Philosophy of Psychiatry and Psychopathology

In the present article, we aimed at describing the diagnostic process in Psychiatry through a phenomenological perspective. We have identified 4 core concepts which may represent the joints of a phenomenologically oriented diagnosis. The "tightrope walking" attitude refers to the psychiatrist's ability to swing between 2 different and sometimes contrasting tendencies (e.g., engagement and disengagement). The "holistic experience" includes all those intuitive, nonverbal, and pre-thematic elements that emerge in the early stages of the clinical encounter as an emanation of the (...) atmospheric quality of the intersubjective space. The "co-construction of symptoms" regards the hermeneutic process behind psychiatric symptoms, involving both the patient as a self-interpreting agent and the clinician as a translator of his/her experience. Finally, by the "evolving typification" we mean that the closer the relationship becomes with the patient, the more specific and nuanced becomes the typification behind psychiatric diagnosis. Each of these concepts will be accompanied by an extract from a clinical case deriving from one of the authors' most recent clinical experiences. (shrink)

There have been renewed calls to use phenomenology in psychiatry to improve knowledge about causation, diagnostics, and treatment of mental health conditions. A phenomenological approach aims to elucidate the subjective experiences of mental health, which its advocates claim have been largely neglected by current diagnostic frameworks in psychiatry (eg, DSM-5). The consequence of neglecting rich phenomenological information is a comparatively more constrained approach to theory development, empirical research, and care programmes. Although calls for more phenomenology in psychiatry have been met (...) with enthusiasm, there is still relatively little information on how to practically facilitate this integration. In this Personal View, we argue that phenomenological approaches need a shared semantic framework to drive their innovative potential, thus enabling consistent data capture, exchange, and interoperability with current mental health data and informatics approaches (eg, the Research Domain Criteria project). We show how an applied ontology of phenomenological psychopathology offers a suitable method to address these challenges. (shrink)

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

Dysmenorrhea, or menstrual pain, is regularly suffered by 45 to 95% of menstruating women. Despite its prevalence, and despite the philosophical importance of pain as a general phenomenon, dysmenorrhea has been all but completely overlooked in contemporary analytic philosophy of mind. This paper aims at rectifying this situation. We single out three properties of what is often considered the paradigmatic case of painful experience, what we call injury-centered pains, and argue that dysmenorrhea does not have any of them, and hence (...) that it does not neatly conform to the injury-centered model of pain. This calls into question the centrality of the injury-centered model, and suggests novel research avenues within theoretical debates on affectivity. (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)

Most mental health research largely ignores or minimises gender and age differences in depression. In ‘Don't mind the gap: Why do we not care about the gender gap in mental health?’, Patalay and Demkowicz identify a dearth of research on the causal factors of depression in young women. They attribute this to an over-reliance on biological accounts of gender differences in depression. Patalay and Demkowicz conclude that a person-centred approach that meaningfully engages with the reports of young women with depression (...) is more likely to expose the social drivers of depression that impact this group. This commentary focuses on Patalay and Demkowicz's call to examine the patient's lived experience. We argue that there is an urgent need to reflect upon the methodologies involved in examining lived experience and how they can be best utilised. Ultimately, we advocate for an approach known as ‘phenomenological psychopathology’, through a phenomenological investigation of depression in young women, we can go some way towards closing the gender gap. (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)

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)

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)

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: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)

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 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)

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)

This is a commentary on the article “The Empathic Migrant” (Aragona et al., 2020), in which the authors explore the experience of empathy in male African refugees and asylum seekers in Italy with a diagnosis of PTSD (N=20). In the publication cited by the authors, I theorise that empathy may be impacted in individuals diagnosed with PTSD. I am drawing on a thin, phenomenological notion of empathy as a pre-reflective mode of perception and argue that in some situations, traumatised individuals (...) may cease to experience the other as another subject that offers possibilities for interaction (Wilde, 2019; cf. Stein, 1917, p. 53). The Interpersonal Reactivity Index (IRI) administered by the authors suggests a different understanding of empathy. (shrink)

