This is a case that should go to the European Court of Human Rights. A decent, senior qualified family doctor was accused by his mentally ill daughter of sex abuse. Without real evidence except for what the girl told another mentally ill patient at a psychiatric hospital she stayed at for several years, and wit just two witnesses, one a younger child wo saw none of the accused offences, and the other parent, struck off the General Medical Council Register for (...) drunk driving more than once, the case was fitted up by those who are rampantly seeking to raise statistical numbers for child sex abuse offences by high level persons- a bizarre situation and a travesty against tis family doctor's human rights, because a judge can use his 'discretion' to send a much needed family doctor to 18 years in jail. The International Community should scrutinize the United Kingdom's Criminal Justice System. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Clarifying the Relationship Between Vice and Mental Disorder: Vice as Manifestation of a Psychological DysfunctionMichael B. First (bio)KeywordsDSM-IV, psychiatric diagnosis, impulse control disorders, sexually violent predator commitmentIndividuals generally present for psychiatric evaluation for one of two reasons: either because they themselves are suffering from a psychiatric symptom that causes distress (e.g., severe panic) or impairs their ability to function effectively (e.g., memory loss), or else they are (...) brought to clinical attention because their behavior or attitudes are considered by others to be problematic. There are a wide range of behaviors that fall into this second category. In some cases, the individual is pressured to seek treatment because of the negative impact that a behavior has on a relationship partner (e.g., sexual dysfunction, anger outbursts) or an employer (e.g., excessive alcohol use). Often, however, the external trigger for a clinical evaluation falls under Sadler’s definition of vice, that is, criminal (illegal) behaviors or attitudes that could be considered “wrongful” or “immoral” in the social arena because the behavior violates the law or an important social more.Given that one of the most important goals of the Diagnostic and Statistical Manual of Mental Disorders (DSM) is to facilitate clinical practice (First et al. 2004) and in doing so provide a diagnostic code to cover any patient that might present himself or herself to a mental health professional, the DSM has evolved over its various editions to become a veritable laundry list of psychological and behavioral ills, some of which may constitute a violation of the rights of others or society. The DSM-III (and its successors) have adopted a descriptive approach wherein disorders are defined in terms of their presenting surface symptomatology, which was necessitated by the field’s lack of knowledge about the underlying etiology of mental disorders. Given this reliance on presenting symptoms, it is therefore inevitable that some disorders are defined in terms of behaviors that can be considered vices. For example, impaired impulse [End Page 35] control often leads to acting out behavior that, at its mildest is inappropriate, and at its most severe is destructive to self and others. Many of the disorders cited by Sadler as being vice-laden fall into this category, namely, pyromania (failure to resist impulses to set fires), kleptomania (failure to resist impulses to steal), intermittent explosive disorder (failure to resist aggressive impulses), certain forms of substance abuse (i.e., those involving possession and use of illegal substances) and paraphilias (i.e., those involving nonconsenting victims).It is important to clarify from the outset that the criteria for determining whether a behavior is a “vice” (i.e., whether it is illegal or immoral) is not equivalent to the criteria for determining whether a behavior is indicative of a mental disorder. According to the DSM-IV-TR definition, a mental disorder is conceptualized as a “clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom” (American Psychiatric Association [APA] 2000, xxxi). The definition warns against considering “deviant behavior[s] (e.g., political, religious, or sexual)” and “conflicts that are primarily between the individual and society” to be evidence of mental disorder except in those cases in which the “deviance or conflict is a symptom of a dysfunction in the individual.” Thus, when considering whether a particular “vice” behavior is a component of a mental disorder, it is crucial to determine whether the behavior is a manifestation of an underlying psychological dysfunction, such as a dysfunction in impulse control. If so, it may potentially be appropriate for that individual to be treated as “medically ill” in addition to, or instead of, being treated simply as a criminal.Let us examine some illustrative examples of cases that demonstrate the relationship between vice and mental disorders and the different ways in which the legal and mental health systems might deal with such cases. Consider the case of an individual who breaks... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Vice, Mental Disorder, and the Role of Underlying Pathological ProcessesNancy Nyquist Potter (bio) and Peter Zachar (bio)Keywordsresponsibility, virtue theory, cultural norms, psychopathologyThe issues discussed by John Sadler are among the most complicated in the philosophy of psychiatry, if for no other reason than that they highlight an area where disciplinary fault lines between clinical psychiatry/ psychology and philosophy seem most evident. We spent a year writing an article (...) on the relationship between the assessment of personality disorders and moral evaluations, and these fault lines became manifest not only between ourselves, but also when discussing our ideas with members of the various disciplines.Many practicing psychiatrists acknowledge that moral attributions (such as manipulativity) might be made about people with certain disorders (such as borderline personality disorder), but also find the argument that psychiatric diagnoses are moral rather than medical conditions to be a ludicrous bit of antipsychiatry in the Szaszian tradition. Philosophers, on the other hand, are less involved with these diagnostic categories in their day-to-day work and are more willing to be skeptical. Whether they are doing philosophy of psychiatry, moral theory, or sociopolitical philosophy, they are interested in digging a little bit deeper and are not impressed by arguments to the effect that—it’s obvious that these are really disorders. Being “obvious” is not a persuasive philosophical argument.The metaphysical task of determining what belongs in the category of criminality compared with other ways of sorting behavior has parallels in moral philosophy: Why is fraud, or theft, criminalized whereas (most) lying is not? Why is one set of moral norms enforceable, whereas a second set is aspirational? Does the difference involve property, where infractions of property are thought to be more serious wrongs than lying, which is “only” psychological rather than material? Are the “most serious” wrongs the ones we mark as crimes? Why is sodomy still criminalized in some areas but betraying one’s lifelong love is viewed as morally reprehensible but not criminal? Both actions are private, and only one seems to do harm—unfaithfulness—yet that is the one that is not criminalized. The point here is that, regardless of domain, our classification systems need to be justifiable, yet justification is most often mystifying. [End Page 27]The same is true for classifying mental disorders. The class of mental disorders appears to be a somewhat inconsistent collection of heterogeneous conditions and does not form a natural kind (Zachar 2000). At the most, the class of mental disorders names a family of loosely related conditions and the reasons for inclusion can shift from disorder to disorder.If the class of mental disorders does not specify an internally coherent kind akin to gold, deciding on the scope of psychiatric practice becomes an important problem. As Sadler asks, for what reasons do we classify pedophilia with schizophrenia—both as disorders—but omit sadism? This is an important question of disciplinary scope.This question of scope is itself ethically charged because, on the one hand, bringing a condition under the purview of psychiatry offers the possibility for treatment, and at least establishes the goal of improving the lives of people with specific kinds of problems. Making lives better is one of the humanistic justifications for science itself; clearly it is a raison d’être of psychiatry. On the other hand, medicalization sets up the conditions for a certain kind of social control. Hospitalization, educational services, day treatment, and disability payments are all contingent upon psychiatric diagnostic practices. These programs and the institutions that manage them are both socially available and socially prescribed. The diagnosed behaviors can now be considered to be entities, and explanations of them can be developed. New technologies for altering them will also be introduced. Such practices have been associated with dehumanization (Phillips 2009).Two important questions also need to be distinguished. The first is a question for moral philosophy—What degree of responsibility do people with putative mental disorders have for their behaviors? For example, should people with psychotic disorders or personality disorders be held responsible for crimes they commit? If so, under what conditions? Should responsibility for certain behavior be mitigated? If so, under what conditions? Moral philosophy... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Psychopathy, Other-Regarding Moral Beliefs, and ResponsibilityLloyd Fields (bio)AbstractIn this paper I seek to show that at least one kind of psychopath is incapable of forming other-regarding moral beliefs; hence that they cannot act for other-regarding moral reasons; and hence that they are not appropriate subjects for the assessment of either moral or legal responsibility. Various attempts to characterize psychopaths are considered and rejected, in particular the widely held view (...) that psychopaths are, in general, incapable of understanding moral concepts. The particular disability proposed here, the incapacity to form other-regarding moral beliefs, is then derived from an analysis of what is required for someone to be a responsible agent. This is illustrated with a detailed case history. A defect of this kind is shown to vitiate moral responsibility, because it renders the psychopath irresponsive to the social pressures which normally ensure respect for moral norms. It is also shown that the psychopath is not a suitable subject for the assessment of legal responsibility, because he lacks the capacity to act from common prudence to avoid sanctions. I conclude that the attempt to characterize particular defects from among the heterogeneity of psychopathic subjects, could lead to better targeted, and hence to more effective, management of particular cases.KeywordsCriminality, mental illness, personality disorder, blame, liability, moral beliefs, guilt, social moralityIntroductionThe term “psychopath” has been used with a wide variety of different meanings and, no doubt, covers a heterogeneous group of subjects (Criminal behaviour and mental health 1992). My aim in this paper is to argue that at least a subgroup of those subjects are characterized by an inability to form other-regarding moral beliefs—and hence, for this particular reason, are not morally responsible agents—and that they also lack the capacity for prudence, and hence are not legally responsible agents.I begin by distinguishing the particular sense in which I will be using the term “psychopathy.” I then consider some suggestions in the literature regarding the defect by which psychopaths might be characterized—that they are mentally ill, or incapable of understanding moral concepts. In rejecting these, I come to the suggestion that the relevant defect is an inability to form other-regarding moral beliefs, a defect which is graphically illustrated by a case report from the literature. I explore the implication of this kind of defect for [End Page 261] moral responsibility as a socially-embedded notion, and the implication of the psychopath’s inability to exercise prudence in relation to legal liability.Nothing in this paper should be taken to suggest that psychopaths are irredeemable. On the contrary, as I argue in an endnote, correctly characterizing the defect from which they suffer leads directly to forms of treatment whose effectiveness has acquired a measure of empirical support.The Nature of PsychopathyPsychopathy is not a homogeneous concept; there are different types of psychopaths. For example, Henderson identified a type of psychopath who he classified as “Predominantly Creative,” exemplified by such figures as T. E. Lawrence and Joan of Arc. In people of this type genius is associated with heightened sensitivity, psychosexual immaturity and emotional instability (Henderson 1939, 108–20; Henderson and Gillespie 1969, 317). Predominantly creative psychopaths do not come within my purview.By “psychopathy” I shall mean the specific form of personality disorder described by Cleckley in his book, The Mask of Sanity (Cleckley 1964). Cleckley’s description forms the basis of Hare’s Revised (20-item) Psychopathy Checklist. The Checklist includes the following personality traits and deviant behaviors:1. Glibness/superficial charm.2. Grandiose sense of self-worth.3. Need for stimulation/proneness to boredom.4. Pathological lying.5. Conning/manipulative.6. Lack of remorse or guilt.7. Shallow affect.8. Callous/lack of empathy.9. Parasitic lifestyle.10. Poor behavioral controls.11. Promiscuous sexual behavior.12. Early behavior problems.13. Lack of realistic, long-term plans.14. Impulsivity.15. Irresponsibility.16. Failure to accept responsibility for own actions.17. Many short-term marital relationships.18. Juvenile delinquency.19. Revocation of conditional release.20. Criminal versatility (Hare 1986, 18). 1This conceptualization resembles in many respects the category of Antisocial Personality Disorder as described in the American Psychiatric... (shrink)

