In lieu of an abstract, here is a brief excerpt of the content:The Future Is Political and TransdisciplinaryAwais Aftab (bio)Philosophy, psychiatry, & psychology (PPP) is a transdisciplinary oasis, one of the few journals in mental health care that facilitate a meaningful dialogue between philosophers, psychiatrists, psychologists, and scholars from related disciplines. The fact that PPP successfully provides such a space is of no small importance, especially from my perspective as a psychiatrist. The multidisciplinary nature of the undertaking has been a (...) central aspect of the identity of the journal from the very beginning. PPP has maintained this transdisciplinary inclusive spirit over the years, and its editorial and advisory boards remain richly representative, but the challenge of ensuring continued participation of clinicians is not insubstantial. After all, the point is not token participation, but a robust and transformative interdisciplinary engagement. Clinicians have much to contribute to philosophical debates, however, such capacity for dialogue requires sustained cultivation (Aftab & Waterman, 2021), and forces in medical education have led to a situation where comparatively fewer psychiatrists have the interest or the ability to engage in such rigorous dialogue with philosophers. Philosophy of mental health has grown and specialized exponentially since the mid-90s. Keeping up with this literature is difficult even for philosophers, it is no small feat for full-time clinicians.This means that PPP and its affiliate organizations have a responsibility to take a more active role in supporting educational initiatives to ensure that future generations of psychiatric clinicians are able to contribute to philosophical debates, and that philosophy of psychiatry does not become divorced from clinical and practical concerns. My advice to clinicians based on my experience would be two-fold: first, it is essential to acquire a basic familiarity with the philosophy of psychiatry literature. Aftab and Waterman (2021) offer a sample list of reading recommendations. At the time of this writing, the International Network for Philosophy and Psychiatry is also undertaking efforts to develop curricula aimed at clinicians. Second, it is important to find ways to interact with others in the philosophy of psychiatry community. Formal avenues to do so include the annual meetings of the Association for the Advancement of Philosophy and Psychiatry and the Philosophy Special Interest Group of the Royal College of Psychiatrists, among others. There are also various online communities active on social media that many find helpful.In recent years, we have seen an unprecedented enthusiasm and support for inclusion of lived experience in mental health care. This is a welcome and much needed development, but we are only just beginning to scratch the surface of [End Page 5] how to philosophically navigate this inclusion. Frameworks such as standpoint epistemology and epistemic justice offer us starting points (Knox, 2022), but much remains to be worked out (Aftab, 2022). There are notable philosophical challenges, such as ascertaining the limits of lived experience, and the biases and errors to which it is vulnerable; the application of scientific method and philosophical criticism to lived experience; methods to resolve disagreements when different forms of lived experience contradict each other; handling discrepancies between knowledge from lived experience and knowledge from other sources be handled; and analyzing the intersection of politics of lived experience with other differentials of power. I anticipate that these topics will be of central importance to the field and to the journal in the coming years.It is also vital that philosophy of psychiatry engage with the sociopolitical dimensions of madness (Kalathil & Jones, 2016). The failure of philosophy to do so in a meaningful way has already been articulated powerfully by commentators such as Nev Jones (2022). An important aspect of acknowledging philosophy's failures in this regard comes from the notion of "elite capture," recently popularized by Olúfẹ́mi O. Táíwò (2022). It refers to how progressive philosophical ideas such as standpoint epistemology are co-opted by the "elite" to serve their own ends. Discussions on social media have already begun to point out that concepts in philosophy of psychiatry such as "epistemic injustice" show signs of elite capture by the psychiatric establishment, resulting in token participation but no systemic changes. Philosophy of psychiatry needs to tackle its own vulnerability to co-option. This will require creative forms of philosophizing and engagement with... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Narrative Formulation RevisitedOn Seeing the Person in Mental Health RecoveryAnna Bergqvist (bio)The use of narrative in mental health contexts models consciousness as something necessarily embodied, as already part of the world, in an inherently value-laden and perspectival way. As such narrative presents a powerful tool for critical reassessment and reevaluation of preconceived ideas in relating to difficult concepts in clinical interactions.Narrative structures can reveal psychological differences between persons in (...) a way that matters for the provision of effective treatment and management. As emphasized by Solomon (2015), narrative reasoning is also motivated by distinctly first-personal concerns that are operative in the practitioner–client relationship. I maintain that the dynamics of that interpersonal relationship are part and parcel of what it means to address the patient's needs to be seen as a person in humanistic empathetic care—without thereby reducing truth to an individual person's perspective to encourage positive transformation.1The notion of empowering narratives to encourage positive change is a core concept behind the emphasis on the critical role of empathy in explaining human development and psychoanalytic change within the self-psychology tradition but is also key to recovery-based models of the significance of person-centered quality of life in medicine more generally. This is defined in mental health as recovering a good quality of life as determined by the values of (by what matters or is important to) the individual concerned (Allott, Loganathan, & Fulford, 2002; Fulford, 1989, 2004; Fulford, Peile, & Carroll, 2012). The importance of strengths in this regard was reflected for example in the UK government program on values-based mental health assessment. The 3 Keys program, as it was called (National Institute for Mental Health in England, NIMHE, and the Care Services Improvement Partnership, 20082) identified three shared 'keys' to good practice in mental health assessment: three