Traumatic experiences do not merely impact on the individual’s body and psyche, they alter the way we experience others, our interpersonal relationships, and how we make sense of the world. In my dissertation, I integrate work in phenomenology, psychopathology, philosophy of mind, philosophy of psychiatry, and trauma studies, and draw on trauma testimonies ob- tained in an online questionnaire. I engage analytically with the question of what constitutes a trauma, whether psychological trauma is necessarily pathological, and what the causal and (...) im- plicatory relations between traumatising and post-traumatic experiences are. Informed by these preliminary elaborations, I focus on the intersubjective dimension of trauma, drawing on a qualitative study I conducted in 2020. I show that empathic abilities may be altered but are not necessarily diminished through traumatising experiences; I suggest a framework for under- standing feelings of alienation in the aftermath of trauma; and I demonstrate how feelings of belonging may be re-established. My dissertation is exemplary of how phenomenological frameworks can contribute to a better understanding of psychological trauma and that engaging with trauma can, in turn, inform and enrich philosophical thinking. (shrink)

This paper presents a naturalist skill-based alternative to traditional function-based naturalist theories of mental health and disorder. According to the novel skill view outlined here, mental health is a skilled action of individuals, rather than a question of the functioning of mental mechanisms. Mental disorder is the failure or breakdown of this skill. This skill view of mental health is motivated by focusing on the process of mental healing. This paper argues that, when we start with a focus on how (...) and why individuals heal from mental disorders, we gain a better understanding of what mental health is: the exercise of self-regulatory metacognitive skill. (shrink)

The notion of belief appears frequently in cognitive science. Yet it has resisted definition of the sort that could clarify inquiry. How then might a cognitive science of belief proceed? Here we propose a form of pluralism about believing. According to this view, there are importantly different ways to "believe" an idea. These distinct psychological kinds occur within a multi-dimensional property space, with different property clusters within that space constituting distinct varieties of believing. We propose that discovering such property clusters (...) is empirically tractable, and that this approach can help sidestep merely verbal disputes about what constitutes “belief.”. (shrink)

Recent trends in psychiatry involve a transition from categorical to dimensional frameworks, in which the boundary between health and pathology is understood as a difference in degree rather than as a difference in kind. A major tenet of dimensional approaches is that no qualitative distinction can be made between health and pathology. As a consequence, these approaches tend to characterize such a threshold as pragmatic or conventional in nature. However, dimensional approaches to psychopathology raise several epistemological and ontological issues. First, (...) we review major sources of evidence usually recruited in support of the dimensional trend (focusing on clinical observation and biological data), and we show that these are connected to different conceptualizations of how dimensional traits extend across health and pathology. Second, we criticize two unquestioned assumptions that stand at the core of the dimensional trend: a) that there is continuity from health to pathology at the symptomatic level; b) that such continuity reflects an underlying continuity in the genetic liability for pathological conditions. Third, we argue against the idea of a conventional threshold by showing that such a view implies a linear relationship between the genotype and the phenotype. Fourth, drawing on epigenetics and developmental biology, we offer a characterization of mental disorders as stable and dynamic constellations of multi-level variables that differ qualitatively from ‘healthy states’. We conclude by showing that our account has several theoretical advantages over both categorical and dimensional approaches. Notably, it provides crucial insights into psychological development over time and individual differences, with major implications in terms of intervention and clinical decision-making. (shrink)

This paper aims to provide clear guidelines for researchers studying conspiracy theory belief. It examines the meta-linguistic question about how we should conceptualize 'conspiracy theory' and its relationship to the evaluative question of how we should evaluate beliefs in conspiracy theories, addressing normative issues surrounding the meaning, use, and conceptualization of ‘conspiracy theory’, as well as how these issues might impact how researchers study conspiracy theories or beliefs in them It argues that four norms, the Empirical Accuracy Norm, the Linguistic (...) Norm, the Social Norm, and the Academic Fecundity Norm, underlie debates about how we should conceptualize or define ‘conspiracy theory’. We zoom in on the linguistic norm, as it has been treated as more fundamental than the other norms. We then scrutinize the argument that normative conceptualizations prematurely settle the question of how conspiracy theories and belief in them should be evaluated, and argue that it fails. Subsequently, we turn to the risks normative conceptualizations pose when it comes to certain assumptions and biases in the study of conspiracy theory belief. Finally, we explore where this leaves us regarding the meta-linguistic and evaluative questions, and formulate seven guidelines for studying conspiracy theory belief, whether it be theoretical, historical, or empirical. (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)