This dissertation examines psychiatry from a philosophy of science perspective, focusing on issues of realism and classification. Questions addressed in the dissertation include: What evidence is there for the reality of mental disorders? Are any mental disorders natural kinds? When are disease explanations of abnormality warranted? How should mental disorders be classified? -/- In addressing issues concerning the reality of mental disorders, I draw on the accounts of realism defended by Ian Hacking and William Wimsatt, arguing (...) that biological research on mental disorders supports the inference that some mental disorders (e.g., schizophrenia, mood disorders, and anxiety disorders) are real theoretical entities, and that the evidence supporting this inference is causal and abductive. In explicating the nature of such entities, I argue that real mental disorders are natural kinds insofar as they are natural classes of abnormal behavior whose members share the same causal structure. I present this position in terms of Richard Boyd’s homeostatic cluster property theory of natural kinds, and argue that this perspective reveals limitations of Hacking’s account on the looping effects of human kinds, which suggests that the objects classified by psychiatrists are unstable entities. I subsequently argue that a subset of mental disorders (e.g., schizophrenia and Down syndrome) are mental illnesses insofar as they are disorders caused by a dysfunctional biological process that leads to harmful consequences for individuals. I present this analysis against Thomas Szasz’s argument that mental illness is a myth. -/- In addressing issues of psychiatric classification, my analysis focuses on the Diagnostic and Statistical Manual of Mental Disorders (DSM), which has been published regularly by the American Psychiatric Association since 1952, and is currently in its fourth edition. After examining the history of DSM in the twentieth century, and in particular, DSM’s shift to an atheoretical and purely descriptive system in the 1980s, I consider the relative merits of descriptive versus causal systems of classification. Drawing on Carl Hempel’s analysis of taxonomic systems in psychiatry, I argue that a causal classification system would provide a superior approach to psychiatric classification than the descriptive system currently favored by DSM. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Clinical CommentaryChua Hong Choon, Adjunct Associate ProfessorThe case for commentary describes a difficult, and yet not uncommon, clinical situation faced by clinicians at the Institute of Mental Health (IMH) in the course of their work. Based on the information provided on the case, the patient is likely to be suffering from the paranoid subtype of schizophrenia, and his illness is characterised by hostile and aggressive behaviour during episodes (...) of relapse.Although aggressive behaviour is known to be associated with young, male patients with paranoid delusions, auditory hallucinations and lack of insight,1 it is still necessary to exclude other causes of aggressive behaviour in this young man. Two causes of aggressive behaviour that are sometimes misattributed to schizophrenia are antisocial personality disorder and substance abuse. However, Mr. T did not have a history of conduct or behavioural problems prior to the onset of his psychotic illness, and he was also not reported to be violent or disruptive during the periods when he was on regular medication. There was also no history of illicit drug use.The initial onset of Mr. T’s illness while he was serving his National Service is a fairly common presentation of the first episode of schizophrenia in Singaporean males. While traits apparent prior to National Service such as his academic difficulties and inability to make friends are associated with the development of schizophrenia,2 the stress of regimented life and military drills might be more closely associated with his initial full-blown psychotic episode with prominent paranoid (and persecutory) delusions.The systematised nature of Mr. T’s delusions and the prominent threatening auditory hallucinations significantly increase his risk of [End Page 217] dangerousness,3 and when his wife became “incorporated” into his delusional beliefs, he began to threaten her physically during episodes of relapse. Despite being only 28 years old, Mr. T has already been hospitalised numerous times for inpatient treatment, due to frequent relapses of his illness. While relapses in schizophrenia may be attributed to various factors, including lack of social support, substance abuse, poor (or partial) response to medication and psychosocial stressors, Mr. T’s multiple relapses were primarily due to the stopping of his medication and his refusal to continue with any form of psychiatric treatment.The key problem to be addressed in this case is therefore the patient’s severe lack of insight which leads to recurrent episodes of treatment non-adherence and subsequent relapses.Mr. T’s wife has come to the clinic to ask for medication to secretly put into his food. Although the patient is apparently in remission of his condition (having just been treated and discharged from hospital), he has again stopped his medication, and she is justifiably afraid that he will become unwell again. Recognising that the patient’s lack of insight is the main (and possibly only) reason for his refusal to take medication, it would be prudent to first consider if all possible actions had been taken to create an awareness and to help the patient gain insight into his illness and the need to take medication. This may yet be possible in the window of opportunity that exists when the patient is in remission of his illness (and is therefore not disturbed by the symptoms of his psychotic disorder).Recent studies have demonstrated that psycho-education is able to reduce self-stigmatisation in individuals with schizophrenia, and also significantly improve insight 4 (as measured by the Birchwood’s Psychosis Insight Scale). A 2011 Cochrane Review 5 also concluded psycho-education does seem to reduce relapse, readmission and encourage medication compliance, as well as reduce the length of hospital stays in patients with schizophrenia. In this case, psycho-education could be given to Mr. T even after he has been discharged from hospital; he might not want to continue with medication, but he might consider seeing a trained clinician (case manager, nurse or medical social worker) to make sense of his life experiences. Engaging Mr. T through psycho-education may result in sufficient insight for him to consider resuming medication voluntarily, at least in the short term.Although there is a paucity of studies examining specific psycho-therapies (including cognitive behavioural therapy... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Vice, Mental Disorder, and the Role of Underlying Pathological ProcessesNancy Nyquist Potter (bio) and Peter Zachar (bio)Keywordsresponsibility, virtue theory, cultural norms, psychopathologyThe issues discussed by John Sadler are among the most complicated in the philosophy of psychiatry, if for no other reason than that they highlight an area where disciplinary fault lines between clinical psychiatry/ psychology and philosophy seem most evident. We spent a year writing an article (...) on the relationship between the assessment of personality disorders and moral evaluations, and these fault lines became manifest not only between ourselves, but also when discussing our ideas with members of the various disciplines.Many practicing psychiatrists acknowledge that moral attributions (such as manipulativity) might be made about people with certain disorders (such as borderline personality disorder), but also find the argument that psychiatric diagnoses are moral rather than medical conditions to be a ludicrous bit of antipsychiatry in the Szaszian tradition. Philosophers, on the other hand, are less involved with these diagnostic categories in their day-to-day work and are more willing to be skeptical. Whether they are doing philosophy of psychiatry, moral theory, or sociopolitical philosophy, they are interested in digging a little bit deeper and are not impressed by arguments to the effect that—it’s obvious that these are really disorders. Being “obvious” is not a persuasive philosophical argument.The metaphysical task of determining what belongs in the category of criminality compared with other ways of sorting behavior has parallels in moral philosophy: Why is fraud, or theft, criminalized whereas (most) lying is not? Why is one set of moral norms enforceable, whereas a second set is aspirational? Does the difference involve property, where infractions of property are thought to be more serious wrongs than lying, which is “only” psychological rather than material? Are the “most serious” wrongs the ones we mark as crimes? Why is sodomy still criminalized in some areas but betraying one’s lifelong love is viewed as morally reprehensible but not criminal? Both actions are private, and only one seems to do harm—unfaithfulness—yet that is the one that is not criminalized. The point here is that, regardless of domain, our classification systems need to be justifiable, yet justification is most often mystifying. [End Page 27]The same is true for classifying mental disorders. The class of mental disorders appears to be a somewhat inconsistent collection of heterogeneous conditions and does not form a natural kind (Zachar 2000). At the most, the class of mental disorders names a family of loosely related conditions and the reasons for inclusion can shift from disorder to disorder.If the class of mental disorders does not specify an internally coherent kind akin to gold, deciding on the scope of psychiatric practice becomes an important problem. As Sadler asks, for what reasons do we classify pedophilia with schizophrenia—both as disorders—but omit sadism? This is an important question of disciplinary scope.This question of scope is itself ethically charged because, on the one hand, bringing a condition under the purview of psychiatry offers the possibility for treatment, and at least establishes the goal of improving the lives of people with specific kinds of problems. Making lives better is one of the humanistic justifications for science itself; clearly it is a raison d’être of psychiatry. On the other hand, medicalization sets up the conditions for a certain kind of social control. Hospitalization, educational services, day treatment, and disability payments are all contingent upon psychiatric diagnostic practices. These programs and the institutions that manage them are both socially available and socially prescribed. The diagnosed behaviors can now be considered to be entities, and explanations of them can be developed. New technologies for altering them will also be introduced. Such practices have been associated with dehumanization (Phillips 2009).Two important questions also need to be distinguished. The first is a question for moral philosophy—What degree of responsibility do people with putative mental disorders have for their behaviors? For example, should people with psychotic disorders or personality disorders be held responsible for crimes they commit? If so, under what conditions? Should responsibility for certain behavior be mitigated? If so, under what conditions? Moral philosophy... (shrink)

As a contribution to a wider discussion on moral discernment in theological anthropology, this paper seeks to answer the question “What is the impact of mental illness on an individual’s ability to make moral decisions?” Written from a clinical psychiatric perspective, it considers recent contributions from psychology, neuropsychology and imaging technology. It notes that the popular conception that mental illness necessarily robs an individual of moral responsibility is largely unfounded. Most people who suffer from mental health problems (...) do not lose the capacity to make moral decisions, and mental illness on its own rarely explains anti-social or criminal behaviour. Moreover, the assumptions of some scientists, that recent developments in neuropsychology and brain imaging suggest biological determinism, must be treated with caution. (shrink)

