In lieu of an abstract, here is a brief excerpt of the content:Could Understanding Harm?Iskra Fileva, PhD (bio) and Linda A.W. Brakel, MD (bio)We would like to thank the editors for organizing this symposium and our commentators—Marga Reimer and James Phillips—for the thought-provoking feedback. Although we had thought about the ideas we discuss from many different angles, our commentators raised several interesting issues we had not considered. We are grateful for the opportunity to continue the conversation.Reply to ReimerAs Professor Reimer (...) notes, we advocate an approach to self-constitution that we dub “understanding first.” On this approach, non-moral and non-normative understanding of the origin of maladaptive traits must precede moral evaluation and attempts to free oneself—or as we say “prune”—undesirable traits. Professor Reimer presents several interesting cases meant both to extend and test the limits of our proposal. We appreciate this approach and respond to each case in turn.Genes and AlcoholismSuppose Alejandro, an adult raised by adoptive parents, struggles with alcohol addiction. He learns that his biological parents died of alcoholic liver disease and comes to believe that his alcohol problem is caused by a genetic propensity toward alcohol abuse. One can ask: “Does an understanding first approach have the potential to undermine the sense of agency that is necessary for the effective treatment of maladaptive traits?”Answer: It can be explained to Alejandro that genetic proclivities are just that—proclivities—that can be overridden. In fact, behavior can alter our very genes—although not at the sequence level— changes known as “epigenetic.” And the liver disease of the biological parents can serve as a cautionary tale. If even in light of these considerations, Alejandro’s tendency to see genetic propensities as deterministic persists, it is worth asking why. There is no evidence that “genes are destiny,” so the disposition to see them that way must have a psychological explanation. What is the explanation? A self-destructive desire? Fear of freedom? This exploration can itself be empowering. [End Page 211]Adaptive ForgettingSuppose Beata, who has an eating disorder, was molested by her own father when she was a child. Subsequently, her father shot himself and now she has no recollection of the molestation. However, Beata’s eating disorder is largely a result of those experiences. It is quite possible that if Beata were to recall being molested, that would do more harm than good. In this connection, one can ask together with Reimer: “Does an understanding first approach have the potential to undermine an adaptive ‘forgetting’ of root causes of maladaptive traits?”Answer: Here, understanding the history, instead of forgetting it, might allow Beata to gain insight into and empathize with possible motives that may have led to becoming obese. For example, she might have the phantasy that if she had been obese and unattractive, she could have prevented the molestation—hence, become that way now to prevent it from happening again, and more wishfully reverse it. (In unconscious goings-on time is thought to be in the “unexamined present” (Brakel 2009, p. 63; 2015, p. 131; 2022, p. 4; 2023, p. 404.) One benefit of this is that in gaining this type of recognition, Beata might find it easier to change her behavior that she otherwise would not have; it was never her responsibility to prevent her own molestation, and there is no reason whatsoever for her to now make herself unattractive to her deceased father, and very little reason to remain obese in an attempt to deter current day men.Ego-Syntonic Maladaptive TraitsClaire is a concert pianist and alcoholic. Importantly, Claire does not see her own desire for alcohol as destructive but rather, as something constitutive of her own identity. “I wouldn’t be myself without alcohol,” she says. Reimer asks whether our approach would “work for cases where the agent sees a maladaptive trait as constitutive of their identity?”Answer: Although no approach can guarantee success, our claim is that our approach has a better chance than the main alternative known as the pruning view. Since Claire, by stipulation, is not inclined to see her own drinking as a problem, a... (shrink)

In this paper, we criticize what we dub the “pruning view” of self-constitution, championed widely by philosophers, mainly though not exclusively in the Kantian tradition, and instead defend an alternative view inspired by psychoanalysis. We argue that normative assessment comes much too early on the pruning view, so early that it interferes with achieving deeper self-understanding that can produce lasting change. On the proposal we advocate, self-constitution must begin with a non-moralizing attempt to truly understand why one has undesirable and (...) unwanted propensities. We call this the “understanding first” principle. Only after deeper self-understanding has been achieved are attempts to liberate oneself from unwanted elements likely to succeed. (shrink)

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