Abstract:This article brings together considerations from philosophical work on standpoint epistemology, feminist philosophy of science, and epistemic injustice to examine a particular problem facing contemporary psychiatry: the conflict between the conceptual resources of psychiatric medicine and alternative conceptualizations like those of the neurodiversity movement and psychiatric abolitionism. I argue that resistance to fully considering such alternative conceptualizations in processes such as the revision of the Diagnostic and Statistical Manual of Mental Disorders emerges in part from a particular form of epistemic (...) injustice (hermeneutical ignorance) leveled against a particular social group (which I call the "psychopathologized"). Further, insofar as the objectivity which psychiatry should aspire to is a kind of "social objectivity" which requires incorporation of various normative perspectives, this particular form of epistemic injustice threatens to undermine its scientific objectivity. Although many questions regarding implementation remain, this implies that psychiatry must grapple substantively with radical reconceptualizations of its domain if it is to achieve legitimate scientific objectivity. (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: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)

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)

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)

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)

The aim of this virtual special issue is to bring together philosophical and historical perspectives to address long-standing issues in the interpretation, utility, and impacts of quantitative genetics methods and findings. Methodological approaches and the underlying scientific understanding of genetics and heredity have transformed since the field's inception. These advances have brought with them new philosophical issues regarding the interpretation and understanding of quantitative genetic results. The contributions in this issue demonstrate that there is still work to be done integrating (...) old and new methodological and conceptual frameworks. In some cases, new results are interpreted using assumptions based on old concepts and methodologies that need to be explicitly recognised and updated. In other cases, new philosophical tools can be employed to synthesise historical quantitative genetics work with modern methodologies and findings. This introductory article surveys three general themes that have dominated philosophical discussion of quantitative genetics throughout history: (1) how methodologies have changed and transformed our knowledge and interpretations; (2) whether or not quantitative genetics can offer explanations relating to causation and prediction; and (3) the importance of defining the phenotypes under study. We situate the contributions in this virtual special issue within a historical framework addressing these three themes. (shrink)

Se presenta una visión de la epistemología como lógica del pensar y se la lleva a una elaboración de la práctica clínica como una lógica del padecimiento psíquico. Esto basado en los planteamientos de Deleuze y Guattari. Para ello se toma como punto de partida la noción de los movimientos aberrantes que, leyendo la obra de Deleuze, elaboró David Lapoujade entendiéndolos como movimientos que se producen en la relación entre distintos términos heterogéneos, pero manteniendo su heterogeneidad. Esto es vinculado con (...) la invitación que hace el mismo Lapoujade a entender la obra deleuzeana como el desarrollo de lógicas irracionales, intentando pensar desde ahí una lógica de la locura y del padecimiento mental con base en, a su vez, una lógica de las obras literarias de Proust y Kafka, tal como las leen los mismos Deleuze y Guattari. En relación con ello destacamos, por un lado, cierta lógica de conjuntos abiertos y no totalizables que estos últimos autores encuentran en la obra de Proust y, por otro lado, una lógica de la contigüidad que encuentran en la obra de Kafka. Al mismo tiempo, se establecen puntos en común entre estas dos lecturas a propósito de lo esquizoide como algo que excede a la significación del discurso, así como a la normatividad de la conducta. Asimismo, en distintos puntos del escrito se extraerán las implicaciones que estos modos de pensar tienen para una práctica clínica en relación con modos de existencia subjetivos que se escapan a lo que está establecido en el campo social. De esa manera, ponemos en conjunción una aproximación epistemológica con una política. (shrink)