Psychopathy continues to be a challenge in forensic contexts, and evidence of its association with destructive behaviors, such as aggressive antisocial behaviors, is extensive. However, the potential role of intelligence as moderator of the well-established association between psychopathy and aggressive antisocial behaviors has largely been neglected, despite intelligence having been independently related to both concepts. Increased knowledge of whether intelligence is relevant to this association is needed because of its possible implications on the assessment and treatment of individuals (...) with psychopathic traits and aggressive antisocial behaviors. This study aimed to investigate the association between psychopathic traits, aggressive antisocial behaviors, and intelligence in young violent offenders and to test whether intelligence moderates the relationship between psychopathic traits and aggressive antisocial behaviors. Participants were 269 male violent offenders aged 18 to 25 years, assessed on the Psychopathy Checklist-Revised (PCL-R), the Life History of Aggression (LHA), and the General Ability Index from the Wechsler Adult Intelligence Scale, 3rd edition. Associations were tested with Spearman’s rho and moderation analysis was performed through ordinary least squares regressions. The PCL-R four-facet structure was used for the analyses. We found a positive association between psychopathic traits and aggressive antisocial behaviors, and a small, negative association between the Affective PCL-R facet and intelligence. In the moderation analyses, a small yet statistically significant moderation effect of intelligence on the association between the Interpersonal facet and LHA total scores was demonstrated. However, the amount of variance in the LHA total score explained by the model was very small; 2.9%. We suggest that intelligence, however important for rehabilitation strategies and everyday functioning, is not necessarily pertinent to understanding aggressive antisocial behaviors in young offenders with psychopathic traits. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 12.4 (2005) 335-342 [Access article in PDF] Psychoanalysis as a Hybrid of Religion and Science Quinton Deeley Keywords Freud, psychoanalysis, religion, science, evolution Introduction De Block's paper, "Freud as an Evolutionary Psychiatrist," discusses Freud's writ-ings—including a recently discovered paper on the evolution of psychopathology—to establish the Freudian "philosophy of man" that human beings are "ill to the core" (i.e., that mental illness is an (...) inevitable byproduct of human psychological processes). This perspective is then used as a basis for proposing a way in which psychoanalysis can be integrated with contemporary evolutionary psychology. However, this undertaking raises fundamental questions about psychoanalysis itself, which are addressed in this commentary. First, to what extent is a systematic theoretical unity imposed on, rather than discovered in, Freud's writings? Also, has De Block succeeded in grounding the Freudian philosophy of man in evolutionary theory, and how is this ambition affected by general questions about the scientific status and evidence for psychoanalytic conceptions? Further, if there is only limited experimental evidence for psychoanalytic concepts, how are claims to knowledge justified in psychoanalytic discourse, and how does this relate to the forms of epistemic justification found in religion and science? Finally, is psychoanalysis closer to religious or scientific discourse, and if it combines features of both, what kind of activity is it? The Exposition of the Freudian Philosophical Project The key claim of De Block's paper is that any evolutionary psychology faithful to Freud's account of human nature must be constrained by a fundamental premise: the psychological organization of human beings is such that "there is a quantitative, but not a structural, difference between psychiatric patients and so-called healthy or normal individuals" (2005, 323). From De Block's perspective, this reflects the Freudian perspective that the normal operation of psychological processes inevitably results in some degree of mental distress: "every repression produces symptoms, every defense mechanism produces more suffering than is strictly necessary" (2005, 321). As a result, "when Freud writes that there is only a gradual difference between neurotics and normals, he does not mean the normals are non-neurotic, but only that they suffer less under their neurosis" (2005, 318). This Freudian perspective is variously summarized throughout the paper; for example, "we think there is only one underlying motive of Freud's research, which [End Page 335] could also function as a cornerstone of a 'Freudian' philosophy. This underlying motive is the intuition that there is no substantial difference between the so-called normal human being and the mentally insane" (2005, 315).De Block's exposition of the Freudian account of human nature also emphasizes the doctrine of psychosexuality: "the Freudian philosophy of man presumes primarily that every human being has to react in some way of another to sexual problems" (2005, 317). One of the problems confronting any expositor of Freud is the fact that his voluminous writings show considerable development in his thought. This heterogeneity raises the question of the extent to which the coherence of Freudian theory as a systematic whole is imposed by expositors, rather than lying in the corpus itself. De Block's approach to this heterogeneity is to extract different kinds of relations between sexuality and psychopathology from Freud's writings (e.g., neurosis and the Oedipal instincts, psychosis and narcissism), and then to argue that they explain Freud's interest in less obviously sexual aspects of mind, behavior, and society. As De Block comments after his exegesis of different connections between sexuality and psychopathology: but probably, he [Freud] only meant that in neurosis, people wrestle first and foremost with love, in perversion with sex and violence, and in psychosis with identity and issues related to identity, such as death and "the meaning of life." At least, such an interpretation can explain why Freud—in some of his works—recognized the importance of problems like aggression, love, and death for the human psyche and human psychopathology...; he nevertheless refused to modify the primacy of sexuality in psychopathology. (2005, X) Whether all of Freud's explanations of psychological phenomena involve... (shrink)

Psychopaths routinely disregard social norms by engaging in selfish, antisocial, often violent behavior. Commonly characterized as mentally disordered, recent evidence suggests that psychopaths are executing a well-functioning, if unscrupulous strategy that historically increased reproductive success at the expense of others. Natural selection ought to have favored strategies that spared close kin from harm, however, because actions affecting the fitness of genetic relatives contribute to an individual’s inclusive fitness. Conversely, there is evidence that mental disorders can disrupt psychological (...) mechanisms designed to protect relatives. Thus, mental disorder and adaptation accounts of psychopathy generate opposing hypotheses: psychopathy should be associated with an increase in the victimization of kin in the former account but not in the latter. Contrary to the mental disorder hypothesis, we show here in a sample of 289 violent offenders that variation in psychopathy predicts a decrease in the genetic relatedness of victims to offenders; that is, psychopathy predicts an increased likelihood of harming non-relatives. Because nepotistic inhibition in violence may be caused by dispersal or kin discrimination, we examined the effects of psychopathy on (1) the dispersal of offenders and their kin and (2) sexual assault frequency (as a window on kin discrimination). Although psychopathy was negatively associated with coresidence with kin and positively associated with the commission of sexual assault, it remained negatively associated with the genetic relatedness of victims to offenders after removing cases of offenders who had coresided with kin and cases of sexual assault from the analyses. These results stand in contrast to models positing psychopathy as a pathology, and provide support for the hypothesis that psychopathy reflects an evolutionary strategy largely favoring the exploitation of non-relatives. (shrink)

Psychiatric labeling has been the subject of considerable ethical debate. Much of it has centered on issues associated with the application of psychiatric labels. In comparison, far less attention has been paid to issues associated with the removal of psychiatric labels. Ethical problems of this last sort tend to revolve around identity. Many sufferers are reticent to relinquish their iatrogenic identity in the face of official label change; some actively resist it. New forms of this resistance are taking place in (...) the private chat rooms and virtual communities of the Internet, a domain where consumer autonomy reigns supreme. Medical sociology, psychiatry, and bioethics have paid little attention to these developments. Yet these new consumer-driven initiatives actually pose considerable risks to consumers. They also present complex ethical challenges for researchers. Clinically, there is even sufficient evidence to wonder whether the Internet may be the nesting ground for a new kind of identity disturbance. The purpose of the present discussion is to survey these developments and identify potential issues and problems for future research. Taken as a whole, the entire episode suggests that we may have reached a turning point in the history of psychiatry where consumer autonomy and the Internet are now powerful new forces in the manufacture of madness. (shrink)

The ‘multicultural clinical interaction’ presents itself as a dilemma for the mental health practitioner. Literature describes two problematic areas where this issues emerges - how to make an adequate distinction between religious rituals and the rituals that may be symptomatic of ‘obsessive compulsive disorder’ (OCD), and how to differentiate ‘normative’ religious or spiritual beliefs, behaviours, and experiences from ‘psychotic’ illnesses. When it comes to understanding service user’s ‘idioms of distress’, beliefs about how culture influences behaviour can create considerable confusion (...) and ‘normative uncertainty’ for mental health practitioners. In the absence of clear diagnostic and assessment criteria on distinguishing between ‘culture’ and ‘psychopathology’, practitioners have had to rely on their own intuition and seek out possible ‘strategies’ or ‘procedures’ from a contradictory and cross-disciplinary evidence base. Decontextualisation of service users’ experiences may result in the pathologisation of culturally ‘normative’ phenomenon, ‘category fallacy’ errors, and poor health care experiences and outcomes for service users. This paper situates this dilemma within a wider debate that has concerned both the biomedical and social sciences, namely, the unresolved question of ‘normality’ or ‘abnormality’. Indeed, issues that arise from dilemmas surrounding the question of ‘culture’ or ‘psychopathology’ are intimately tied to wider cultural ideas about what is considered ‘normal’. The disciplines of psychiatry, psychology, and medical anthropology have struggled to establish workable criteria against which to judge behaviour as ‘normal’, ‘abnormal’, or ‘pathological’. Three models for understanding mental ‘abnormality’ are evident in ‘transcultural psychiatry’ (what is now commonly known as ‘cultural psychiatry’), and these models have corresponded closely to the interpretive models used by anthropologists attempting to make sense of the apparent diversity of human societies. The three models of ‘absolutism’, ‘universalism’ and ‘cultural relativism’ have not only important consequences for the nature and conduct of research enquiry, but also have implications for how the dilemma of ‘culture’ or ‘psychopathology’ is attended to in clinical practice. (shrink)

The most important epistemological problem in psychiatry is the detection of malingering. This is a consequence of the fact that there is no objective way to confirm any psychiatric diagnosis. Psychiatric diagnosis is based on subjective complaints. The discovery of objective markers for psychiatric diagnosis is problematic because it presupposes we can tell valid from faked subjective symptoms. But this is the difficulty. If we use pervasive irrationality as a sign of mental illness, we encounter the problem of identifying (...) pervasive irrationality. To understand someone's behaviour, we have to assume it is largely rational. This precludes us from using behaviour to separate genuine from faked mental illness. There are a number of strategies used to solve any epistemological problem, and the most successful is the hypothetico-deductive method. If we use this, we can solve our epistemological problem. Genuine mental illness can be identified when it is the best explanation of the person's overall behaviour. Consilience of inductions is critical in supporting the validity of such explanations. This implies that it is merely a hypothesis that mental illness exists, and that we might discover that many mental illnesses, perhaps all, do not exist. We must embrace this possibility - only if we take a risk will we gain any knowledge. (shrink)

This study investigated subjective experiences of nine men who had been psychiatrically hospitalized upon being assessed as "dangerous-to-others-due-to-a-mental-illness." Using a phenomenological interviewing approach, researchers helped subjects construct narratives of their pre-hospitalization experiences. The research illuminated aspects of life-contexts that were shared among all or nearly all subjects: feeling ostracized and alone; struggling with longstanding and pervasive feelings of inadequacy; experiencing a sense or a fear of having little or no control or options in life; and feeling emotionally depressed, misunderstood, (...) and uncared for. Situations immediately preceding hospitalization were characterized by subjects experiencing threats to their sense of self-esteem that were of heightened intensity. In five cases, subjects reported anxiety related to self-fragmentation or becoming "nothing." Perceived threats to self-worth and self-structure were accompanied by anger and aggressive acts or impulses. In all cases, aggressive impulses and threats, and violence appeared to be in the service of self-validation and self-empowerment. In cases of violent behavior, an apparent function of the subjects' behaviors was toward self-consolidation. Based on findings, the researchers discuss implications consistent with humanistic psychology and existential psychotherapy principles and practices. (shrink)

The Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association, currently in its fourth edition and considered the reference for the characterization and diagnosis of mental disorders, has undergone various developments since its inception in the mid-twentieth century. With the fifth edition of the DSM presently in field trials for release in 2013, there is renewed discussion and debate over the extent of its relative successes - and shortcomings - at iteratively incorporating scientific evidence on the often ambiguous (...) nature and etiology of mental illness. Given the power that the DSM has exerted both within psychiatry and society at large, this essay seeks to analyze variations in content and context of various editions of the DSM, address contributory influences and repercussion of such variations on the evolving landscape of psychiatry as discipline and practice over the past sixty years. Specifically, we document major modifications in the definition, characterization, and classification of mental disorders throughout successive editions of the DSM, in light of shifting trends in the conceptualization of psychopathology within evolving schools of thought in psychiatry, and in the context of progress in behavioral and psychopharmacological therapeutics over time. We touch upon the social, political, and financial environments in which these changes took places, address the significance of these changes with respect to the legitimacy (and legitimization) of what constitutes mental illness and health, and examine the impact and implications of these changes on psychiatric practice, research, and teaching. We argue that problematic issues in psychiatry, arguably reflecting the large-scale adoption of the DSM, may be linked to difficulties in formulating a standardized nosology of psychopathology. In this light, we highlight 1) issues relating to attempts to align the DSM with the medical model, with regard to increasing specificity in the characterization of discrete mental disease entities and the incorporation of neurogenetic, neurochemical and neuroimaging data in its nosological framework; 2) controversies surrounding the medicalization of cognition, emotion, and behavior, and the interpretation of subjective variables as 'normal' or 'abnormal' in the context of society and culture; and 3) what constitutes treatment, enablement, or enhancement - and what metrics, guidelines, and policies may need to be established to clarify such criteria. (shrink)

The word stigma comes from ancient Greece, and was initially used in reference to signs or symbols physically cut into or burned onto the bodies of those deemed to be of an inferior status. It was a marking of one's tarnished and flawed character. Today, stigma is more often attached to one's social standing, personality traits, or psychological makeup. "People are no longer physically branded; instead they are societally labeled—as poor, as criminal, homosexual, mentally ill, and so on. These (...) labels influence public perceptions and behavior and lead to devaluation and denigration of those who are so labeled" (Wahl 1999, 11–12).The modern usage of the term stigma and contemporary focus on the concept as a topic of .. (shrink)

This essay argues that the Chinese Mental Health Act of 2013 is overly individualistic and fails to give proper moral weight to the role of Chinese families in directing the process of decision-making for hospitalizing and treating the mentally ill patients. We present three types of reactions within the medical community to the Act, each illustrated with a case and discussion. In the first two types of cases, we argue that these reactions are problematic either because they comply with (...) the law but undermine the patient’s interests by refusing the family’s request to have the patient hospitalized, or violate the law by hospitalizing patients in response to the real concerns of their families. In the third type of situation, psychiatrists inappropriately encourage families to produce evidence of the patient’s behavior that is harmful to self or others in order legally to commit the patient. Each of these problems, we conclude, should be tackled by supplementing Article 30 of the Act with the stipulation that a psychiatrist may authorize the involuntary hospitalization of a patient, who is not at risk of causing physical harm to self or others, with the consent of all major family members. Drawing on the deeply culturally embedded moral traditions of Confucian medical familism, this proposal would facilitate the proper treatment of a significant number of Chinese mentally ill patients under the care of their families. (shrink)

Youth antisocial behaviour is frequently considered to be displayed by children and adolescents who suffer from behavioural disorders. Consequently, attempts to reduce ASB have increasingly comprised mental health interventions. Moreover, early signalling of children at risk and early prevention of behavioural problems are regarded as crucial remedies. Critical investigations of these developments, however, are in particular concerned with the consequent medicalization of society and the behaviour exhibited by infants, children and adolescents. Consequently, the new Dutch youth law even (...) refers to demedicalization as a central aim. From an ethical point of view, this article critically discusses the meaning and relevance of the medicalization reproach in the context of ASB. The aim is to show that the term medicalization can reasonably be attached to three different developments: the biomedical turn, an increase in youth mental health care and early signalling and prevention. The ethical implications of these developments, however, are diverse, referring to both risks and benefits. By itself, neither the term medicalization nor demedicalization carries a self-evident normative meaning. Therefore, a careful ethical analysis is needed to reveal which social developments are actually recommendable or disadvantageous. (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)

Raine (2019) reviewed previous research on the neural correlates of antisocial, violent, and psychopathic behavior based on previous studies of neuroscience of morality. The author identified neural circuitries associated with the aforementioned types of antisocial behaviors. However, in the review, Raine acknowledged a limitation in his arguments, the lack of evidence supporting the presence of the neural circuitries. In this correspondence, I intend to show that some of his concerns, particularly those about the insula and cingulate cortex, (...) can be addressed with additional evidence from recent neuroimaging research. In addition, I will propose that the additional evidence can also provide some insights about how to design future neuroimaging studies to examine the functionality of the striatum in the circuitries. (shrink)

Although less observable than the overt actions of fighting and assault, covert antisocial behaviors such as stealing and property destruction comprise an important subclass of externalizing behavior patterns, displaying considerable predictive power toward delinquency in adolescence. I discuss a laboratory paradigm for objective observation of such behaviors in children that has shown impressive concurrent and predictive validity among samples of boys with and without attention deficit hyperactivity disorder. Addressed herein are crucial questions regarding the ethics of tempting children (...) to steal objects and small amounts of money and to deface property as well as the types of informed consent and debriefing procedures utilized in research with this paradigm. Weighing ethical considerations alongside the ability to predict delinquent behavior presents provocative issues for those interested in understanding the development of antisocial behavior. (shrink)

While research has consistently found that general distress and psychopathology are not predictive of sexual recidivism, examination of specific syndromes and their relationship to offending has revealed a potentially more complicated relationship. One proposed mechanism for the mixed findings with respect to major mental illness and sexual offending may be the confound of neurological injury. As identified in Mann et al. work on psychologically meaningful risk factors, mental illness represents an area in need of more study given the (...) indirect influence it may exert on risk. To this end, the current paper summarizes the study of the relationship between neurological injury, psychosis and problematic sexual behavior among two Canadian samples of forensic and civil psychiatric patients. In the first study we observed higher than expected rates of sexually-themed psychotic symptoms and problematic sexual behavior among a combined group of forensic and civil psychiatric patients. Indeed 70 percent of those individuals who engaged in PSB endorsed sexually-themed psychotic symptoms. While comorbidity is common amongst this group, brain injury appeared to represent a specific liability. Compared to those who did not engage in PSB, those who did were almost 4x more likely to have a documented history of brain injury. In the second study we sought to replicate this finding in a larger forensic sample of 1,240. However, the recorded rates of brain injury were significantly less, such that no relationship to PSB was observed. Based on the mixed findings to date, including our own data, questions remain about the nature of a potential shared vulnerability for psychosis and PSB previously postulated. Among psychiatrically complex individuals who engage in PSB, understanding etiology and links to risk are helpful, but perhaps more importantly is attention to the mechanisms through which symptoms confer risk and how best to treat and manage them. (shrink)

This book is psychiatry's reply to the diverse group of antipsychiatrists, including Laing, Foucault, Goffman, Szasz and Bassaglia, that has made fashionable the view that mental illness is merely socially deviant behaviour and that psychiatrists are agents of the capitalist society seeking to repress such behaviour. It establishes, by the use of evidence from historical and transcultural studies, that mental illness has been recognised in all cultures since the beginning of history and goes on to explore the philosophical (...) and medical basis for psychiatry's diagnosis and treatment of mental illness. Finally, it tackles two issues where psychiatry has recently been seen as at odds with the values prevailing in society: involuntary hospitalization and the insanity defence. The Reality of Mental Illness does not pretend to offer simple answers to the complex problems it discusses, but will leave the reader with a much greater understanding of psychiatry's aims, practices and problems. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 9.4 (2002) 381-382 [Access article in PDF] The Borderlands of Psychiatry and Theology Stephen Sykes Keywords: psychiatry, theology, spirituality. THE DISCUSSION OF THE TERMS we use to speak of experiences on the boundaries between spirituality and mental disorder is very important. Jackson and Fulford (1997) have gone a long way to avoid flattening the concepts into a single conceptual scheme, too far for some (...) of their critics like Littlewood (1997) and Storr (1997), but not far enough for Bratton and Marzanski (2002), who eventually accuse them of "anthropocentric psychologism." They want to preserve theological categories intact, mainly because this is how the subjects themselves see their experiences, but also because there is, they hold, additional explanatory value in such a language schema. As evidence they point to unremarkable attitudes and practices, which are nonetheless demonstrably part of the Christian way of life.The borderlands between theology and psychiatry are not alone in witnessing this dispute. A similar conflict has arisen in the discussion of public policy. In politics, people of religious conviction or representatives of faith communities have sometimes been told either to hold their tongues (because "not many people believe these things nowadays" or because "it's wrong to impose your beliefs on other people") or to formulate their proposals in nonreligious language. It is far from obvious that this is not a sophisticated form of discrimination, nonetheless objectionable for its being practiced by nonreligious people. The creation of genuine equality of access to the space for public discussion of political proposals is not at all easy.I have personal experience of the analogous difficulty in psychiatric practice. In a discussion of the overinvolvement of carers for a person with mental health problems self-sacrificing behavior was used with a negative connotation. But, as in the case of Carol, how were these actions to be construed—were they normal for a Christian or psychopathological? My personal response is that it is correct to say that a boundary exists between ordinary Christian spiritual experience (the kind that religious believers would immediately recognize as part of their religious lives) and disturbed or distorted perceptions that are the result of mental illness and can be mitigated by appropriate treatment. But the fact that a boundary exists in principle does not necessarily imply that it is always easy to draw the distinction in practice. Typically the cases that cause the most difficulty lie on the borderlands. Although on the face of it, it looks attractive to demonstrate the security of the criteria by making discriminations in precisely this area (and the point of the cases in Jackson and Fulford is precisely that they raise these complexities), in [End Page 381] fact it may be that such instances require both languages. In this case, Bratton and Marzanski are correct to argue for the retention of a theological frame of reference. The strength of their argument lies precisely in the support that fellow members of the respective faith communities are able to give to the people who, despite their manifest illnesses, persist in religiously justifiable courses of action.The paper raises one very important matter that bedevils a lot of the current literature, namely how spirituality is to be understood. In my view, there is a lot of purely arbitrary definition of this term, whose meaning has developed rapidly under specific social conditions (Sykes 2000a). In medicine, it functions best when it is taken to be a reminder that a patient may have had contact with a specific religious tradition that has contributed or still contributes to her worldview. In modern Western society, account has to be taken both of residual religiosities or fallback positions, and of new religions, as well as of traditional religious groupings. In the case of mental illness, it may be very important for a medical practitioner to be aware of the impact of these religious promptings on the formulation of the narrative identity of an individual—no easy task (Sykes 2000b).The generality of spirituality ought not to deflect the professional from attending to the particular tradition or traditions which have... (shrink)