things that were identified in a wide-ranging consultation as being important alike by health professionals of all kinds and by 'service users' thus understood as patients and carers (Fulford, Duhig, Hankin, Hicks, & Keeble, 2015a; Fulford, Dewey, & King, 2015b). The third of these keys was defined in [End Page 7] the subsequently published Good Practice Guidance, as "a person-centred focus that builds on the strengths, resiliencies and aspirations of the individual service user as well as identifying his or her needs and challenges" (NIMHE, 2008: 6); and the guidance included a number of real-life case examples of best recovery practice reflecting this aspect of mental health care (Slade et al., 2014).What my (Bergqvist, 2018, 2020, 2022, forthcoming) account adds to this claim is that while such choices are revelatory or expressive of a distinctly first-personal stance, they do not constitute or determine selfhood and self-interpretation in a fixed way. Moreover, the reason is that one can also adopt a second-personal stance on one's own experience and address oneself, where the relationship between the first- and the second-personal narrative perspective on experience and self-understanding is itself a dynamic and open-ended evaluative process.Anna Bergqvist Anna Bergqvist is Reader in Philosophy at Manchester Metropolitan University since 2021, and has been Postgraduate Research Coordinator and AHRC North West Doctoral Pathway Consortium Lead for Philosophy since 2020. I was elected to a Visiting Fellowship at St Catherine's College University of Oxford for Michaelmas Term 2021. Her service to the profession out with the University includes acting as Secretary of the World Psychiatric Association (WPA) Section for Philosophy & Humanities in Psychiatry (October 2020 – present), Executive Committee Member of the Royal College of Psychiatry (RCPsych) SIG in Philosophy (February 2020 – present) and External Examiner, University of Liverpool (November 2019 – present, 4-year tenure). She is also Director of the Values-based Theory Network at St Catherine's Collaborating Centre for Values-based Practice at the University of Oxford, and Member of its Whiteness and Race Equality Network. Her approach to philosophy bridges the disciplines of moral philosophy, moral psychology and philosophy of psychiatry to improve lives through her reputable expertise in moral perception and co-production as a mechanism for change.Notes1. Here I side with Goldie (2012) and Solomon (2015), who... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Vulnerabilization and De-pathologizationTwo Philosophical SuggestionsHavi Carel, PhD (bio)Alastair Morgan raises useful and interesting philosophical critiques of the 'power-threat-meaning' framework proposed by Johnstone et al. (2018). In what follows I make two suggestions that may clarify some aspects of the debate. First, to broaden the notion of threat: we can think more broadly about adverse life events as the source of mental suffering by broadening the notion of threat to (...) what I term (in joint work with Ian James Kidd) Vulnerabilization. Second, I offer a distinction between de-pathologizing psychiatric disorders (i.e., removing stigma and negative stereotypes) and de-medicalizing such disorders (i.e., rescinding them from a diagnostic manual), in order to suggest that de-medicalizing on its own does not solve the problem of stigma, but de-pathologizing is a better candidate for achieving that.Threat and VulnerabilizationMorgan argues that the notion of threat is too limited to cover the breadth of psychiatric conditions and presentations. Threat and power may often be present, but how they lead to the appearance of behaviors that meet certain diagnostic criteria, is, as Morgan states, unclear at best and only a partial explanation for psychiatric disorders (it explains some behaviors, not all). I suggest we view threat as one type of a broader category, which I propose to term 'Vulnerabilization' (Carel & Kidd, 2021).Vulnerabilization refers to the effects of interactions and actions that impact on people by harming them and making them more vulnerable to future adversity. For example, removing a struggling child from a classroom causes them to miss the lesson, and if done repeatedly, harms their capacity to continue studying. Leaving a weak patient unsupervised in the wrong kind of bed may cause them to fall and become more vulnerable to disease and infection. Failing to organize accommodation for an inmate about to be released from prison forces them onto the streets and makes them more vulnerable to reoffending. The point of the term is to draw attention to the fact that one is not born vulnerable, to paraphrase de Beauvoir, [End Page 73] but becomes vulnerabilized through acts and omissions of others. Such acts and omissions often take place under the auspices of an institution—health care, social care, education, criminal justice, and so on—and are therefore intimately tied to ethoi and conduct of institutions (for a full analysis see Carel & Kidd, 2021).Vulnerabilization is a common theme in the testimonies of people who have negative experiences of social institutions, including, of course, health care institutions. Ideally, health care systems, schools, courts, and other major institutions scaffold and protect our agency, efficiently support our endeavors, and fairly and reliably disperse social and epistemic resources. But while some people have reliably satisfying experiences of social institutions, others find that many, if not all, of the institutions they encounter abandon, ignore, silence, harm, or even kill them and people like them (this is not an exaggeration: inquiries such as the Francis Report (2013) on the Mid Staffordshire patient neglect case and the Sheldon Review (n.d.) provide plentiful examples of that).1 When vulnerable people encounter institutions, they are often at an epistemic and communicative disadvantage that makes their interactions with institutions a source of suffering and injustice and indeed makes such people even more vulnerabilized. They may be affected by poverty, disability (especially mental ill health and learning disabilities), trauma, domestic violence, ill health, racism, sexism, ageism, or other sources of disadvantage, prejudice and discrimination; and, of course, they can be disadvantaged by a combination of such factors. Seeing power as the source of much suffering, social injustice and poor mental health is, of course, entirely in line with this view and I agree with Morgan that Johnstone et al. (2018) identified an important source of suffering.De-Medicalizing Versus De-PathologizingAnother important issue about psychiatric diagnoses is the stigma and negative stereotypes surrounding mental illness. Calls to de-medicalize a specific or all mental disorders is, in part, a call to remove stigma and negative stereotype from the behaviors and mental states that characterize a mental disorder. However, to de-medicalize... (shrink)