A lo largo de la tradición psicopatológica, incluso de la pre-fenomenológica, se encuentra la categorización del delirio como creencia. Jaspers asumió ese uso y lo fundó fenomenológico-existencialmente, definiendo su carácter de convicción. El concepto de creencia ha tenido un largo recorrido dentro de la historia del pensamiento, aunque recientemente se ha intensificado el debate acerca de la visión doxástica del delirio. En virtud de lo ya mencionado, en el presente artículo presentamos un análisis conceptual de la creencia, con el objetivo (...) de identificar de manera precisa los aspectos esenciales que permiten al delirio definirse según ella. De esta manera, se discutirán algunas de las principales incursiones realizadas en el concepto desde la antigüedad periplatónica hasta José Ortega y Gasset, remarcando en cada pensador las directrices esenciales de su aproximación a la creencia. A su vez, introducir al filósofo español al debate psicopatológico permitirá incluir en la discusión dos aspectos importantes que creemos pueden ser fructíferos para la discusión filosófica sobre el delirio: la diferencia entre ideas y creencias, y la vitalidad de estas últimas. Finalmente, hacemos referencia al actual debate pro- y antidoxástico, haciendo hincapié en la necesidad de considerar la amplitud del concepto de creencia en su genealogía histórica. Con base en ello estaríamos en condición de acercarnos a la visión doxástica moderada que han defendido autoras como Lisa Bortolotti. (shrink)

En el presente artículo realizamos un análisis del estatus ontológico de la noción de psicopatología que se deriva de cuatro aproximaciones metodológicas a su estudio, a saber: aproximación psiquiátrica, fenomenológico-existencial, constructivista-histórica y antipsiquiátrica. Por medio de una metodología de revisión bibliográfica sistematizada y siguiendo el marco de trabajo metaframework ReSiste-CHS (Revisiones Sistematizadas en Ciencias Humanas y Sociales), sostendremos que dicha noción presenta divergencias en al menos tres puntos: (i) la relevancia de la sintomatología como característica, (ii) la existencia o inexistencia (...) del sufrimiento psíquico y (iii) la relevancia de los factores sociales en su configuración. En el apartado introductorio abordaremos las consideraciones históricas generales relacionadas con el estudio de los trastornos mentales. En el segundo apartado nos referiremos a la metodología empleada para la realización del artículo. En el tercer apartado expondremos los rasgos fundamentales de las cuatro metodologías de estudio mencionadas anteriormente, dividiendo la descripción en los siguientes puntos: orientación, etiología, clasificación, diagnóstico y tratamiento. En el cuarto apartado contrastaremos los conceptos de psicopatología que pueden ser extraídos de ellas. A modo de conclusión, propondremos una sistematización de las condiciones mínimas que debe cumplir una noción de psicopatología que sea fructífera desde un punto de vista teórico y práctico. Estas condiciones incluyen un posicionamiento crítico ante los extremos reduccionista y relativista, la consideración del sufrimiento psíquico como rasgo constitutivo y núcleo fundamental de este género de experiencia, así como una dimensión ética relacionada con su abordaje. Por último, mostraremos algunas limitaciones y futuras directrices que se derivan del trabajo realizado. (shrink)

This paper offers an overview of the philosophical work on epistemic injustices as it relates to psychiatry. After describing the development of epistemic injustice studies, we survey the existing literature on its application to psychiatry. We describe how the concept of epistemic injustice has been taken up into a range of debates in philosophy of psychiatry, including the nature of psychiatric conditions, psychiatric practices and research, and ameliorative projects. The final section of the paper indicates future directions for philosophical research (...) of epistemic injustices and psychiatry, concerning neurocognitive disorders, identity prejudices in psychiatric illness, concepts of epistemic privilege in psychiatry, and the prospects for combining phenomenological psychopathology and epistemic justice. We argue that much remains to be done in the conceptualization of these epistemic injustices and suggest that this future work should be multidisciplinary in character and sensitive to the phenomenology of psychiatric conditions. (shrink)

This paper asks when a natural disease kind is truly 'reactive' and when it is merely associated with a corresponding social kind. I begin with a permissive account of real kinds and their structure, distinguishing natural kinds, indifferent kinds and reactive kinds as varieties of real kind characterised by super-explanatory properties. I then situate disease kinds within this framework, arguing that many disease kinds prima facie are both natural and reactive. I proceed to distinguish ‘simple dependence’, ‘secondary dependence’ and ‘essential (...) dependence’ between a natural kind and its classification, and argue that a natural kind is only really reactive, in an important sense, under conditions of essential dependence. On this basis, I offer a principled hypothesis for why psychiatric kinds tend to be more metaphysically unstable than paradigm somatic disease kinds. (shrink)