This paper examines the representation of mental illness and mental disorder in the Washington Community Protection Act of 1990 (WCPA), the first package of sexual predator legislation passed in the United States. I focus on the public outcry over a violent crime committed by a repeat sexual offender, Earl Shriner, and show how the act was drafted in direct response to this outcry. Following his arrest, there was a public discussion of a) whether the state had a (...) responsibility to cure individuals like Shriner before releasing them, and b) whether sex offenders could be cured at all. The WCPA was a landmark law because it shifted forensic psychology in the use of sexual criminals from an intervention model to a containment model, from a model that sought to separate out those sexual criminals who could be treated to a model that separated out sexual criminals because they could not be treated. I demonstrate here that this shift was made in response to the representation of Earl Shriner as a member of a group classified by legislators as having a coherent, recognizable and untreatable mental disorder that caused them to commit acts of sexual violence. (shrink)

The Malleus Maleficarum was a detailed manual for Dominican witch-hunters. It codified specific criteria for identifying witches and guidelines for their application. It elaborated a system of symptoms that indicated illness caused by witchcraft . These symptoms were seen as the visible projections of a vast and complex organization of behavior. Since the existence of witches was presupposed by those who used the manual, its criteria were confirmed repeatedly during the Inquisition. Once the Malleus was published, its diagnostic system acquired (...) a momentum of its own and generated its own evidence . Its authors saw physicians as experts at distinguishing physical illnesses from those caused by witchcraft. The authors began the manual by asserting that belief in the existence of witches is an essential part of the Catholic faith. Priests and inquisitors were not to doubt the existence of witches . Like the Malleus Maleficarum, the Diagnostic and Statistical Manual is a detailed text which codifies specific criteria for identifying people who are seen as abnormal. It codifies guidelines for applying these criteria and elaborates a system of symptoms that indicates illnesses known as mental disorders. These symptoms are seen as the visible projections of a vast and complex organization of behavior. Since the existence of these disorders is presupposed by many of those who use the manual, its criteria are confirmed repeatedly in the diagnostic process. Once DSM was published , its diagnostic system acquired a momentum of its own and has generated its own evidence. Its authors regard psychiatrists as experts at applying the manualís criteria. They are also seen as experts at distinguishing mental disorders from other illnesses. Belief in the existence of mental disorders is an essential part of the psychiatric faith. (shrink)

We have made huge progress in understanding the biology of mental illnesses, but comparatively little in interpreting them at the psychological level. The eminent philosopher Jonathan Glover believes that there is real hope of progress in the human interpretation of disordered minds. -/- The challenge is that the inner worlds of people with psychiatric disorders can seem strange, like alien landscapes, and this strangeness can deter attempts at understanding. Do people with disorders share enough psychology with other people to (...) make interpretation possible? To explore this question, Glover tackles the hard cases—the inner worlds of hospitalized violent criminals, of people with delusions, and of those diagnosed with autism or schizophrenia. Their first-person accounts offer glimpses of inner worlds behind apparently bizarre psychiatric conditions and allow us to begin to learn the “language” used to express psychiatric disturbance. Art by psychiatric patients, or by such complex figures as van Gogh and William Blake, give insight when interpreted from Glover’s unique perspective. He also draws on dark chapters in psychiatry’s past to show the importance of not medicalizing behavior that merely transgresses social norms. And finally, Glover suggests values, especially those linked with agency and identity, to guide how the boundaries of psychiatry should be drawn. -/- Seamlessly blending philosophy, science, literature, and art, Alien Landscapes? is both a sustained defense of humanistic psychological interpretation and a compelling example of the rich and generous approach to mental life for which it argues. (shrink)

The central thesis of Schizotypy: Implications for Illness and Health is both challenging and controversial: that the features of psychotic disorders actually lie on a continuum with, and form part of, normal behaviour and experience. The dispositional or 'schizotypal' traits associated with psychotic disorders certainly predispose an individual to mental illness, but they may also lead to positive outcomes such as enhanced creativity or spiritual experience. Discussion of each aspect of this theme is supported by extensive experimental and clinical (...) evidence, questioning the received medical wisdom which treats psychotic illness in the narrow context of neurological disease. The result is an authoritative and provocative overview of an important topic in psychological research and clinical practice. (shrink)

In this paper, I discuss the question whether objective criteria could be provided for judging something to be a mental illness. I consider the two most prominent objectivist or naturalistic accounts of mental illness, evolutionary and bio-statistical account, which offer such a criterion by relying on the notion of biological function. According to such suggestions, illness is a condition in which there is dysfunciton in some feature of an organism. In this context, I consider different accounts for ascribing (...) functions in biologyand their relationship with the suggested accounts of illnesses. Special focus is placed on the objections according to which the ascription of functions, as envisaged in naturalistic accounts of illness, is incompatible with actual medical and psychiatric practice. I conclude that these objections are legitimate insofar we want to an account of illness that preserves the current practice of ascribing illness. However, the question remains, could a theory that tries to capture the actual medical practice be value-neutral, since our ordinary conception of illness is permeated with value judgments that indirectly enter into medical practice. In that respect, it seems that the requirement for pure objectivity is too strong and thus, it is not reasonable to expect that naturalistic accounts can satisfy it. (shrink)

Obligations of global justice rest mainly on the global rich but also to a lesser extent on the global poor. The governments of poor countries are obliged to fulfill requirements of non-aggression, good governance and decency, along with all other requirements which facilitate the achievement of global justice. So far, obligations of poor countries seem to be taken as given yet the behavior of governments in poor countries and occurrences therein attest to the contrary;this suggests a (...) need to mainstream these obligations in discussions about global justice. If poor countries do not live up to these requirements obstacles arise to the realization of global justice; and they act unjustly in relation to citizens of rich countries which provide them with aid. Uganda is taken as a case in point. (shrink)

Obligations of global justice rest mainly on the global rich but also to a lesser extent on the global poor. The governments of poor countries are obliged to fulfill requirements of non-aggression, good governance and decency, along with all other requirements which facilitate the achievement of global justice. So far, obligations of poor countries seem to be taken as given yet the behavior of governments in poor countries and occurrences therein attest to the contrary;this suggests a (...) need to mainstream these obligations in discussions about global justice. If poor countries do not live up to these requirements obstacles arise to the realization of global justice; and they act unjustly in relation to citizens of rich countries which provide them with aid. Uganda is taken as a case in point. (shrink)

Selective serotonin reuptake inhibitors’ wide use, combined with the blurry limit between health and psychological illness, have led neuroscientists, clinicians and ethicists to envision the possibility of these medications’ use in non-clinical populations. This prospect has evoked ethical debates, which have often ignored the findings of the empirical literature. In this context, an evaluation of the empirical evidence for SSRIs’ personality enhancing effects is needed. The present paper examines SSRIs’ effects on healthy personality, including the Five Factor Model traits Neuroticism (...) and Extraversion, as well as some of their facets: Angry Hostility, Impulsiveness, Vulnerability, Warmth, Gregariousness and Assertiveness. The review encompasses investigations in healthy humans, human clinical populations, as well as relevant animal studies. Emerging data raise the possibility that SSRIs, when used by people without a currently diagnosable mental disorder, may reduce some facets of Neuroticism, especially Angry Hostility. On the other hand, very limited support exists for an SSRI-driven change in other Neuroticism facets, such as Impulsiveness, in healthy humans. An increase in Extraversion is possible, but currently available evidence is only indirect. Future research is needed, both to clarify methodological ambiguities in existing studies, and to answer unaddressed questions, such as ones of the stability, predictors, moderators, dose- and context-dependency of the effects. (shrink)

The enduring psychiatric myth is that particular personal, interpersonal and social problems in living are manifestations of ‘mental illness’ or ‘mental disease’, which can only be addressed by ‘treatment’ with psychiatric drugs. Psychiatric drugs are used only to control ‘patient’ behaviour and do not ‘treat’ any specific pathology in the sense understood by physical medicine. Evidence that people, diagnosed with ‘serious’ forms of ‘mental illness’ can ‘recover’, without psychiatric drugs, has been marginalized by drug-focused research, much of (...) this funded by the pharmaceutical industry. The pervasive myth of psychiatric drugs dominates much of contemporary ‘mental health’ policy and practice and raises discrete ethical issues for nurses who claim to be focused on promoting or enabling the ‘mental health’ of the people in their care. (shrink)

We argue that cognitive empathy and other instances of mental state attribution are a byproduct of self-awareness. Evidence is brought to bear on this proposition from comparative psychology, early child development, neuropsychology, and abnormal behavior.

Cybersecurity research often describes people as understanding internet security in terms of metaphorical mental models (e.g., disease risk, physical security risk, or criminal behavior risk). However, little research has directly evaluated if this is an accurate or productive framework. To assess this question, two experiments asked participants to respond to a statistical reasoning task framed in one of four different contexts (cybersecurity, plus the above alternative models). Each context was also presented using either percentages or natural frequencies, and these (...) tasks were followed by a behavioral likelihood rating. As in previous research, consistent use of natural frequencies promoted correct Bayesian reasoning. There was little indication, however, that any of the alternative mental models generated consistently better understanding or reasoning over the actual cybersecurity context. There was some evidence that different models had some effects on patterns of responses, including the behavioral likelihood ratings, but these effects were small, as compared to the effect of the numerical format manipulation. This points to a need to improve the content of actual internet security warnings, rather than working to change the models users have of warnings. (shrink)

Abstractabstract:Most of Charles Darwin's ideas have withstood the test of time, but some of them turned out to be dead ends. This article focuses on one such dead end: Darwin's ideas about the connection between piloerection and mental illness. Piloerection is a medical umbrella term to refer to a number of phenomena in which our hair tends to stand on end. Darwin was one of the first scientists to study it systematically. In The Expression of the Emotions in Man (...) and Animals (1872), he discusses piloerection in the context of his analysis of the expressions involved in fear and anger, relying heavily on the evidence provided by one of his correspondents, the British psychiatrist James Crichton Browne. This essay reveals how Darwin's initial doubts about the similarity between piloerection in animals and psychiatric patients were eased when studying photographic portraits of female psychiatric patients sent to him by Crichton Browne. It considers arguments against Darwin's reading of these portraits and the apparent contrast between this reading and his own skepticism, in later years, about the value of documentary photography. The article concludes with some notes regarding the reception of Darwin's ideas about psychopathology. (shrink)

This article argues in favor of modifying the medical model of severe psychiatric disturbances that underlies calling them "mental illness." The key reason for this proposal is that numerous specialists other than physicians as well as non-specialists contribute to the process of assisting a person recover from what the author suggests might better be called "extraordinary functional disability." There is little uniformity in existing definitions under state laws, but all involve three types of intervention: civil commitment; civil determination of (...) legal competency; and standing to be subject to criminal law. Physicians typically make relevant determinations in each of these areas; but non-physicians are the principal care-givers once a determination has been made. (shrink)