In lieu of an abstract, here is a brief excerpt of the content:Philosophers, Carers, and Psychodramatic GamesCorinne Gal (bio), Alexandre Chapy (bio), Marielle Fau (bio), and Muriel Guaveia (bio)Dear Jonathan D. Moreno,Thank you for the honor of taking the time to comment on the work we do. It is very meaningful for us to be able to talk with you.We, too, see a big difference between philosophers and carers (in the broadest sense) who deal with the suffering of patients and (...) try to find methods to help them. But, if theory is at the service of the clinic, it becomes a formidable asset to refine our therapeutic methods and better understand what is happening to our patients.Indeed, patients suffering from psychosis, severe neurosis … are difficult to accompany and “recalcitrant to therapy by word alone” to use your terms. It is on this point that Ludwig Binswanger distanced himself from psychoanalysis. Binswanger ran a sanatorium in Switzerland (the Bellevue Clinic) and took in patients suffering from this type of psychological pathology. Aware that “the divan” and the analysis of the transference (unconscious) made little progress, he sought other ways of understanding his patients. The work of Edmund Husserl, the founder of the phenomenological movement, and then the work of Martin Heidegger1 fascinated him because they attempted to answer fundamental questions about being. The patients we work with ask themselves and us the same question: What is being? How can we feel existence within ourselves? Binswanger then created daseinsanalysis as an analysis of existence in which he was able to develop, among other dimensions, what he called “artists’ gestures,” including the possibility of (physical) contact with the patients. The body regained existential importance in the therapy.There are also strong similarities between psychiatric phenomenology and the work of Jacob Levy Moreno (2014, p. 214). We would like to quote your work: “ Nonetheless, there were links between them. Heidegger and J.L. shared preoccupation with personal authenticity and meaning [End Page 230] just enough to be considered part of the trends that led to postwar existentialism and fueled the new humanistic psychology, NTL, and encounter groups.”Jacob Levy Moreno’s working methods are much more powerful, allowing us to work as closely as possible with bodily feelings, since the body involved in the action is so present in psychodrama. Because, to this question of being posed by our patients, is linked the body as a felt, sensing body: the body that I am (which differs from the object body). Schizophrenic patients often express, and this is a terrible suffering, that they no longer feel anything, that they no longer feel they exist, that they no longer feel emotions or feelings. They do not know how to be in the world and with others. For us it is a fundamental symptom, as much as hallucinations. We link it to the loss of natural evidence (Blankenburg, 1991), the loss of contact with reality (Minkowski, 1929). Most of the time, in psychodrama, we “externalize” what the patients feel in different roles played by players, which allows us to work at the heart of each person’s difficulties in interaction. Trained in psychodrama by Anne Ancelin Schützenberger, we have to our credit a set of techniques to support the expression of psychodramatic play, a sort of “toolbox.” Depending on the context, the moment of the patient, our own state, we open our toolbox and try to choose and use the technique that best fits the needs of the game, of what we understand about the difficulty of the protagonist or the group. We do not do anything systematic, we are craftsmen. We have chosen to present a very simple game, without any technique used, except for the initial soliloquy, with a stabilized patient suffering from paucisymptomatic forms of schizophrenia. This is to demonstrate how the possibility of encounter, constitutive of existence, is a fundamental dimension of psychodrama.We thank you for the examples you have given us, they will be a source of inspiration and will fill our toolbox.To John Nolte:We thank you very much for your comments which honor us.The aim of the article was to present how the encounter in... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:“What Is Actually Being Measured?”: Causality and Underlying Scientific Thinking Process in the Assessment of DepressionGreta Kaluzeviciute-Moreton, PhD (bio)Depression is a complex mental health phenomenon due to its multifaceted nature. For one, depression is thought to have a significant genetic component, with studies suggesting that heritability is a significant factor in the development of the disorder (Sullivan, Neale, Kendler, 2000). In clinical psychology, environmental factors such as childhood trauma, (...) chronic stress, social isolation and negative life events (e.g., the loss of a loved one) have been documented as significant risk factors for the development of depression or as trigger events for depressive episodes (Fu & Parahoo, 2009; Kendler, Kuhn, & Prescott, 2004; Neitzke, 2016). Despite this, causal theories of mental health conditions are often tricky and/or scarcely reflected in both diagnostic and rating scales. For instance, the Diagnostic and Statistical Manual of Mental Disorders classifies mental health disorders primarily based on observable symptoms and behaviors, rather than on the underlying psychological and neurobiological processes that may contribute to these symptoms (Kendler, 2006).Similarly, rating scales for depression are typically designed to assess the severity of symptoms, rather than their underlying causes, that is, most rating scales are used as screening tools to identify individuals who may require further evaluation and treatment. Some rating scales may include items related to causal factors, such as the Beck Depression Inventory-II (BDI-II) includes an item that asks about “loss of interest in sex,” which could be related to either biological or psychological factors. Several rating scales include items assessing risk factors for depression, such as family history of depression or personal history of trauma. This may be indicative of both genetic and environmental risk factors, such as the Patient Health [End Page 255] Questionnaire-9, includes an item that asks about family history of depression. However, while risk and causal factors are related, they are distinct in the assessment of depression. Risk factors refer to factors that increase the likelihood of developing depression, while causal factors refer to factors that directly contribute to the development of the condition. The presence of a