happy’; ‘madness’ out of ‘mad,’ etc.). For “what is?” questions are typically most perspicuously mooted when what’s being pursued are enquiries into (what we might call) the ‘essential nature’ of (what philosophers used to call) ‘substances’ or (of what are more ordinarily called) types of ‘thing’ or ‘entity.’ Invoke, by taking one’s lead from the fact that an ‘x’ is grammatically speaking a substantive, the specter of substance, and you can endlessly baffle yourself by now pondering the mysteries of the putative thing. (Vide discussions of “the nature of consciousness.”) Hence the boon of instead pursuing questions of an ‘opposed to what?’ sort; hence Wittgenstein considering using the Earl of Kent’s “I’ll teach you differences” (King Lear) as a motto for his Investigations. Rather more reflective wisdom regarding ‘x’ may thus be gained when we learn to contrast it with ‘y’ and ‘z’ than when peering into x’s non-existent constitution or groping for its never-instituted genus.Later, I make the case that Garson’s conception of reason itself might suffer from a form of substantialization and that, if I’m right in this, troubling implications follow for his approach to madness. But let’s begin by considering his enquiry into the relation of madness, idiocy and reason. So perhaps we’re reflecting on matters legal, and considering—since we’d hitherto been inclined to take ‘reason’ as univocal—what justifies our different treatments of the insane, the intellectually subnormal, and the normal. Or perhaps—proceeding from the same inclination—we’re puzzled by how someone may boast an exceptional IQ or demonstrate marvelous formal rationality (i.e., make deductions of a sort which would please the logician if no-one else) and yet still be quite mad. And then we realize that at which Garson’s Late Moderns seem to have been gesturing: The lack of reason qua intelligence in idiocy is a different [End Page 307] species from the lack of reason qua sanity in madness. An amethyst is lifeless in a different manner than an expired possum (it was never living, never moribund); the arational lack reason in a different sense than do the irrational (and a baobab cannot jump to conclusions.) There is, say his Late Modern theorists, something ‘perverse’ rather than simply deficient about the irrationality of madness.Now an important part of Garson’s thesis has it that “idiocy is a better candidate for the opposite of reason than madness.” One of the reasons for his making this claim is that he follows his Late Moderns in claiming that madness has reason somehow alive within it, albeit in an unconventional or surprising form. I return to his own explication of this below. Consider first, though, the different thought-referencing descriptions under which the speech acts of the thought-disordered, the speech-disordered, the delusional, and the learning disabled subject may be brought. The sufferer of speech disorder has difficulty with fluency or sound production, but once we get used to this we can find our way to the bona fide rational thought immanent within their discourse. The speech acts of the intellectually impaired subject aren’t chaotic, but instead want for invention and richness; they fail to express... (shrink)

A basic question of philosophy of psychiatry is “what is madness (mental illness, mental disorder…)?” Contemporary thinkers err by framing the problem as one of defining madness in contrast with sanity. For the Late Modern theorist of madness, the problem was not one of defining madness in contrast with sanity, but in contrast with “idiocy”—the apparent diminution or abolition of one’s reasoning power. This altered reading of the problem has an important consequence. For what distinguishes madness from idiocy is not (...) the failure, absence, or lack of reason, but its presence—albeit in a perverse and mutated form. For the Late Modern theorist, madness was always, by its very nature, infused with reason. This “infusion” of madness by reason has two consequences for philosophy of psychiatry today: it reframes the project of defining “mental disorder,” and it provides intellectual scaffolding for the emerging movement known as Mad Pride, mad resistance, or mad activism. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Rules and CommunityJeffrey Bedrick, MDThe paper, “The Dilemma of Compliance: Roles and Rules in Schizophrenia, Censorship, and Life,” by Riley Paterson raises a number of interesting issues. I am only able to address a few of these issues here, and I do so in the hope of broadening our consideration of some of the basic concerns.Paterson focuses his attention on the potentially repressive side of rules, even while acknowledging (...) the broader role of rules in human life. Thus, towards the end of his paper he writes “While I regard all experience as rule- and role-bound, the aforementioned groups”—those who “experience schizophrenia, persecution, or are otherwise marginalized and vulnerable”—“experience rules and roles with particular violence.” He admirably warns us to be sure that in our work with people we are not traumatizing or re-traumatizing them.But rules play a broader role in human life. Paterson discusses censorship and the role that rules can play in repressing the expression of ideas. But rules also allow the use of language and govern communication in general. Writers living under censorship resorted, Paterson notes, to a system of exoteric and esoteric writing