This paper performs a critical review of twin and adoption studies looking at possible genetic factors in criminal and antisocial behavior. While most modern researchers acknowledge that family studies are unable to separate possible genetic and environmental influences, it is argued here that twin studies are similarly unable to disentangle these influences. The twin method of monozygotic–dizygotic comparison is predicated on the assumption that both types of twins share equal environments, and it is argued here that this assumption is (...) false. Adoption studies have been promoted as a better way of separating genetic and environmental influences. However, there is good reason to believe that adoption studies of criminal and antisocial behavior were confounded by selective placement factors. In addition, these studies suffered from bias and serious methodological errors. In spite of these problems, no adoption researcher claimed to have found evidence of a genetic predisposition for violent crime. It is concluded that the weight of the evidence from family, twin, and adoption studies does not support a genetic basis for any type of criminal or antisocial behavior. The historical background of genetic theories of criminality is also discussed. (shrink)

In this paper, the author argues that the requirement to conduct randomised clinical trials to inform policy in cases where one wants to identify a cheaper alternative to known effective but expensive interventions raises an important ethical issue. This situation will eventually arise whenever there are resource constraints, and a policy decision has been made not to fund an intervention on cost effectiveness grounds. It has been thought that this is an issue only in extremely resource poor settings. This (...) paper gives an example from the United Kingdom illustrating that this is also a problem faced by richer countries. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 11.1 (2004) 87-94 [Access article in PDF] Talk and the Nature of Delusions:Defending Sociocultural Perspectives on Mental Illness Eugenie Georgaca Keywords discourse, social constructionism, delusions, psychosis, mental illness, context It is very pleasing to see writers from philosophy, psychiatry and psychology, the three disciplines represented by this journal, debating the issue of delusions. The majority of the papers in this volume set out (...) to determine the underlying mechanisms responsible for delusions. As such, they offer themselves as discussions of the etiological factors of the formation and maintenance of delusions. My paper analyzes the interactional presentation and negotiation of statements that would be considered as delusional. This led some commentators (Ghaemi 2004; Sass 2004) to argue that the analysis of talk about delusions is useful, but cannot be extended to claims about the nature of delusions. In the following section, I discuss the ways in which analyzing interactions can be useful in clinical research and practice. Subsequently, I identify and critically discuss the assumptions about the nature of delusions that underlie these criticisms and the majority of the papers in this volume. The Usefulness of the Study of Interaction My paper can be seen as part of a growing body of studies that attempt to elucidate the role of interactional and discursive processes in the identification and management of disorders (Barrett 1988; Coulter 1975; Hak 1989; Pollner 1975; Smith 1978; Soyland 1994). Microsociological and ethnographic studies look at the properties of client-professional interaction with the aim of clarifying the tacit skills and knowledges used in such encounters. Palmer (2000), for example, argues that the recognition of disorder is a social and interactional issue both in the sense that the judgment of disorder is based on social criteria and in the sense that diagnosis is an interpersonal process with its own inherent social order. The aim, therefore, of analyzing professional-client interactions would be to articulate the properties of this implicit social order. Other researchers argue that diagnosis is not a process of identification or recognition of disorder, but rather a process of active construction of disorder and of transforming the person to a mental patient. Barrett's (1988) analysis of the transformation of a [End Page 87] person to a "person suffering from schizophrenia" and subsequently a "schizophrenic" through interviewing and report writing is an excellent example of this kind of work.The application of this approach to the field of delusions would attempt to address the issue of how delusions are diagnosed and managed through the interactions between the delusional patient and the clinician. In this paper and in previous work (Georgaca 1996, 2000) I showed that statements that have been diagnosed as delusional are presented and argued through using appropriate conversational strategies, drawing on socially meaningful systems of knowledge and applying appropriate rules of evidence. Moreover, I argued that there was no way in which these disagreements over competing versions of reality could be definitely settled conversationally, and that instances of breakdown in communication were due not to the delusional version being proven wrong, but to lack of explanatory frameworks within which the competing versions could be negotiated. At least in the exchanges analyzed, the criteria of implausibility, conviction, and incorrigibility were shown not to apply.Clinicians do not customarily investigate the truth of patient claims against empirical data (Maher 1992), which means that they have to judge claims on the basis of the patient's presentation in the diagnostic interview. Because there are no technical guidelines for the assessment of truth and falsity, plausibility and implausibility, rationality and irrationality, clinicians have to rely on personal judgment. The question then is on what grounds the clinician's personal judgment is granted the status of determining the truth of someone else's claim and in what capacity clinicians are called to make such decisions. I will not pursue this argument any further here. The point I want to make is that the analysis of professional-client interactions foregrounds the active role of professionals in clinical decisions and questions the criteria upon which decisions are... (shrink)

Setting the terms of praise‐ and blameworthiness has long dominated philosophers’ discussions of responsibility. Analytic philosophy has most often looked to reason and the abstract relations between individual rational judgements and actions to advance the discourse on moral responsibility. Those whose capacity for reasoned judgement is impaired are deeply problematic. Is it proper to morally appraise ‘the mentally ill’? The philosopher T.M. Scanlon discusses moral responsibility as a precondition of moral appraisal and contends that it is not appropriate to appraise (...) a person as (morally) praise‐ or blameworthy if that person cannot be held responsible for the action(s) for which he is being praised or blamed. What are the conditions, then, under which one can properly be said to be responsible for one's actions? Can one hold ‘the mentally ill’ responsible for their actions? If not, can it in any way be reasonable to expect them to ‘take responsibility’ for their actions and/or characters? The expectation that ‘the mentally ill’ will attempt to control, i.e. take responsibility for their behaviour despite the fact of their mental illness is a pervasive feature of psychiatric approaches to the care and treatment of ‘the mentally ill’. It would seem that such treatment approaches are coherent only to the degree ‘the mentally ill’ can be considered responsible moral agents. This paper explores these issues with regard to that form of mental illness categorized as the personality disorders. It describes the morally and clinically relevant features of personality disorder, explains how they do not fit traditional analytic paradigms of ‘mental illness’ and elaborates the argument that persons with this category of mental illness are fully moral persons who are rightly subject to praise and blame. (shrink)