In painting portraits, artists used to subtly place objects which reflected the biography or ambitions of the subject, but it is only more recently that objects which were part of the everyday life of institutionalized individuals became themselves part of the narratives offered by historians and other scholars of psychiatry. Excavating these remains – and finding ways to listen to them – is part of telling a fuller story of the people who lived for many years in mental institutions, and (...) indirectly of madness as both part of medical science, and a figment of our culture. (shrink)

Abstract:Since the birth of autism as a psychiatric category, autistic individuals have been described as preoccupied with the world of objects and detached from the world of subjects, thus marking a distinction between the “social” and the “non-social” still prevalent in autism research and diagnostic criteria. The aim of this article is to question this distinction by examining the role of things in autistic forms of social interaction. Drawing on qualitative data from an ongoing qualitative and phenomenological study on social (...) interaction among youth with autism, I argue that material things enjoy a sustaining and facilitating role in autistic social interaction for two reasons: First, by being sensible things open to tactile, auditory, and visual engagement, and second, by being things that incorporate normative practices. This relation between the material and the social in which the latter is mediated by the former, is beneficial to individuals with autism because it exploits a particular relation to materiality to consolidate a shaky attunement to the social world. I propose a materially mediated mode of interaction guided by the approaches to perception, embodiment, and materiality developed by Maurice Merleau-Ponty and James Gibson. This account puts pressure on the phenomenological emphasis on the face-to-face encounter and brings intersubjectivity into view as a many-faceted phenomenon realizable not only through interbodily dynamics but also through the material landscapes situating social encounters. (shrink)

Tilmes concludes his interesting and informative piece with the sentence that “analysis of psychiatric vagueness merits further consideration.” I agree with this point, as well as with his earlier assertion that how one understands psychiatric vagueness may implicate the diagnostic model that one adopts, and the research that one pursues. Fortunately, there has been recent attention to vagueness in psychiatry, addressing both degree-vagueness and combinatorial vagueness.Vagueness in psychiatry is related to a range of nosological debates, including about the...

In “semantic vagueness in Psychiatric Nosology,” Nicholas Tilmes offers a conditional claim for further consideration. The conditional is that “if psychiatric vagueness exists, there is reason to think that some cases of it are at least partially semantic.” From this, some conclusions worth investigating follow. In this brief commentary I will set out a question Tilmes introduces by, like him, drawing on a paper by Miriam Schoenfield, which also examines vagueness as semantic, epistemic or ontic though she draws a contrasting (...) conclusion for her subject matter: moral judgment. Highlighting a supposed contrast between semantic and ontic vagueness will also highlight an issue for... (shrink)

Ithank the commenters for their insightful remarks, from which I have learned much. In my article, I sought to explain psychiatric vagueness, which arises in borderline cases where there is no fact of the matter as to whether a diagnosis rightly can be said to apply.1 I argued “if psychiatric vagueness exists, then some of it is at least partially semantic”. A semantic account holds that vague utterances express different propositions since small gaps in how linguistic communities apply terms modify (...) their referents, making their precise extension indeterminate.2 On my view, this best accommodates intuitions about the nature of conditions and explains historical changes in the application of... (shrink)

Both woody and Wharne provided insightful commentary on my view that survivors of trauma have a duty to repair any impaired natural powers caused by symptoms of trauma by seeking empirically informed treatment. While Woody agrees with the main aspects of my view, they disagree with the motivation for seeking treatment. Woody argues that the “helplessness” caused by symptoms of post-traumatic stress disorder should motivate survivors to pursue treatment. I disagree with this characterization and will discuss my concerns in the (...) first part of this reply.Wharne contends that the symptoms of PTSD should be characterized as understandable responses to trauma rather than deviations from normal experience. We should... (shrink)