and communication. But those esoteric texts, if they were not to remain purely private and unknowable to those who read the texts, had to follow certain rules and conventions to signal the reader that the exoteric text was not all there was, and that there was another, esoteric, meaning to be found within the text. Writing under conditions of censorship remained a communal, intersubjective, endeavor.With schizophrenia, the seeming central topic of the paper, the situation becomes even more complex. We shall see that Paterson’s analyses point us in two different directions.Paterson writes:In schizophrenia we see an exaggerated instance of the dilemma raised above: There is a gap that exists between the publicly available roles, and the person we feel ourselves to be. We are required to conform with the demands of these roles to preserve what we feel most natural in ourselves. People with schizophrenia often must conceal, at times, their experiences of hallucinations and delusions in order to preserve some ability for social interaction. In my clinical work, however, people with schizophrenia have often reported it has felt freeing to learn when and with whom they can share those thoughts and experiences. Freeing, not because they need to hide part of themselves but because doing so opens up possibilities of social interaction and community.Further, Paterson writes of the difficulties people with schizophrenia may have with ‘weintentionality.’ Referencing Salice and Henriksen (2021) [End Page 381] he concludes that “the self-disorders of schizophrenia preserve a capacity for joint intentionality (rule following) but severely inhibit an experience of group belonging and identity (weintentionality).” Indeed he notes, again following Salice and Henriksen (2021), “that some individuals experiencing more mild forms of schizophrenia spectrum disorders found great comfort and safety in rule following.” The problem for people with schizophrenia thus seems less with applying specific rules, which might in some cases be meant to regulate or repress behavior, than in establishing we-intentionality. Many phenomenologists have explored the concept of intersubjectivity and have noted, as have many psychoanalysts and therapists, that there is no pure, interior subject but that our very selfhood is formed in interaction and relation to others. (See, for one example, the work of Alfred Schutz (1967) for a phenomenological investigation of intersubjectivity and the social.) To borrow Paterson’s gardening metaphor, there are no sole, beautiful flowers. They must be cared for to grow, or be part of a natural ecosystem that allows them to flourish.Cognitive and negative symptoms are widely accepted as posing more of a burden to schizophrenia than the more flamboyant hallucinations and delusions. These seem to me to be due less to a difficulty conforming or complying to social rules that may be felt to be restrictive or repressive and more due to the difficulties with intersubjectivity and we-intentionality. The people I have worked with who were most limited by their schizophrenia in my judgment have been people with severe thought disorders who demonstrated severe loosening of associations and word salad. I say... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Experience, Institutions, and EpistemologyRiley Paterson, MA (bio)I am grateful for these comments on my paper, “The Dilemma of Compliance,” because they illuminate the limitations of the paper’s emphasis. The paper is, above all, meant to caution or warn providers of subtle but serious harm that can occur in institutional settings. I want to attune providers to the ways in which institutional coercion and violence occur in the ordinary process (...) of following rules and filling of roles. Thus I write that the goal is “to become self-conscious observers of systems of compliance, rather than unconscious conformers.” Institutional coercion is a social process like any other and thus involves intersubjective dynamics. These dynamics do not appear as measurable, physical structures, but rather as invisible patterns in time, made visible only by being named and grasped experientially. I am offering language that can help make these invisible dynamics visible, so that providers can navigate institutions differently.My desire to caution and attune other providers can be explained partly by the conditions in which I wrote the paper: making sense of my time in forensic mental health, where I worked with clients who were mandated mental health treatment upon avoiding or exiting incarceration. I was processing my own experience of submitting monthly “compliance reports” to various agencies. I was concerned with the experiential process of navigating coercive environments. Thus my commenter is correct to try and widen our consideration, as my paper is indeed limited by its focus on the lived experience of censorship, oppression, and institutional coercion.This emphasis means that I am neglecting other dimensions, such as the positive role of rules in organizing communities, and the way in which some mental health institutions are working on creating safe and healing formal environments. I also believe, however, that the fields of psychology, psychiatry, and mental health broadly need to be careful about institutions, rules, and roles. We are not, in my estimation, in danger of providing too many safe spaces in which healing can occur. Quite the