BackgroundMany of the important elements of a valid informed consent – comprehension, voluntariness, and capacity – can be compromised or unmet in the context of psychiatric research. The inability to protect their own interests puts mentally ill subjects at an increased likelihood of being wronged or harmed and makes them particularly vulnerable in the context of clinical research. Therefore, they are due extra protection. Sometimes, these additional safeguards can significantly limit the possibilities for research involving subjects deemed unable to consent (...) due to their mental illness. Montenegro, a middle-income country in Southern-Eastern Europe, goes so far in their policy to protect these subjects from harms of research, as to ban all biomedical research on mentally ill persons who are unable to provide consent.Main bodyMental health research is often neglected and very low on the list of health research priorities, especially in low- and middle-income countries. Despite the fact that mental health disorders are among leading causes of disability, the need for evidence-based services and interventions for those affected remains unmet.To exclude all members of a certain group of subjects seems extremely restrictive and unnecessary. Such a policy is discriminatory and unethical, because it inflicts further harms and exclusion of those patients from participation in society. This unjust exclusion policy obstructs research of certain psychiatric disorders and implies that new treatments for conditions that directly affect these incapacitated subjects will not be developed.ConclusionsScientific and clinical development must not be precluded by overly restrictive, discriminatory and unjust practices, such as the normative ban on research on decisionally-impaired mentally ill subjects. Rather, there should be a regulative framework that ensures that those who cannot consent for themselves are respected and protected in research, the anticipated benefits maximized, risks minimized, their autonomy recognized and extended. These patient-subjects must be appropriately included unless there is a clear and compelling rationale and justification that inclusion is inappropriate with respect to the health of the participants or the purpose of the research. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Should Clinicians’ Views of Mental Illness Influence the DSM?Elizabeth H. Flanagan (bio) and Roger K. Blashfield (bio)Keywordsclinicians, DSM, values, psychopathology, scienceThe relationship between clinicians and the DSM is complex. Clinicians are the primary intended audience of the DSM. However, as Widiger (2007) pointed out in his commentary, there is a tension associated with trying to meet the clinical goals of the DSM and also trying to optimize the (...) scientific goals of the DSM. Most commentators would agree that the recent editions of the DSM (from the DSM-III onward) have favored scientific values (e.g., Sadler 2005). Some commentators have taken sides and aligned themselves with either clinicians or with the science of classification. For instance, Garb (2005) has argued that clinicians should receive incentives to align themselves more closely with the science of the DSM. In contrast, Westen and Shedler (1999) have favored a clinician-based approach to the DSM and have argued that an ideal classification should be based on the prototypes that clinicians use to conceptualize diagnostic categories. Perhaps an extreme suggestion on how to deal with this tension between the values of clinicians and the values of scientists is to adopt the ICD-10 solution and create two versions of the next DSM. One version would be written for clinicians and another for researchers (Phillips et al. 2003).Widiger (2007) wondered whether the two of us as authors are on the fence about how the views of clinicians should affect the DSM. As clinical psychologists who are both clinicians and researchers, we understand his comment, especially in light of our attempt in our article not to overgeneralize from the time-consuming, labor-intensive, yet methodologically limited study we reported in our major paper.Nonetheless, our answer to the question asked in the title of this response, “Should clinicians’ views of mental illness influence the diagnostic manual?” is a clear and unequivocal yes. In our view, too much of the research literature stimulated by the recent DSMs has primarily used the diagnostic criteria in these DSMs to specify patient samples and then perform various experiments to study the DSM categories. We favor a different approach to research which is consistent with a comment once made by the philosopher of science, Karl Popper: “scientific theories originate from myths, and... a myth may contain important anticipations of scientific theories” (1963, 39). We believe that clinicians, with their years [End Page 285] of experience dealing with the ambiguities, the emotionality, and the chaos of psychopathology, have formed complex conceptual systems to try to understand the mysteries of abnormal behavior. We strongly support increased research attempts that will use clinicians as subjects and that will attempt to understand how clinicians use diagnostic concepts to understand patients.Although research on clinicians has not attracted a large amount of attention in the field, there is a long history of such research studies. For instance, in the 1970s, Overall used multivariate techniques to create graphical maps of how clinicians represented relationships among diagnoses (Overall et al. 1977). Widiger has used a similar strategy in some of his research (Widiger et al. 1987). In the early 1980s, a view of concept formation from cognitive psychology was used by Cantor et al. (1980) to look at psychiatric diagnoses as representing prototypes. Horowitz and colleagues extended this research. Blashfield and his colleagues had a grant to use the prototype model to study personality disorders and performed research investigating both case histories (Blashfield et al. 1985) and analyses of diagnostic criteria (Blashfield and Breen 1989; Davis, Blashfield, and McElroy 1993). Westen and colleagues have attempted to reconceptualize DSM personality disorder categories using the prototype model (Westen and Shedler 1999). Ahn and her colleagues (Ahn et al. 2006; Kim and Ahn 2002) have taken more recent applications of ideas from cognitive psychology to study how clinicians use and understand diagnostic categories. Finally, Flanagan and colleagues (Flanagan and Blashfield 2006; Flanagan, Keeley, and Blashfield, in press; Flanagan, Miller, and Davidson, submitted) have used qualitative and quantitative data analysis techniques to try to understand the diagnostic concepts held by experienced clinicians.Besides empirical studies of how clinicians use diagnostic concepts, we also support the increased interest in... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Adolf Meyer: Psychiatric AnarchistS. Nassir Ghaemi (bio)KeywordsMeyer, biopsychosocial model, Jaspers, pluralism, philosophy, psychiatryThey had weekly lunches in 1920s New York City: In one door stepped a stooped philosopher, with a mustache and a twinkle, perhaps ruminating on some recent Marxist theory; in the other door came the elegant Swiss physician, goateed and erudite. Every week, for a time, John Dewey (leader of American pragmatism) and Adolf Meyer (dean of (...) mid-twentieth century American psychiatry and long-time chair of the Johns Hopkins psychiatry department) lunched together and, somewhere in those conversations—one might imagine—the field of philosophy and psychiatry was born (Meyer 1948, 152).Yet pragmatism—as a proper school of philosophy—does not capture Meyer’s psychiatry. Rather, the core of his thinking, in my view, is to be found in a vague term that deserves analysis: eclecticism.EclecticismIt has been said that eclecticism is a vice in theory but a virtue in practice (Stone 1981), which highlights why so many are attracted to it. Deep down, practitioners just want to be free: They believe that their freedom of choice will tailor treatments best to patients and thus result in best outcomes. As a conceptual theory for psychiatry, eclecticism is a model that views any theory or method as potentially correct, but no theory or method as definitively incorrect. There is no way to avoid an “anything goes” practice with eclecticism: It is—to use a political analogy—an anarchism of mind.William James once remarked that the basis for all philosophies lies in the personalities of philosophers. So it was with Meyer’s eclecticism: congenial personally, he seemed congenitally incapable of disagreeing with any person. Any idea, even the most unusual, would receive a respectful hearing from Meyer. (Double brings out new, excellent documentary evidence of this extreme indecision in the drafts of Meyer’s unsent letters to the behaviorist John Watson.) Although quaint and commendable pedagogically, this excessive open mindedness left American psychiatry—so dependent on Meyer—prey to hard-headed biological radicals and psychoanalytic dogmatists. This is where his eclecticism failed us.Enabling Biological ExtremismMeyer played a key role in legitimizing extreme biological approaches. In addition to his interest in insulin coma (which Double mentions), Meyer enabled the popularization of colectomy and frontal [End Page 341] lobotomy. Psychiatric colectomy, developed by Henry Cotton, was based on the focal toxin theory of mental illness—the idea that mental illness was caused by toxins released by bacteria in the body, the specific locations of which where were the colon and rotted teeth. In one hundred case reports, with mostly short-term follow-up, published in his prominent text, The Defective Delinquent and Insane (Cotton 1921), Cotton laid out his case, which Meyer legitimized by writing a generous foreword. Meyer’s authority was powerful enough to render Cotton’s limited evidence base much more credible than it might otherwise have been. In the 1920s and 1930s, tens of thousands colectomies and full mouth teeth extractions were conducted in patients with mental illness. (Meyer himself sometimes recommended it).1The other biological extremist story is more famous. In a 1936 conference, with Meyer in attendance, the neurologist Walter Freeman presented, for the first time, cases of refractory schizophrenia treated with a new method: frontal lobotomy. Psychoanalyst attendees protested that Freeman was proposing nothing more than mutilation of the brain; yet Meyer intervened in favor of Free-man (“I am not antagonistic to this work, but find it very interesting” [El-Hai 2005]). Unfortunately, Freeman, like Cotton, was a dogmatist: Over time, he performed frontal lobotomy more and more extensively, not just as a treatment of last resort in the most ill schizophrenics (as in the first cases presented to Meyer), but later as a treatment of first resort for the mildest mood disorders. (By 1950 Freeman had personally conducted 2400 transorbital lobotomies, an “office procedure” that allowed him to lobotomize a patient in 15 minutes [El-Hai 2005]).2Lest my critique of Meyer in that era be seen as a Whiggish interpretation of history (the claim that we are so much smarter than those shrinks of the past; in fact I think... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Back to the Nineteenth Century Is ProgressJeffrey L. Geller (bio)Keywordshistory, monomania, impulse control disorders, DSMJohn Sadler Eloquently Makes the case that the phenomena of criminality, wrongful conduct, and mental illness are befuddled in current diagnostic manuals, for example, the Diagnostic and Statistical Manual (DSM)-IV-TR. The lack of clarity in the “vice–mental disorder relationship” reflects centuries old struggles to create clear demarcations between “mad” and “bad.” Sadler points (...) out that the DSMs have been and are both the products of historical, cultural, and social forces and the purveyors of defining boundaries that shape contemporary psychiatric and judicial practices. Sadler does American psychiatry a great service by resurrecting a discussion that was quite rich in the nineteenth century, but generally dormant in the twentieth. I thought I could best use this commentary by bringing to the attention the readers of Philosophy, Psychiatry & Psychology the scope of the debate amongst Sadler’s nineteenth-century predecessors.Sadler’s PredecessorsPhilippe Pinel, who presented the first clear modern description of the form of mental illness subsequently named moral insanity appeared well aware, in the early years of the nineteenth century, of the difficulties there would be accepting the concept of a limited or partial moral mania:There are certain rare examples of a peculiar turbulent and embittered character, who otherwise show no evidence of disturbed reason. Ought they to be included under the heading of “mania without delirium?” At any rate the authorities have preferred to have them admitted to asylums rather than let them mix with delinquents in houses of correction.(As cited by Walk 1954, 821)James Cowles Prichard, a British physician, is credited with “inventing” the term moral insanity, which he defined as “a morbid perversion of the feelings, affections, and active powers, without any illusion or erroneous conviction impressed upon the understanding” (Prichard 1837, 20; 1842). Prichard warned against the failure to recognize this form of insanity, illustrating his point with what we might now refer to as pyromania:Many lunatics, whose disorder was merely a destructive propensity, have set fire to houses or public buildings, and it is not to be doubted that men have been occasionally executed as criminals for such actions, who, if they had been kept in confinement, would have proved to be insane. Until the existence of moral insanity is distinctly recognized, there will always be a danger of this event ensuing in the trials of mischievous lunatics.(Prichard 1837, 287)Prichard referred to such acts as “instinctive madness” (Prichard 1842). [End Page 19]Isaac Ray, the first American to specifically address these matters (in the first edition of his Treatise on The Medical Jurisprudence of Insanity (1838), defined “partial moral mania,” indicating that, “In this form of insanity, the derangement is confined to one or a few of the affective faculties, the rest of the moral and intellectual constitution preserving its ordinary integrity” (p. 186). Ray highlighted those partial moral mania he considered to “have the most important legal relations” (p. 187): “an irresistible propensity to steal,” “an inordinate propensity to lying,” “erotic mania,” “a morbid propensity to incendiarism,” and “homicidal insanity” or “homicidal monomania” (pp. 187–234). Ray cogently described what we would categorize today as an impulse disorder: “Amid the rapid and tumultuous succession of feelings that rush into his mind, the reflective powers are paralyzed, and his movements are solely the result of a blind, automatic impulse with which the reason has as little to do, as with the movements of a newborn infant” (p. 261). Ray believed these monomanias “completely annulled... all moral responsibility for acts committed under their influence,” and consequently “the laws can rightfully inflict no punishment on their unfortunate subjects” (p. 276).Ray, like his European predecessors, was not insensitive to the conundrum these partial moral manias would likely produce:True, cases of a disputable character sometimes occur—cases in which we may well doubt whether the active principle is depravity or disease. I have no wish to conceal any difficulty which this subject may present(Ray 1861, 120).The English translation of Esquirol’s treatise in 1854 supported Ray’s views. In a lengthy chapter on the different forms of... (shrink)