Abstract:The titular question, of what makes a disorder 'mental,' has an obvious answer: mental disorders are disorders of the mind. I argue that this is not so, before proposing a positive theory of what makes a disorder 'mental,' that what makes a disorder 'mental' is its relationship to psychiatry. The overall thrust of my argument is that mental disorder is mental in name only—to have a mental disorder is not to have a disorder of the mind. Instead, mental disorder is (...) psychiatric disorder, a class of conditions grouped together not because of anything to do with the mind, but because of their relationship to psychiatry, a concrete group of methods, practices, and institutions. (shrink)

In 20141 and 2016,2 respectively, Québec and Canada adopted legislation permitting medical assistance in dying (MAID). In this context, the question of whether persons with mental disorders should be able to access MAID has received considerable scrutiny.Over the last 5 years, I have been involved in the academic and policy debates about assisted dying for persons with mental disorders. Policymakers and clinicians alike demand that public policy be based on 'evidence' by which they tend to mean empirical, usually quantitative, data. (...) There is little acknowledgement that some questions are not empirical and that facts require interpretation.The debate about whether a request for assistance in dying by a person with a... Read More. (shrink)

Abstract:In the fields of psychoanalysis and psychotherapy, case study researchers rarely justify their knowledge claims on formal epistemological grounds. This poses several issues to the case study method. First, without articulating the standards by which our knowledge is being justified, we are potentially enabling the criticism that case studies are mere anecdotal reports and should not be treated as forms of evidence. Second, without the guidance of wider epistemological standards for case study research, we risk falling into arbitrary justifications of (...) other as well as our own case studies. This paper seeks to address these issues by examining and developing epistemic practices in psychoanalytic and psychotherapy case studies. Drawing from different social science resources, the paper describes three epistemological concepts appropriate for case study research: retroductive reasoning, analytic generalization and working hypothesis. The paper demonstrates how each epistemological concept can be used in psychotherapy research and explicates specific methodological guidelines. Social science definitions and principles are applied in a psychotherapy and/or psychoanalytic research context, and further considerations about canons of evidence are provided. The impetus of this paper is to strengthen qualitative research standards, particularly case study research standards, in clinical case study writing. (shrink)

Abstract:In this paper, I offer a philosophical critique of the Power Threat Meaning Framework (PTMF). This framework was launched in the UK in January 2018 as a non-pathologizing way of understanding mental distress. It argues that those experiences diagnosed as mental illnesses are better understood as meaning-based threat responses to the negative operation of power. My critique consists of three parts. First, the PTMF argues that it is opposed to a concept of mental distress as illness. However, the PTMF unfolds (...) an account of mental distress that is very similar to other accounts of mental illness in the philosophical literature. The PTMF does not reflect upon, recognize or give an account of its own grounds for judging mental distress as distress. If it were to do so, I argue that it would produce an account of mental distress that is very similar to many other accounts of psychiatric illness or disorder. Second, I criticize the account given of meaning in the PTMF. I argue that this account is ultimately a reductive, behavioral account of adaptation that downplays important existential aspects of experience. Furthermore, the account of interpretive sense-making in the PTMF is conceptually confused. Finally, I outline a critique of the way that the concept of power, the great strength of the PTMF approach, is reduced to a concept of threat. I argue that this tends toward a linear view of causality that is reductive in its search for the meaning of mental distress. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Remnants of SenseAlastair Morgan, PhD (bio)In an interview outlining her approach to understanding mental distress, Lucy Johnstone states that when faced with ostensibly bizarre, irrational or distressing experiences:[T]he guiding principle of "At some level it all makes sense" applies. In fact, I can't immediately think of anyone I've worked with for whom it did not, in the end, turn out to be true.1The two commentaries on my paper (...) point to two levels where this sense-making might operate; a structural and an individual level.Havi Carel (2023) draws attention to the important concept of power in the Power Threat Meaning Framework and suggests a widening of the concept of threat to a concept of vulnerabilization that refers to the multiple factors that expose people to institutional neglect and violence that is interlaced with a range of forms of discrimination, neglect and disadvantage. Whilst the main strength of the PTMF approach is to draw attention to the structural importance of power in contributing to forms of psychic distress, the emphasis on a concept of threat tends towards a reactive and reductive concept of power. Carel (2023) helpfully points to a wider concept of power that can be utilised for further work in understanding the impact of societal violence on forms of mental distress.Such a widening of the concept of power does not only rest on a critique of institutions but also an understanding of the ways in which people can be abandoned and neglected by state support of one kind or another. Power operates through a dual logic of exposure and abandonment. Some people are particularly exposed to forms of institutional power from an early age and vulnerabilized by such exposure, but there is also a logic of abandonment within such exposure; the ever present possibility of neglect. Such an operation of power is not univocal (or embedded in one profession) but dispersed and differentially applied. As Didier Fassin (2018, p. 43) writes: "All lives are precarious but certain lives much more so than others—and above all, quite differently."Psychiatric power is one important focus when trying to understand this