opposite, psychiatry and psychotherapy have, since their outset, been intertwined with troubling political motivations, and we continue to struggle with the manipulative tendencies of the field (Carr, 2018; Cabanas & Illouz, 2021).I, therefore, would like to take this opportunity to restate the core argument of my paper, and to situate this argument within the context of my other publications and the overall project they belong to. There is likely some ambiguity about [End Page 385] the central thrust of my paper. When commenting on my discussion of schizophrenia, my commenter refers to it as “the seeming central topic of the paper.” This is understandable. Schizophrenia is the topic I discuss that has the most obvious clinical implications. Indeed, I am making an argument about the phenomenological intelligibility of schizophrenia. With both my discussions of schizophrenia and censorship, however, I am making both immanent arguments and transcendent arguments. In other words, although I am making arguments about both schizophrenia and censorship, those arguments need to be understood as an example of a broader problem of coercion within human relationships. My intent is to highlight general dynamics present within human relationships and communities that contribute to institutional violence and the excessive regulation of individuals. My concern is with rules, roles, and coercion in general; schizophrenia and censorship provide exaggerated examples of what is fundamentally an ordinary, daily experience. Mental health institutions are uniquely involved in coercive institutional processes, but almost all human environments carry some danger of coercion and oppression in terms of fitting, belonging, or conforming with rules and roles. My exploration of schizophrenia and censorship is certainly meant to illuminate those particular topics, but the broader point concerns all human experience.The phenomenological or experiential thrust of the paper must be situated within my broader analysis that also includes institutional and epistemological dimensions. My reviewer is correct to point out that with schizophrenia, censorship, or trauma, the crucial dimension is communities in which people feel safe enough to learn, grow, and develop their capacities. In this vein, my reviewer points to Geel as an admirable model of communally driven care. I am largely in agreement with this line of thinking. In... (shrink)

While loneliness has been linked to various mental and physical health problems, the sense in which loneliness is a cause of these conditions has so far attracted little philosophical attention. This paper aims to fill this gap by analyzing research on health effects of loneliness and therapeutic interventions through current approaches to causality. To deal with the problem of causality between psychological, social, and biological variables, the paper endorses a biopsychosocial model of health and disease. I will investigate how three (...) main approaches to causality used in psychiatry and public health apply to loneliness: interventionism, mechanisms, and dispositional theories. Interventionism can specify whether loneliness causes specific effects, or whether a treatment works, incorporating results from randomized controlled trials. Mechanisms help explain how loneliness brings about negative health effects, spelling out psychological processes involved in lonely social cognition. Dispositional approaches help stress particular features of loneliness connected to negative social interactions, such as defensiveness. I will conclude by showing that previous research alongside emerging approaches to health effects of loneliness lend themselves to analysis in terms of the causal models under discussion. (shrink)

Critical notice of Puddifoot, Katherine. 2021. How Stereotypes Deceive Us. NY: OUP.--------- -/- Kathy Puddifoot makes a compelling and enlightening case for a striking pair of claims: 1) false stereotypes sometimes steer us to the truth, while 2) true stereotypes often lead us into error. This is a wonderful book, a seamless integration of epistemology with ethics, of philosophy with social science, and of “mainstream” or “Western analytic” approaches with marginalized and underappreciated contributions from critical social traditions, especially black feminism. (...) The integrations are so seamless, in fact, as to give the reader the impression that Puddifoot is simply picking up conversations already underway. Instead, she has done a tremendous service in bringing representatives from wide-ranging, often-siloed disciplines into dialogue. Another virtue of Puddifoot’s book is how thoroughly it maps out the actual and possible views and logical spaces revolving around each topic she addresses. How Stereotypes Deceive Us could therefore be used to introduce budding epistemologists to the field, as it offers clear and careful explanations of leading approaches to a range of topics, including virtue epistemology, theory of mind, and more. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Diagnostic Criteria, Psychological Tests, and Ratings Scales: Extending the HistoryPeter Zachar, PhD (bio)Le moigne narrates a history of the development of psychiatric ratings scales as hybrids between psychological tests and diagnostic categories. In his telling, psychological tests seek to quantify population-based traits on which every person has a position and which tend to be conceptualized as being stable. Personality traits are often conceptualized as dispositions. Diagnostic categories represent not (...) trait-like properties of populations but episodic states consisting of clusters of symptoms experienced by individuals with disorders. Ratings, scales, he notes, are hybrids between the two. They are used to quantify psychiatric symptom clusters so that change over time can be measured. Le Moigne argues that these distinctions were initially suggested during the development of measures that could assess outcomes in psychopharmacological treatment studies.With respect to depression, Le Moigne writes that in the 1970s and 1980s something akin to depressive personality was reconceptualized as a temperament. A key move, somewhat reflective of Kraepelin’s notion of a depressive temperament, was to view a dysthymic temperament as both a predisposing factor and an attenuated form of depression. Thus, an episodic state commandeered the predisposing–dispositional role that was assigned to stable personality traits.This conceptual shift allowed test-like ratings scales to be seen as useful for quantifying not just stable traits, but salient features of episodic states that are potentially subject to change in response to interventions. To put it another way, in the development of a psychological test, one goal is to have high test-retest reliability (i.e., stability of measurement). With rating scales used to measure change, one wants the scores to not be as stable; ideally the scores on the later assessments will be lower. According to Le Moigne, when dysthymia was subsequently placed on axis I of the Diagnostic and Statistical Manual of Mental Disorders (DSM)-III (as a syndrome) and segregated from personality disorders which were placed on axis II, personality traits were evicted from the conceptualization of depressive disorders.One perennial feature of psychiatry and psychology is that even if an older idea is superseded [End Page 253] in the view of some thinkers, it can still attract adherents. Indeed, interest in understanding a relationship between personality and attenuated states did not fully disappear. For example, based on research in genetics, the schizophrenia spectrum concept included not only schizophrenia, but also milder conditions such that were conceptualized as personality disorders; that is, schizotypal personality disorder and paranoid personality disorder (Kety, Rosenthal, Wender, & Schulsinger, 1971).During the development of the DSM-IV, some people wanted to add depressive personality disorder to the manual (Phillips, Hirschfeld, Shea, & Gunderson, 1995). It seems to have become a territorial dispute between mood disorder specialists and personality disorder specialists The mood disorders specialists challenged the personality disorder specialists to differentiate depressive personality disorder from early onset, chronic dysthymia. They were able to do so by using criteria such as critical, blaming, and derogatory toward self. After the mood disorders work group proposed incorporating some of those criteria into a revised criteria set for dysthymia, the two sets overlapped. The result was the old criteria for dysthymia were printed in DSM-IV and criteria for depressive personality disorder and the revised criteria for dysthymia were both placed in the appendix.In the DSM-5, Axis II was eliminated and personality disorders were placed alongside all the syndromic symptom clusters at the same level. Even so, interest in attenuated presentations as personality-related lingered still. During the development of the DSM-5 there was some thought to using diagnostic spectra as a meta-structure for organizing the manual (Andrews et al., 2009). One idea was to move some personality disorders into a best fitting spectrum, akin to attenuated forms. This did occur with schizotypal personality disorder which is both in the DSM-5 chapter on schizophrenia and in the chapter on personality disorder. In the schizophrenia chapter it is positioned as the earliest emerging disorder on the spectrum. There was also some interest in grouping avoidant personality disorder with the anxiety disorders, but the evidence supporting such a change was not available.These issues may... (shrink)

Psychiatric diagnoses are increasingly seen as viable categories around which self and social identities might be drawn. This introduces a new pressure on the “boundary problem” for psychiatry: when members of the public request diagnoses to affirm their self-identities how should we draw the line between mental disorder and normality? If psychiatrists have the authority to recognize and diagnose mental disorder, how can roles as diagnosers and gate-keepers be balanced in a post-stigma era of mental health care? Focusing on the (...) disorder identified would-be patient who would not attract the diagnosis they seek were they not to seek it, this essay explores what it means to have an identity bound to a psychiatric diagnosis and considers a framework for psychiatrists to negotiate clinical encounters that involve the seeking of identity affirming diagnoses. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Psychodramatic Psychotherapy for Schizophrenic IndividualsJohn Nolte, MD, PhD (bio)As a long-time student, practitioner, trainer, author and advocate of J. L. Moreno, MD,’s works and specifically the psychodramatic method, I am always appreciative of efforts, like Chapy’s, to commend and advocate for psychodrama. This is especially so because for a time, Moreno and psychodrama were heavily criticized, even maligned in the mental health professions. At the same time, considering how (...) poorly Moreno and his methods have been understood as well as the difficulty of accessing his original material, I feel an obligation to set the record straight when confronted with incomplete, inadequate, or sometimes incompetent expositions of Moreno’s psychodrama.Chapy’s article recommends psychodrama as a treatment method for schizophrenic people by calling upon existentialist and phenomenological concepts. Psychodrama, he proposes, opens up existence by allowing “schizophrenic patients to incorporate the experience of an ‘absolutely other.’”There are major flaws in Chapy’s presentation. His “clinical illustration,” the presentation of a psychodrama with a schizophrenic patient, while it may be considered psychodrama under the broadest definition of the term, hardly fulfills the requirements of a psychotherapeutic psychodrama. We must question the competence of the psychodramatist in Chapy’s example. Chapy’s description of the drama itself falls short of being an adequate account of a psychodrama, failing to convey the emotional intensity and realness which a well directed and reported psychodrama achieves. We do not learn, for example, if Damien’s perception of his father is introduced through role reversal with the father, a standard psychodramatic technique which is done in order to give the auxiliary ego taking that role an understanding how Damien experiences his father. We do not know if role reversals are made throughout the drama so that Damien can experience how he is perceived by father, can feel the force of his confrontation in the role of father, and is required to reply as his father to his confrontation. We are given little information about the psychodramatic techniques employed by the director other than the scene setting of the studio in which the psychodramatic [End Page 227] encounter takes place, and the soliloquy in which Damien expresses his worry and hopes for the outcome of the confrontation. It should be clear in the description of the drama whether the father’s statements in the drama were produced by Damien in role reversal, or by the auxiliary ego playing the role. There is a difference and it is significant. Although we are told that Damien “evokes a systematic relationship between him and his father” during the psychodrama, we do not see how this happens. Every psychodrama is an existential experience and its description should fully communicate its meaning and emotion.A more serious problem, however, is that this drama does not deal with Damien’s psychosis. Although Damien may be diagnosed as schizophrenic, his disorder is obviously in remission or controlled by psychotropic drugs. The drama reveals none of the hallucinations, delusions, or disorder characteristic of schizophrenic disorders. It could be psychodrama of any young man with a complaint about his father.The notion that people with schizophrenia can be successfully treated by psychodrama is not new. Moreno began developing psychodramatic psychotherapy at his Beacon Hill Sanitarium, established in 1936. He and psychodrama gained some fame because of his success in treating schizophrenic patients at a time when schizophrenic individuals were considered incapable of benefitting from psychotherapy. Moreno’s approach to the treatment of schizophrenic patients was much more robust than the psychodrama described by Chapy. During a psychotic attack, the individual’s perception of the world and self are distorted in ways that made action and interaction in the world of conventional reality impossible. Additionally, the psychotic episode makes the psychotic person incapable of being comprehended by anyone else, including the psychiatrist. Moreno’s solution was to make the chaotic, bewildering, sometimes violent and always terrifying inner world visible and tangible in the surplus reality of the psychodramatic stage. In moments of lucidity following the psychotic episode, he asked his schizophrenic patients to reenact their psychotic experiences. The result was that, “In this imaginary reality on the psychodramatic stage, the... (shrink)

The authors argue that Morenian-inspired existential psychodrama turns out to be a formidable lever for opening up existence as it allows schizophrenic patients to incorporate the experience of an “absolutely other” on which the foundation of any autonomous self is built. More precisely, by relying on their clinical experiences, the authors show how psycho-dramatic play goes along with an intense movement of original projection which carries psychotic patients externally in relation to themselves. Offset from their pathological world, these patients feel (...) more inclined to “wear someone else’s shoes,” for the duration of the game, and they do so in a manner that is both sensorial and pathic. This surprising and creative “journey,” which allows them to return to the world better attuned to others and to themselves, is merely an enactment of a “true” intersubjective encounter: the very essence of existential psychodrama. By applying phenomenology to this psychodramatic method, notably by relying on the hypothesis of psychosis being a disorder of what Bin Kimura calls the “ aida,” the authors hope to contribute to the advancement of psychosis’ psychotherapy. (shrink)