continent. 1.1 (2011): 22-25. The Author gratefully acknowledges the financial support of CAPES (Coordenação de Aperfeiçoamento do Ensino Superior), Brazil. From the multifarious subdivisions of semiotics, be they naturalistic or culturalistic, the realm of semiotics of value is a ?eld that is getting more and more attention these days. Our entire political and economic systems are based upon structures of symbolic representation that many times seem not only to embody monetary value but also to determine it. The connection between monetary (...) and linguistic exchanges is self-evident: the former requires the latter and develops in direct relation to it. Creative experimentation and design of digital systems of value exchange are blossoming on the web. Dr. Gilson Schwartz, an economist turned media theorist and professor at the University of São Paulo, adopted the concept of Iconomics, originally created by Michael Kaplan, an author concerned with the linguistics of economic value. Empowering local communities and unlocking new levels of value creation and representation via digital technologies are the main goals of Dr. Schwartz’s projects, aiming at the re-designing of our relationship to the economic value of imagination and the social control of property. Schwartz is Assistant Professor at the School of Communication and Arts of the University of São Paulo, a former Chief Economist at BankBoston, Brazil and Advisor to the President of the National Social and Economic Development Bank (BNDES). FURTHER READING: Kaplan, Michael. “Iconomics: The Rhetoric of Speculation.” Public Culture . 15.3 (2003): 477-493. Renata Lemos-Morais: You have recently produced and directed a short documentary about Creative Currencies in Latin America. Could you tell us a bit about its process and its findings? Gilson Schwartz: The “Creative Currencies” project is a work-in-progress platform which unfolds as an action research agenda connected both to the production of audiovisual content and the development of social currency software. The initiative dates back to 2003 when I led an experimental project supported by the Presidency of Brazil. At that time, we issued paper currency in a small, touristic village in the Northeast Region which stimulated local cultural projects. But it was only in 2009 that the Central Bank of Brazil acknowledged “social currencies” as a legitimate economic agenda, calling for more debate at the I Financial Inclusion Forum. This year, the monetary authorities organized a second forum that also opened the room to discussions on mobile payment systems and new perspectives on poverty alleviation via State subsidies. The Ministry of Culture funded the “Creative Currencies” project in 2009-2010 and our next stage in this discovery process is to be supported by the National Social and Economic Development Bank (BNDES). In short, there is genuine interest among public officials in different areas and public funding for social currencies is on the rise in Brazil. However, after all these years we are still at a very early stage of research and practice. Some of the most successful initiatives (such as Banco Palmas) actually evolved out of local monetary creation to become correspondent banking operations for commercial banks and other financial groups. After eight years of price stability and social inclusion, Brazil stands out as a major opportunity for social experimentation, even the Grameen Bank is now entering the Brazilian market and many NGOs are geared towards different forms of entrepreneurialism in the base of the pyramid, riding solidarity economic models, microfinance and microcredit for local development. It is yet to be seen, however, whether these developments are just one more stage of “bankarization”, that is to say, an extension of regular banking services or actually a new form of social and symbolic self-determination at the local level. So far, the Central Bank of Brazil is open to new forms of credit and local finance as long as they are strictly territorial and very close to barter among the poor. In other words, whether the process of monetary creation could be made to fit an open source paradigm is yet to be seen. Community banking and social currencies might as well end up as just another channel for access to and use of banking services. The “Creative Currencies” project aims at promoting the discussion of more fundamental issues, such as the limits of central banking, the prospects for local financial development and the possibility of creating and managing financial icons as cultural assets. The purpose of this project is to produce short documentaries that will bear testimony to this evolving regulatory framework while inducing more discussion about the fundamental iconomic issues concealed in the process of money and wealth creation. RLM: What new potential is there in applying digital technologies to currency creation? GS: Globalization is a result of the virtualization of money, that is, the overcoming of illusions such as the “gold standard”. Money is an icon created by institutions, not on supposedly natural or material foundations but out of political and financial interests. The “dollar standard” is an outstanding evidence of this phenomenon and Kaplan´s paper, the first to use the expression “iconomics”, insists on the rhetoric and semiotic effects associated to a supposedly scientific model of money creation and management. This is a fundamental change that was perceived and discussed much before the digitalization of the world by unorthodox economists such as John Maynard Keynes since the early 20th century. The digitalization of global financial flows accelerated this immateriality and the creation of the Euro was yet another evidence of the political foundations of currencies. The banking establishment, however, is keen on the idea that scientific formulae hold the key to sound money creation. Keynesianism has been repeatedly associated to “inflationism” while the supposedly sound monetary policies of the Orthodoxy serve well the political and financial interests of a technocratic elite. Corporate media also serve this fictitious depiction of the monetary process despite the cyclical bust of monetary rules and financial regulations. The internet, however, has created numerous opportunities for the disintermediation in industries such as film, music and commodities. There is no reason to doubt that the financial industry can also be transformed by Peer-to-Peer (P2P) infrastructures. Money is media as well. Credit is but confidence. Once people realize that the distributed computing power of networks can also be the platform to weave new monetary and credit operations, there is room for grassroots emancipation out of the established owners of monetary institutions. So far, however, there has been a privatization of monetary management and there is not a clear path or model for the emergent (P2P) property democratization that is inherent to the internet. Digital assets, however, clearly have an inherent potential to escape central control and proprietary regulatory frameworks. RLM: How are social networks transforming the ways in which we exchange value? Do you believe that online influence and reputation might be translated into a new kind of currency? GS: The foundation for social currencies as envisaged by solidarity economics is the territory. Authorities are willing to concede local monetary creation as long as it is restricted to poor neighborhoods, as a proxy to barter. In this relevant but limited context, reputation, personal knowledge and informal ties form the matrix of local or “proximity” finance which are expected to keep credit and leverage to a sustainable level. Anything beyond that should and would lead to an integration of local finance into the established banking system. However, inasmuch as the internet promotes virtual territories and reputation is now subject to all sorts of digital manipulation and stardom becomes an everyday cultural process among teenagers and elders alike, the territorial “foundation” is substituted for more complex patterns of solidarity, cooperation and exchange that reach beyond the physical territory and even the “human.” Digital assets embody knowledge, technology, cultural and educational values that are exchanged at a global scale beyond the control of democratic States (Chinese-like intervention is the exception, not the rule). Hacktivism is unstoppable and so is monetary hacktivism. Especially in the Third World, mobile communications fast became conveyors of money transfers and other appropriation strategies. Banking and telecom sectors already battle for the control of these emerging markets and, as a matter of fact, have so far contributed to the containment of these processes. Governments serve these moguls and have usually adopted a wait-and-see attitude. If open source hardware and grassroots social movements combine to challenge these proprietary battles, then social networks may evolve into new forms of social capital and thus form the ground on which to design and implement social currencies. The global financial crisis, as well as the dollar demise, are an event of such a proportion that social networks may open the path for emancipator subjects to seize the opportunity. RLM: What are some of the social experiments that you think are revolutionizing the way in which value is exchanged? GS: There is a broad evolution of economic systems towards the valuation of intangible assets such as knowledge, reputation and sustainability. There are many examples of local as well as global events that call the traditional systems of exchange into question, from carbon credits to educational bonuses, digital barter frameworks and locally based solidarity and fair trade networks. These emerging examples, no matter how different in nature or scale, represent a challenge to the traditional value creation schemes and theories which are based on use and exchange value, supply and demand. This is not to say that utility and labour or scarcity are to be totally dismissed, but there is now an emerging perception that value is also a function of behavioral codes, symbolic patterns and the energy of institutional frameworks. The plasticity of digital platforms is relevant insofar as intellectual property becomes the central source of value creation. But when you discuss the property rights of public goods such as the environment or basic social rights (of minorities or localities), then a new paradigm seems to emerge. RLM: Are gaming and online storytelling digital practices that might have an impact on the way new currencies are created and developed? GS: “Play money” has been one of the early and most intriguing phenomena associated to the diffusion of virtual worlds. These virtual currencies have also been prone to “boom and bust” dynamics, speculation and pure theft (Second Life scams were common and led to “intervention” by the owners of the game). Storytelling is a major source of value, that is, the value of attention and the markets for audience. There are plenty of private monies created and managed by corporate entertainment groups, telecom operators (via mobile virtual network operators) and marketing frameworks. The casino economy, as already depicted by Keynes and other unorthodox economists, is always storytelling about future states of the world, confidence building and leverage of animal spirits. The novelty of current events is not the fictitious nature of any form of capital, but the potential for digital democratization of controls over the imaginary nature of value creation. But this is just a potential, a possibility, a figment that more often than not is appropriated by centralized and opaque private powers. The game industry is a testbed for new connections between storytelling and money creation. RLM: Monetary value was originally connected to the scarcity of precious metals, such as gold. Our entire monetary system seems therefore to function according to a logic of scarcity. Do you believe it is possible to reverse this logic into a logic of abundance? GS: The gold standard was a fiction itself, the “scarcity” is always produced by institutions that regulate confidence and access to credit. The key issue is not to fabricate abundance, but to question the institutions which produce scarcity out of any standard, gold or whatever. Central banks are at the service of private banks in the creation and management of scarcity. RLM: The promise that nanotechnology holds for our future is one of radical abundance (or so say transhumanists). The possibility of creating any kind of material substance through nanoengineering seems each day more feasible. What would this possibility entail in terms of systems of value exchange? GS: Nanotechnology, environmental concerns and grassroots appropriation of distributed knowledge are the frontiers of a new horizon of energy creation and management. Social groups in charge of managing scarcity for the sake of wealth and power concentration must be held accountable for the destruction of our future. Once this key political conundrum is accounted for, new systems of value exchange and even a non-mercantile society will come into existence. Revolutionary theorists such as Marx envisaged transformation via the extreme clash of contradictions between capital and labour. This approach has never led to a change in the systemic logic of scarcity for the sake of social control. We are once again facing the threshold of large scale societal change, but the outcome of the current crisis should come from our imagination, not from yet another paradox of abundance and scarcity. As long as we remain attached to the materiality of value, the illusion of freedom will but reinforce the massive manipulation of necessity. RLM: What do you think is the role of crowdfunding in this context? GS: Crowdsourcing as well as crowdfunding are examples of the peer to peer opportunities that come along with distributed computer power. However, the power structure behind wealth and scarcity creation may or may not be changed by crowd management. But it should not be taken at face value, so to speak. The stock market of course is an early form of crowdfunding without calling into question the proprietary framework of the companies offering their investment projects to the market. Any market is a form of crowdsourcing, that is to say, of distributed forms of supply and demand matchmaking. The wealth of networks, however, depends on the contractual ecosystem, the institutional framework, the channeling of social imagination, not on the purely quantitative distribution of bids and offers. I see economics as supply, demand and code. Once you have access to the code, once openness becomes part of the game, then there is a chance of crowd behavior becoming collective intelligence and sustainable imagination. RLM: Is the development of digital currencies headed towards a pluralistic ecology in which many micro currency systems co-exist, or is it penetrating the mainstream monetary system? If it is affecting the mainstream financial system, what would be its effect in the long-term? GS: The same issue is at stake both at local and global levels. The global system is, as a matter of fact, an unstable ecosystem of “micro currencies” whereas the dollar has so far exerted an overwhelming influence. Local currencies and private monies coexist with national currencies only to the extent that the Central Bank admits, for instance, that grassroots monetary emissions remain territorial and strictly connected to poverty. However, the question of how new developments in digital technologies and nanotechnologies might alter not only our current monetary systems but also our understanding of value in itself, is still an open question. (shrink)

In considering the argument that Thomas Szasz advances on behalf of his claim that there is no mental illness, it becomes evident that despite his stated assumptions, moral valuations are necessarily tied up with assessment of disease. By following his remarks about differential diagnosis, it becomes evident that behavior is the occasion for differential diagnosis, that behavior determines which anatomical deviations are counted as diseases, and that Szasz's insistence on autonomy introduces his own moral assumptions into the concept of (...) disease. Consequently, although none of these considerations disproves Szasz's conclusions about the existence of mental illness, neither can his argument support the weight of that conclusion. CiteULike Connotea Del.icio.us What's this? (shrink)

This paper will explore both the ways in which the practices of self-care, specifically related to mental health, have emerged as responses to the increasingly precarious status of life after the economic shocks of the Global Financial Crisis, whilst also looking to the work of Silvia Federici and Kathi Weeks to propose models for immanent critique of these practices. Although it cannot be taken as a pure origin, post-GFC mental health discourse has increasingly seen mental health discussed (...) as a form of resilience to precarity. Furthermore, practices of self-care, and psychological forms of treatment such as cognitive behavioural therapy have become vehicles for the intensification of personal resilience in the face of systemic crisis. If self-care involves an inward looking and depoliticised subject, surely political emancipation lies elsewhere. The possibility of some alternative to our present state of affairs, where self-care increasingly appears as a form of ‘voluntary servitude,’ that is to say, a form of self-subjugation with serious political risks, must surely be taken as a continual project for those engaged in critical inquiry. Then again, to suggest that those engaging in self-care are simply reproducing neoliberal subjectivity would surely miss the ways in which such forms of self-preservation might appear as unavoidable for the individuals in question. Through an engagement with their work—and one that draws parallels between their strategic critiques of reproductive labour broadly speaking, and the more specific area of mental illness and neoliberal governmentality—the question of the “necessity” of self-care will be brought into alignment with the possibilities of its practicality. (shrink)