Philosophy, Psychiatry, & Psychology

Fulford and Colombo's pioneering work (2004)in linguistic analysis offers valuable insights and 'deconstructs' the often inter-related concepts of mental disorder and treatment. Their paper describes a combined philosophical and empirical research program developed to study "the role models of disorder in the community care of people with long-term schizophrenia" (2004, 130). They claim that the approach supplies a key explanatory insight into the nature of the problem presented by models of disorder, a characterization of models, contributions to research design, a theoretical framework—a 'models-grid,' and a basis for turning theory into practice. These claims are not unreasonable in the context of the specific objectives of the research design, but do not necessarily cover everything of importance in the way models are used to describe mental disorder. In particular, this brief response proposes the need to develop an understanding of psychiatric Dasein—mental disorder as presented in the world.

Fulford and Colombo are surely right in their claim that representations of mental disorder are high-level concepts not dissimilar to other high-level concepts such as time. These are concepts that we seem to have little difficulty using in day-to-day practice but have great difficulty defining. In their discussion of this point, they suggest that little progress has been made in relation to models of mental disorder over the previous fifty years, that there is a considerable volume of theoretical literature that has had little impact on practice.

This assertion does not appear to do justice to the significant progress that might be argued to have occurred in psychoanalytic theory, psychodynamic therapy, and other metapsychological developments of the last fifty to one hundred years. Many of these developments have changed markedly our perceptions of mental disorder. Some treatments, it is true, may not have direct relevance or applicability to serious psychotic behavior, although that is contentious; there are psychoanalytic psychotherapists working with people with schizophrenia who would claim success. Recent developments in cognitive-behavioral therapy allied to other treatment modalities, such as careful use of low-dosage medication, have had therapeutic impact in enabling people with schizophrenia to 'manage their voices' and to understand the complex nature of their own thought processes.

Fulford and Colombo also suggest that after this half century of work much of the development of practice has been largely abortive. Is this correct? It is true that we continue to struggle with an understanding of what we mean by mental disorder, which is made much worse, as the authors say, by the multiplicity of definitions of mental illness, models of mental disorder and practical approaches to treatment and management. Multidisciplinary and multi-agency developments of the last twenty years especially have, on the one hand, been a powerful approach to recognizing the multifaceted nature of mental disorder, but, on the other, have tended to a potential fragmentation of effort that has undermined [End Page 147] the necessary focus on the needs of the individual patient.