Abstract:Many discussions in the philosophy of psychiatry hinge on, among other things, the concepts of disorders, the role of underlying mechanisms, and the merits of various diagnostic models. Yet, some such disputes rest on assumptions about vagueness in the sense of susceptibility to the Sorites paradox as opposed to mere uncertainty in clinical practice. Studying borderline cases of psychiatric conditions—those where it is indeterminate whether applying a diagnosis is appropriate—may shed light on broader debates about the nature and boundaries of (...) these conditions. In this article, I will argue that if psychiatric vagueness exists, then some instances of it stem at least partially from how we describe the world instead of the state of the world or what we know about it. In other words, vagueness in psychiatric terms and concepts is at least in part semantic and neither solely epistemic nor solely ontic. On this view, slight differences in how various linguistic communities apply diagnostic terms modify their referents, making their precise extension indeterminate. This implies that we can sometimes answer questions about diagnosis by settling disagreements about language, which may provide traction in debates about the philosophy of nosology and help inform psychiatric practice. (shrink)

Professor katie harster has considered the phenomenon of psychological trauma, bringing philosophical understandings into play. She provides an informed account of observed “symptoms,” and associated treatments. I comment as a counseling psychologist, although I do not specialize in the evidence-based treatments that she describes. Usually, in my work with clients, we are trying to make sense of what has happened, with a concern for what might happen in the future. I am grateful therefore to colleagues who have the expertise that (...) I lack. I recall a discussion with one of these colleagues, who suggested that, “If a house is on fire, your priority should be to put out the flames and you can worry about how it caught... (shrink)

Abstract:Most mental health conditions, though appropriate targets of treatment, do not generate a moral obligation to seek treatment. Trauma, in contrast, is caused (at least in part) by an external event that can happen at any point in the individual’s life. Survivors often experience diverse and enduring symptoms that adversely affect their cognitive, social, emotional, and physical functioning (American Psychiatric Association, 2013). These global impairments diminish an individual’s ability to respond appropriately to morally relevant reasons and stimuli. Fortunately, symptoms of (...) trauma respond well to treatment (Bradley, Greene, Russ, Dutra, & Westen, 2005). The external etiology and effectiveness of treatment allows us examine the moral duties of someone with impaired moral faculties due to trauma within a Kantian framework. The symptoms of trauma interfere with their ability to cultivate what Kant calls “natural powers” of spirit, soul, and body (DoV 6:444–6:445). Kant’s discussion of the natural powers implies that we must possess a baseline level of functioning in these areas in order to fulfill our moral duties (DoV 6:444–446). By Kant’s own reasoning it seems that individuals who experience impairments in any of the three powers are morally obligated to cultivate these capacities. Using Johnson’s (2011) discussion of Kant’s duties to self and careful analysis of available treatments for trauma, I argue that individuals who experience symptoms of trauma and suffer from impairments in Kantian natural powers have an imperfect duty to themselves to repair these powers through empirically informed trauma treatment. (shrink)

One must freely admit that there is here a sort of circle from which, so it seems, there is no way of escape. In order the order of efficient causes, we assume that we are free so that we may think of ourselves as subject to moral laws in the order of ends. And we think of ourselves as subject to these laws because we have attributed to ourselves freedom of the will. Freedom and self-legislation of the will are both (...) autonomy and are hence reciprocal concepts.Post-traumatic stress disorder stems from an overwhelming experience of complete helplessness. The traumatized victim has utterly lost all sense of agency. He or she may well dissociate from that helpless, passive self and become... (shrink)

Autism is a highly heterogeneous phenomenon. Not only is it difficult to understand the various and diverse aspects of autism, their relation to each other is also complex and still poorly understood. In my article, “Material encounters. A phenomenological account of social interaction in autism,” I have addressed this heterogeneity by presenting an understanding of how social features of autism relate to behavioral features. Straddling this divide between the social and the non-social that still pervades much thinking in philosophy, psychiatry, (...) and psychology is crucial for understanding the diverse experiences of autistic persons and... (shrink)

Is autism a condition internal to the person that causes problems in social interaction? Or should we conceive of autism primarily at the level of interaction, as a “two-way” phenomenon that develops in the relation between the person with autism and her social-material environment? Over the last decade or so, this issue has increasingly gained interest, not only in academia, but also in the field of mental health care and in the wider public domain.Much is at stake here. Framing autism (...) as an internal deficit or rather as an interaction phenomenon has far-reaching implications for scientific research and clinical practice. It steers the focus of autism research by determining the kind of... (shrink)