risk factor does not necessarily mean that an individual will develop depression (Peterson & Seligman, 1984). However, the two are frequently blurred and equated in psychotherapy research (Westen & Bradley, 2005).As such, the historical issues of rating and diagnostic scales, aptly depicted by the Le Moigne (2023) as full of “composite, if not contradictory, heritage, weaving together the classificatory and discontinuous tradition of psychiatry, on the one hand, and the psychometric and continuous tradition of psychology, on the other” (p. XX ), suffer from an epistemological oversight when it comes to the assessment of causal factors in complex mental health conditions, such as depression. In turn, this contributes to a wider psychometric issue: what is actually being measured? Le Moigne’s detailed overview predominantly focuses on “superficial” symptomatology of depression (which contributed to two distinct forms of evaluation: hetero- and self-evaluation), and its subsequent impact on the classification and taxonomy of depression throughout history. However, the overarching conceptualization of depression (including a more detailed consideration of causal factors and their assessment) and the usefulness of rating scales in applied research (such as psychotherapy) remain in the background.The question of “what is actually being measured” is obviously not new in psychometrics. However, it is important to continuously revisit this issue, given that rating scales (such as the BDI) are considered to be universally applicable “evidence-based” tools (Rogers, Adler, Bungay, & Wilson, 2005) as well as a common and well-accepted form of scientific thinking in psychotherapy research (Kaluzeviciute & Willemsen, 2020). From an epistemological point of view, a scientific thinking style entails not only cognitive operations common to methodology, but also practices of generating, sharing, assimilating and transforming knowledge(Hacking, 2012).Therefore, it is important to acknowledge that any scientific tool, including rating scales, encompasses not just what but also how researchers find out about their studied phenomena (i.e., a scientific thinking style conveys a performative quality) (Kaluzeviciute & Willemsen, 2020). As identified by Le Moigne (2023), taxonomy leads toward a category-based logic in that it considers the examined phenomenon to be shared by only a... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Close Enemies: The Relationship of Psychiatry and Psychology in the Assessment of Mental DisordersPhilippe Le Moigne, PhDAs Peter Zachar rightly points out in his comment, the assessment of mental disorders underwent new developments with the release of the Diagnostic and Statistical Manual of Mental Disorders-V in 2013 (American Psychiatric Association, 2013). Whereas in 1980, the manual had been thought of in a rigorously categorical way, on the basis of (...) distinct and closed syndromic entities, this new version advocated the development of a radically dimensionalist approach, with the diagnosis aiming this time to restore the whole symptomatological picture of the patient on a spectrum of ratings are supposed to cover the entirety of psychiatric semiology (American Psychiatric Association, 2013).For its part, my article aimed to show how standardized assessment, guided by the return of psychiatry’s authority and the assertion of its legitimacy in the diagnostic field, gave the ascendancy in the 1980s to the classificatory tradition and thus to the categorical model, to the detriment of personality approach and test psychology which offered a competing solution here. This perspective, historically dated, may have led the reader to think that there is an antagonism that cannot be overcome here. Rather, it should be seen as a form of structuring opposition, or even a “complementarity inscribed in rivalry,” between psychiatry and psychology, which is naturally susceptible to change over time.Indeed, the reversal operated by the Diagnostic and Statistical Manual of Mental Disorders-V is not total because it cannot be total. The defense of the dimensionalist approach, dear to the psychological testing tradition, was intended here to allow the identification of co-morbidities, present in most patients but poorly apprehended by the categorical approach, and to open up diagnosis to prevention by screening for minor manifestations of psychopathology when they suggest the [End Page 259] development of a manifest episode of the disease in the more or less long term. The risk here is that we end up with overdiagnosis and thus an over-representation of false positives (Wakefield, 2015). In other words, this type of approach does not escape the obligation to determine threshold scores, likely to indicate the lower limit of the disorder, and thus to resort to a categorical approach. There is a first affinity between the two perspectives which obeys, beyond the divergences in principle, a technical requirement.But the two approaches have even more in common when we look at their epistemological background: they share the idea that the representation and the intervention on mental disorder, to use Ian Hacking’s expression (1983), must be based on the model proposed by the physical and natural sciences. And as Greta Kaluzeviciute aptly points out in her comment, this orientation leads to the idea of measuring mental disorder in particular to conduct elaborate quantification operations to determine, for example, whether two entities are statistically distinct or whether a drug has a significant effect on the evolution of a pathology.This is in fact an old question that can be formulated as follows, to use the expression of the psychometrician Joel Michell (1999): are psychological dimensions metric? In other words, if we want to apply the language of numbers to mental disorders, they must share its properties, two