process of the exposure and abandonment of power, however, as Carel (2023, p. 75) notes, "the medical realm is not its own kingdom." Psychiatry is inserted into a network of dispersed power that has multiple and differential effects, both positive and negative. The focus on the question of psychiatric diagnosis as the apotheosis of societal power neglects the multiple effects of diagnosis or the lack of diagnosis on people who are particularly vulnerable to the operations of power. In situations where institutional care is crumbling and under-resourced the focus on psychiatric care alone as a problem of power risks just compounding such an institutional neglect. [End Page 77] Veena Das (2020) asks the question of what happens before the arrival of the psychiatrist on the scene of care and after her disappearance. Das (2020, p. 174) is interested in the multiple ways that power flows across and between both formal and informal institutions to produce a "milieu of madness." Such flows of power will also apply to increasingly hegemonic psychological formulations of signs of distress as problems in living, as problems in adaptive reactions to adversity. Such formulations are themselves inserted into a nexus of power relations and processes of vulnerabilization and are not somehow free of the taint of other forms of understanding. Indeed, as Carel notes, the process of demedicalization and de-professionalisation can very easily be inserted into the dual logic of exposure and abandonment that I discussed earlier. People can be exposed to power in a wider range of settings as psychic distress is demedicalized but also subjected to abandonment and neglect as mental distress is no longer thought of as an illness but just one of many wider and non-medical problems in living that does not require state support.The structural account of the determinants of mental distress offers an important corrective to individualised and medicalised approaches to meaning, but doesn't completely erase the problem of understanding and interpreting mental distress. Mohammed Abouelleil Rashed's commentary raises important issues with the... (shrink)

Proposing narratives that reflect our values and address what we believe to be, and what in fact in this case are, valid concerns is no doubt an attractive venture. But good intentions are not enough, and often it is careful analysis that shows why this is the case. Alastair Morgan's (2023) essay Power, Threat, Meaning Framework: A Philosophical Critique is a bright example of philosophy-in-action; it demonstrates, to use a popular expression, that the road to hell is paved with good (...) intentions. In this commentary I argue that while the concerns of the authors of the Power Threat Meaning Framework (PTMF) are valid, their proposed solutions lead us to yet another master narrative.The PTMF presents itself as an... Read More. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Introduction to the 30th Anniversary Issue of Philosophy, Psychiatry, & PsychologyJohn Z. Sadler (bio)This issue marks the 30th anniversary of Philosophy, Psychiatry, and Psychology (PPP). All of us at the journal are grateful to our authors, readers, editors, and publishers for enabling this landmark. To commemorate this event, I invited our Founding Editor and Chair of the Advisory Board, K.W.M. "Bill" Fulford to write a brief essay, along with (...) our panel of smart and industrious senior editors. Their instructions were simple: 500 words on PPP past, present, and/or future. These essays appear in the pages to follow. As Editor-in-Chief, I write about PPP's early commitments as a scholarly journal, situate these in the history of academic publishing, and muse over our current moment.Bill Fulford briefly discusses the early years of the journal in his essay. My perspective emerges from an editor's perspective. As co-editors in the early years, Bill and I were committed to an international authorship with comparable editorial oversight. We wanted to build a journal that would equally recognize clinical science and practice and philosophy, maintaining the rigor of each field. We saw philosophers and mental health practitioners as equal partners, collaborators, innovators, and educators. More important, PPP was intended to offer up the best criticism of the mental health and related fields.The scattershot history of scholarly editing has identified several functions of the editor over the centuries following Gutenberg's invention of the printing press in the mid-1440s. The earliest editors took liberties with the language of the Bible, trying to make it more accessible to the public; the printing press permitted fast and inexpensive reproduction. Not surprisingly, this popularizing of the Bible led to praise as well as outrage. The printing of other scholarly works followed quickly. In 1470, only about 25 years after the invention of the printing press, Niccolo Perroni called for Pope Paul II to censor Andrea Bussi's edition of Pliny the Elder's Natural History, an anthology of then-ancient writings about the natural world. This marked the first recorded instance of censorship of a more-or-less secular scholarly work (Monfasani, 1988). In the ensuing centuries, "editors" initially were the popularizers, and later the gatekeepers of texts worth (and not worth) reading. In the [End Page 1] ensuing centuries into the present, editors have been venerated both as defenders of good reading and reviled as censors or intellectual selfaggrandizers.The current moment, in my view, represents a crisis in the history of editing and editorship. Digital communications have liberated communications worldwide. However, this liberty has come at the cost of colossal amounts of material not worth reading and an explosion of divisive, destructive discourse. Even worse, internet "trolls" on social media have moved bullying out of the schoolyard and into international cyberspace. Determining what is worth reading has moved away from a cluster of (hopefully) responsible editors to anyone who wants to go to the small effort of silencing others through online harassment and even violent threats. Such cyberbullying does not eliminate elitism, but instead substitutes a toxic online "elite" without principle other than self-promotion and the alienation of others. Our contemporary online culture has yet to figure out how to shape what is, and is not, worth reading.My wish and intent for the future of PPP is to maintain and grow our place of rational, deliberative, and open discourse, even in the face of such disruptive cultural change.John Z. Sadler John Z. Sadler, MD, is the Editor-in-Chief of PPP. He is the Daniel W. Foster, MD, Professor of Medical Ethics at the University of Texas Southwestern Medical Center, as well as a Professor of Psychiatry there. He has been a PPP editor since its inception.ReferenceMonfasani, J. (1988). The first call for press censorship: Niccolo Perotti, Giovanni Andrea Bussi, Antonio Moreto, and the editing of Pliny's Natural History. Renaissance Quarterly, 41, 1–31. Google ScholarCopyright © 2023 Johns Hopkins University Press... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Compelling ReasonsTim Thornton, MA, MPhil, PhD, DLitt (bio)There are many compelling reasons to have an interest in the philosophy of/and psychiatry. In 1994, when persuaded by Bill Fulford to walk down the corridor at Warwick University to join in his teaching of what seemed a newly developing subject—against my protestations that I knew nothing about mental health care—my main interest was in the irreducibility of meaning to the 'realm (...) of [natural scientific] law,' in Sellars's phrase. This had the bonus of complementing Bill's championing of the irreducibility and centrality of values in psychiatry. (It was only later we realized we disagreed about the not inconsequential issue of whether norms and values were subjective preferences or objective features of the world.) It seemed plausible to me that the irreducibility of the space of reasons to the realm of law might have interesting consequences for psychiatry. But mine was a purely disinterested academic interest. This is perhaps the usual approach to what is in part a professionalized academic subject with its formal rules for publication and dissemination of research.It has only been in the last decade that I have experienced things in a more personal way, following what I would term, though psychiatry would not, a nervous breakdown. My image of a breakdown came from reading Saul Bellow's novel Herzog. The titular Herzog has been left by his wife, cruelly, and retires from academic life to write letters. For example, to Heidegger. "Dear Doktor Professor Heidegger, I should like to know what you mean by the expression 'the fall into the quotidian.' When did this fall occur? Where were we standing when it happened?" I thought I would be able to maintain some sort of inquiring mind and write experientially grounded philosophy of psychiatry as a catharsis. I could study my own illness. This immediately proved a ridiculous hope.As a philosopher with a cognitivist bent—language, thought, and intentionality being guiding interests—I had always assumed that madness was only really a matter of what Jaspers calls 'primary delusions,' belief-like states that strain their belief-status, are hard for others to make sense of, and occur only with particularly severe forms of mental illness. But madness is also a matter of doing, saying and feeling as well as pure reasoning. What I would, previously and disinterestedly, have described as a dysregulation of emotional reactions turned out to transform my entire experience of the world and my ability to think rationally about it. I lost the ability to put my experiences into words. In truth, I lost all interest in that project. Only when not distressed could I take a view on my loss of world. Distressed, I did not understand myself.This is a neat illustration of epistemic disjunctivism. But it also highlights a challenge for, and some of the brilliance in those who have contributed to, the philosophy of mental health care, through their expertise by experience. While experience may be a necessary condition for particular forms of expertise, my own case reveals that it is not sufficient. Further, even an everyday and familiar mental illness (like my own) can render the articulation of experience, in a way that makes sense to others, very much harder. Hence the fact [End Page 11] that there is a thriving mental health service and patient movement, making their own experiences available to others combining first-person narratives with conceptual and phenomenological insight is both admirable and helps to set a part of PPP's future agenda: bringing first-person experience within a philosophically and clinically informed discipline. [End Page 12]Tim Thornton Tim Thornton, MA, MPhil, PhD, DLitt, is Professor of Philosophy and Mental Health and Mental Health and Deputy Head for Research in the School of Nursing at the University of Central Lancashire. As well as contemporary philosophy of thought and language, his research concerns conceptual issues at the heart of mental health care. He has published research papers on clinical judgement, idiographic and narrative understanding, the interpretation of psychopathology and reductionism and social constructionism in psychiatry.Copyright © 2023 Johns Hopkins University Press... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Hermeneutics, Neuroscience and PsychiatryMichael T. H. Wong, MBBS, MD, MA, MDiv, PhD, FRCPsych, FRANZCP, FHKAM (bio)Hermeneutic practice in mental health has been a theme in Philosophy, Psychiatry, & Psychology (PPP) since its very beginnings. In this essay I argue that hermeneutics, the theory and practice of interpretation, promotes therapeutic interaction between mental health professionals, patients and their family.Why does this patient present in such a way at this particular (...) point in time? The distressing symptoms are there. The changes in behavior are obvious. Impairments of functions are hurting. A mental illness clearly runs in the family. There were early losses of loved ones, physical abuse at home, bullying by peers and self-medication with drugs and alcohol. Three in four adults with a mental illness first experienced that before they turned 24. The brain goes through major reorganization during adolescence and early adulthood. If synaptic pruning went wrong, psychoses emerged. When stresses activated the hypothalamic–pituitary–adrenal axis the elevated cortisol level impacted the size and function of the hippocampus and amygdala in the genetically vulnerable; anxiety, depression, bipolar, and personality disorders developed. The patient needs a voice/language to describe all these experiences and events and the psychiatrist needs a discourse to make sense of them.Eisenberg laments the swings between "brainlessness" and "mindlessness" in psychiatry. Engel argues for a "biopsychosocial" discourse. The major challenge for psychiatry is how to organize clinical information of different nature (categories, dimensions, narratives; i.e., objective vs. subjective, personal vs. interpersonal) into a coherent and comprehensible account for us all. Mental illnesses are not only neuropsychiatric spectrum disorders but also dysfunctions of social relationship and environmental/ecological adaptation. Psychiatry as a clinical neuroscience per se lacks the semantics to address the rich interactions between the physical, psychological, social, cultural, and spiritual in the illness experience of our patients. Explanation in the diagnostic formulation (objective scientific discourse on cause and effect) and understanding in the patient narrative (subjective ordinary everyday discourse on significance and meaning) are irreducible to each other (Wong, 2018). They instead interact with one another to achieve an integrative formulation, not through merging different discourses into a single assertion/monologue but via the dialectic/dialogue of "explaining more in order to understand better," as Ricoeur puts it, and between "the whole and the parts," as Schleiermacher highlights.This "therapeutic hermeneutic circle" of "explanation vs understanding" and "the whole vs the parts" includes symptoms behavior function and life events. It correlates between bio-psychosociocultural-spiritual dimensions/perspectives and does not reduce them to any particular/single [End Page 13] stance. The whole integrates the parts and the parts enrich the whole. It explains but does not explain away. It understands through an articulation of meaning and significance. This discourse is a multilayered (bio-psycho-social-cultural-spiritual) personal narrative that formulates diagnosis and care in a correlative (linking different voices/discourses) and non-reductive (no particular voice/discourse is prejudiced against) manner that is comprehensible to us all (Wong, 2021).PPP will be an excellent forum for discussing clinical hermeneutics in the future. In this digital era of social media and virtual reality, hermeneutics has the never-ending task to tackle the unprecedented challenges to meaning illness and health posed by polarizing discourses.Michael T. H. Wong Michael T.H. Wong, MBBS, MD, MA, MDiv, PhD, FRCPsych, FRANZCP, FHKAM, is Hon Clinical Professor, Department of Psychiatry, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, HKSAR, China. Michael is Chair, Section of Philosophy & Humanities in Psychiatry, World Psychiatric Association. He is an Organizational Partner & International Lead with The Collaborating Centre for Values-Based Practice in Health and Social Care, St Catherine's College Oxford. He is Advisor to the Chinese Health Foundation of Australia.ReferencesWong M. T. H. (2018). Ricoeur and the third discourse of the person: From philosophy and neuroscience to psychiatry and theology. London: Lexington Books. Google ScholarWong, M. T. H. (2021). Values, meanings, hermeneutics and mental health. In Stoyanov, D., Fulford, K. M. W. F., Stanghellini, G., Van Staden, W., & Wong, M. TH. (Eds.), International perspectives in values-based mental health practice: Case studies and commentaries (pp. 341–349... (shrink)

Abstract:Since Homeric times, psychotherapy has been an essential part of the medical act. Initially, the word of physicians had a magical character. Plato rationalizes this in many of his dialogues. In "Charmides," he dives deeper into this matter and proposes to apply it to every disease. Analysing this dialogue has fundamental consequences for psychotherapy: 1) Remedy and epodé (charm) must be applied in every doctor–patient relationship. 2) The body can only be healed if the soul is cured first by a (...) charm. Patients must "offer" their souls to the physician, which implies the need for confidence and the unavoidable asymmetry which characterize doctor–patient relationships. 3) The openness of the patient's soul to the physician and the physician's "beautiful speech" to the patient will enable the latter to reach the state of sophrosyne (temperance), the condition of the possibility of true health. In the discussion of the meaning of sophrosyne, Socrates questions every one of the disciples' propositions and concludes that the only thing one can be sure of is that sophrosyne is a way of searching for virtue (areté). Later, in Theaetetus, Plato adds another element: temperance is a homoiosis theó, that is, the assimilation of patient with God. With this, Plato seals the ethical character of psychotherapy forever. (shrink)

First, I would like to thank Dr. Phillips for his generous words about the potential interest of my work. He speaks about the fact that it is "insightful" and thought-provoking ("it offers us much to think about"). In his comment Dr. Phillips reviews the main moments of the evolution of treatment by words in the Greek world and he focuses on Plato's Dialogue Charmides, whose analysis is the center of my article. He even quotes some parts of the dialogue, which (...) I mention too, although in a different translation. He rightfully underlines the moment in which Socrates tells Charmides: "And the soul... my dear friend, is cured by means of certain charms, and these charms consist of beautiful words. It is a result of... Read More. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Decolonizing MemoryLaurence J. Kirmayer*, MD (bio)In this far-reaching essay, Emily Walsh explores the significance of memory for coming to grips with the enduring legacy of colonialism in psychiatry. She argues that "for reasons of self-preservation, racialized individuals should reject collective memories underwritten by colonialism." Psychiatry can enable this process or collude with the structures of domination to silence and disable those who bear the brunt of the colonialist history (...) of violence and its current global incarnations. In this brief commentary, I want to underscore the importance of Walsh's argument, link it to contemporary work in cognitive and social science on the dynamics of memory, and point to some resources for implementing these insights in health services and clinical practice.Memory as Psychological Process, Social Practice and Cultural InstitutionMemory is not simply an individual psychological process of accessing images, stories, and knowledge of the past, but a reconstructive process of building a narrative (Kirmayer, 1996). This narrative is profoundly shaped by available templates, metaphors and models that are provided by the tacit, normative and official histories of society (Hirst, Yamashiro & Coman, 2018). But memory is also shaped by cultural affordances that guide attention and by narrative practices, which depend on other people (Ramstead, Veissière, & Kirmayer, 2017). In effect, remembering is not a matter of reaching down into one's memory archive or sedimented experience, but an embodied and enactive process of thinking with and through others (Laanes & Meretoja, 2021; Veissière, Constant, Ramstead, Friston, & Kirmayer, 2020). Memory then depends on community and on a shared understanding of history and of possible futures through which one can anchor and elaborate one's individual story.A direct consequence is that disconnecting a person from others, disembedding them from their social milieu, will lead to disruptions in memory and in the continuity of self. When the environment is toxic, this severance may sometimes be (partly) beneficial—but it always comes at a cost. Figuring out those costs, making them explicit, and ensuring that those whose history is being suppressed or overwritten by others have a chance to reclaim and write their own, is an ethical and pragmatic imperative.The denial of vital memories (recent or remote, personal or collective) causes fractures in the self that may disorganize the individual, install false consciousness, and cement the exclusionary and disvalued position of colonized, racialized, and [End Page 243] marginalized subjects. This process is not only—or even primarily—about memory. It is part of the structure of everyday life, inscribed in institutions and practices where colonial histories, racism, and economic exploitation are deeply entangled. Representations of the past are part of the way we construe the present and anticipate the future—but not every interpretive frame is a memory; there are structures in and of the moment that condition how we think about ourselves in health and illness and these too convey interests and biases disguised as "just the way things are."Fanon's Politics of Postcolonial Memory and IdentityWalsh offers a reading of aspects of Fanon's philosophy to reveal the workings of colonialism in and through memory. She is concerned with specific subsets of collective memories that are affectively charged and related to the identity of a group (Wertsch & Roediger, 2008). These memories are collective not simply they are shared by or distributed among the members of a group but because they define or constitute the collective itself.History is written largely by the powerful who create dominant or 'master' narratives that serve their own projects of legitimation and self-mystification (Trouillot, 2015; Lindqvist, 2021). But the creation of dominant narratives is not solely the province of those in power. There are many kinds of self-serving collective memory (Baumeister & Hastings, 2013)—from those related to the creation of nation states, which may ignore not only colonized peoples, but all ethnicities, religions or linguistic groups subordinated to the ideals of the dominant group (Anderson, 2006; Gunew, 2013; van Alphen & Carretero, 2015), to other forms of collective identity, even to those created by liberatory movements. These are maintained by institutionalization, ceremonial repetition and reenactment... (shrink)

Dr. Otto Doerr-Zegers's article is so interesting and insightful that I have nothing critical to say about it. On the other hand, in finding Greek, mainly Platonic, origins for psychotherapy, he offers us much to think about. In this brief commentary I will attempt to draw out some of the implications of his analysis for contemporary psychotherapy.Doerr-Zegers's analysis begins with a reflection on Socrates' Maieutics, Socrates' invoking the midwife metaphor to convey his use of dialectics to bring forth the ignorance (...) of his interlocutor. Dörr recognizes that Maieutics is a kind of psychotherapy in that, like psychotherapy, it involves a "treatment by the word." He takes this verbal dimension of the treatment back... Read More. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Memory and the Instituting Social ImaginaryNancy Nyquist Potter*, PhD (bio)Emily Walsh's Article on the way that colonialism is perpetuated in psychiatry through dominant collective memory is simultaneously exciting and challenging, and merits active engagement toward making changes (Walsh, 2022). This presents a challenge to clinicians to address entrenched, often subconscious, ways of being with and helping racialized people with historical memories and current experiences.Such changes are necessary in that (...) dominant collective memory is contributory to mental illness, as Walsh writes. It also contributes to what Walsh calls a traumatic loop, whichinvolves feeling unwell due to racist abuse or the effects racialization has on the psyche, then being unable to voice these concerns to the practitioners who desire to help you. Not having the opportunity to voice these concerns can make patients feel as though these memories are not important, thereby invalidating their own negative experiences of racialization.(Walsh, 2022, p. 232)For these reasons, it is crucial that psychiatrists fully understand the harm they can do by reproducing dominant collective memories and work to change this in themselves and in the institutional systems in which they see patients/service users.I focus on one question briefly and then turn to the heart of active engagement.The question concerns what the content of dominant collective memory is and how it might play out in a particular interaction in psychiatry. This is important for clinicians who want to learn what sorts of changes need to be made in order not to continue to enact colonialism and to avoid doing harm. Walsh does a fine job setting out forms of memory and how Fanon (and she) suggest that clinicians can assist patients toward liberation from dominant collective memory. Yet I am left with uncertainty about what sorts of dominant memory serve to deny the violence in the colonized. A bit of filling out on this idea would help the motivated to move toward change.A pressing question is how to facilitate such changes. Both the limitations and the possibilities of the social imaginary can help us understand why change is so difficult and yet how it nevertheless is possible and, in fact, necessary. The social imaginary, as Code explains it, "refers to implicit but effective systems" of values, meanings, interpretations of reality, norms for living, what counts as knowing and who can be knowers, that are found in a social-political order in ways that shape our sense of self, our ways of relating to others, our responsibilities, and a sense of place (Code, 2008, pp. 31–32). The instituted social imaginary, then, tells us what sorts of persons we should be and [End Page 241] how we should see and treat others. It shapes memories and limits which memories—and whose memories—get acknowledged and which ones and whose memories are erased or ignored. It is difficult to see for what it is because it is implicit and assumed to be fixed and natural. However, this is the instituted social imaginary, where the content of the imaginary is taken as given and is naturalized. It trades in stereotypes of Black and Indigenous and other people of color as well as stereotypes of queers, people living with disabilities, the homeless, and others. It is harmful in that it perpetuates those stereotypes, controls patients/ service users, negates their own personal and community identities, and erases episodic memory. It is difficult to change because it is entrenched and often not questioned. Nevertheless, the instituted social imaginary is not totalizing. There is hope, and energy, and excitement to be found in active engagement with an instituting social imaginary. Here, we find people and communities working to critique the given, the naturalized, and even ourselves: "Imaginatively initiated counterpossibilities interrogate the social structure to destabilize its pretensions to naturalness and wholeness, to initiate a new making" (Code, 2008, pp. 34–35). In the final section, I begin to fill out these moves in relation to Walsh's work on memory and psychiatry.Clinicians are trained to be good listeners, and many of them already practice good listening skills in interacting with their patients/service users. However, many patients' experiences... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Recognizing Wounds and Giving Uptake The Undoing of Dominant Collective MemoriesEmily Walsh*, PhD (bio)I want to begin this response by thanking Dr. Kirmayer and Dr. Potter for taking the time to craft insightful and intellectually stimulating responses to my article. Both commentaries enabled me to clarify the complexity of the question of how best to commence the undoing of dominant collective memories (DCMs) in psychiatry. In this response, I (...) will clarify what I intend to capture by the term DCMs, tackle two problems identified with my account, and end by remarking on the solutions proposed by the authors, defending that a hybrid combination of both positions leaves us with the most robust solution to the problems created by DCMs.I briefly outline in the article that DCMs are singular and exclusionary collective memories underpinned by colonialism. Potter expresses concern about being left with uncertainty regarding what sorts of DCMs serve to deny the violence faced by the colonized given this definition. This concern is important as it shows that there is some conceptual confusion about how to distinguish ordinary collective memories from DCMs, which I propose ought to be rejected. Addressing this concern would also be useful for the reason Potter makes; to help better motivate why change is required in psychiatry regarding DCMs. In response to Potter's definitional concern, I will now posit a thicker explanation of DCMs, which outlines how they are distinct from ordinary collective memories on three grounds.DCMs are unique from other kinds of collective memory insofar as they deny that there could be various perspectives of the same event. This denial occurs in multiple ways, such as silencing, scapegoating, attacking, and undermining others' perspectives, painting certain actors as all good and others as all bad. Therein lies the danger of DCMs as I have defended that people are neither wholly good nor wholly bad, but they are at the mercy of their social situation. Good examples of cases of the kind of DCMs I have in mind are how colonial nations defend their reasons for engaging in colonialism and failing to acknowledge sectors of history entirely (such as failing to recognize horror crimes against certain social and ethnic minorities). Such a failure to integrate both positive and negative parts of a nation's history is not [End Page 249] present in all contexts. For instance, Germany has integrated teaching about the horrors endured during Nazi Germany into their historical narrative of the past to avoid reproducing similar atrocities in the future. Places like the UK and Canada are slower to follow suit and admit that there are horrors present in the nation's past too.DCMs are also unique in legitimizing and reproducing negative and positive stereotypes, ideals, and cultural myths. Such stereotypes tend to be harmful such as "I expect X group always to steal," but they can also be positive "I expect X to be the most intelligent person I've ever met." As Fanon instructed us (Fanon 1964, 1967), these stereotypes are entrenched in the content of DCMs. Similarly, they are reproduced with the intent of controlling specific populations of persons. If, after all, I have 'evidence' that you are a thief by 'nature,' I will seek to protect my belongings from you. The problem is that the 'evidence' is not evidence—it is a form of DCM. The evidence fails to see processes of racialization and colonialism and thereby, advertently or inadvertently, reproduces them.As reiterated by Kirmayer in his commentary, DCMs are not primarily concerned about individual and discrete events, but they aim to produce narratives of events. According to Kirmayer, these narratives are imbued with explanations and rationalizations that drive the plot forward in time. My primary concern in the article was to show that DCMs can work to move the plot backward in time as a means of controlling specific populations—back to a time the world does not recognize as a time but forces racialized persons to keep perpetually enduring the aftereffects of (Al-Saji, 2013, 2021). Thus, there are deep contradictions in DCMs which are not present in all collective memories. On the one hand, DCMs deny the violence inflicted on the... (shrink)

Abstract:This article defends the idea that colonialism still has a grasp on a valuable tool in the construction of our reality: memory. Developments in cognitive neuroscience and interdisciplinary memory studies propose that memory is far more creative and tied to one's imaginal capacities than we used to believe, suggesting that remembering is not simply a reproductive process, but a complex reconstructive process. Drawing on the psychiatric works of Frantz Fanon, in Alienation & Freedom; Black Skin, White Masks; and Wretched of (...) the Earth, this article seeks to illustrate the ways in which colonialism continues to be involved in this reconstructive memory process. Colonialism has affected both episodic memories, the kind we have as individuals regarding our own past, and collective memories, the intersubjective shared narratives we possess in our societies. I argue that dominant collective memories ought to be rejected as a means of self-preservation for racialized individuals because these memories do not do justice to the violence of colonialism. Nevertheless, rejection of dominant collective memories comes at a significant personal cost in our societies, as it creates a traumatic loop for racialized individuals. I propose that psychiatry itself plays an instrumental role in the alienation experienced by racialized individuals because psychiatry has not yet appreciated the ways in which colonialism continues to have a hold on memory. Piecing together a theory of remembering in Fanon's texts, this article suggests that this cycle of alienation can be broken, if psychiatrists incorporate Fanon's insights regarding memory into their practice. (shrink)