of which seem essential: it must be possible to establish that each mental disorder, in the same way as qualities attributable to length for example, has a zero and can be divided by means of gradients (or degrees of intensity) whose interval is constant (Le Moigne, 2018; Michell, 1999). For lack of space, let us only address the second condition. This one has already been denied by many, starting with Bergson at the end of the nineteenth century (1889). He does not believe in the quantification of psychological expressions, starting with sensations. What is the common point, he wrote, between the feeling of a mild pain, as one feels a stiffness, and the sensation of a needle being hammered into your flesh? For him, one and the other of these intensities are incomparable, so that they do not belong to a similar register of sensations that one could stage from a 0 toward a... (shrink)

This article discusses the way how change in depressed patients included in clinical trials was both conceptualized and measured in the 1970s to decide on the efficacy of the first candidate drugs for the treatment of depression. Understanding how this issue was resolved is of major interest as the protocol designed to distinguish the diagnosis of the depressive syndrome from the measurement of its evolution over time built the contours of the methodological device to which the whole of standardized evaluation (...) in psychiatry has since referred. This paper draws on the debates in nascent psychopharmacology in both the United States and Europe and examines the protocols and findings of the research programs on depression the National Institute of Mental Health (NIMH) has developed in the United States at the same time, as well as on the writings of the main authors of the standardized evaluation. This investigation suggests that measurement of patients’ improvement could not be characterized on the basis of psychiatric inventories that were not well-suited to quantification, nor on the basis of psychometric tests which were intended for the evaluation of psychological invariants. This is why the answer given to the characterization of change in depression under therapy rather reveals a syncretism both conceptual and technical, mixing classificatory and psychometric traditions, a syncretism that the distinction endorsed by the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition,between syndromes and personality disorders no longer allows us to perceive. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Notes on Psychodramatic Treatment of a Person with SchizophreniaJonathan D. Moreno, PhD (bio)I have enjoyed reflecting on Mr. Chapy’s account of work in psychodrama with a patient with schizophrenia.Although at one time many years ago I was interested in phenomenological psychiatry, and especially the writings of Ludwig Binswanger and Medard Boss, I am not an authority on dasein-analysis, so I have nothing to add to the discussion. I should (...) say, however, that my father had little interest in this approach, which was far too abstract for his taste. He proceeded from the standpoint of the theater, of action and enactment. He believed that the drama itself provided the insight.For the purposes of this response, I take it as a given that the patient in question has been accurately diagnosed, although in the description of the scene with his father he does not exhibit the usual symptoms, such as auditory hallucinations. People with schizophrenia often find it difficult to manage the voices they are hearing without substantial preparation for a psychodrama. According to psychodramatic method, one way to prepare them is to externalize the voices, allowing a different therapist to take the role of each one as the protagonist instructs them how to play that role. Chair may be set up so that each “voice,” personified by an auxiliary ego, can sit in each chair in an array. This preparation may require a number of sessions. If the scene is to be enacted with a significant other, like the father in this instance, the patient may not be able to warm up to a direct encounter, especially with all the different voices competing for his internal attention. So he may be directed to observe each voice in the encounter with his father, preferably played by a therapist of his choosing and trained for the role, usually by giving the father-player certain lines so that they can learn something about the father and the way he addresses his son.Or consider the patient whose illness manifests itself as delusions, often of a megalomaniac character. They may be a messiah, for example, or the rightful heir of a royal line whose identity is being suppressed by governmental forces. The patient might be invited to choose key therapists to play the roles of key members of their circle, [End Page 225] enacting critical scenes like the sermon on the mount or speeches to their oppressed followers. In this way the patient’s “act hunger” may be to some degree satiated and have a calming effect on their anxiety and irritation with the frustrating world around them that refuses to accept their “authentic” identity and belief system.In these ways, psychodrama therapy can take advantage of one of the remarkable advantages of this method for such patients, who are generally recalcitrant to talk therapy alone and for whom medication is at best modestly effective. Still, these disorders are among the most challenging for psychotherapists. Although the process of treating them may open up insights into the nature of the human mind, as Chapy has pursued in this paper, we await the neuroscience that can affect the kind of long-term remission they and their families so desperately wish. [End Page 226]Jonathan D. MorenoUniversity of Pennsylvania [email protected] D. Moreno Jonathan D. Moreno is a philosopher and historian who specializes in the intersection of bioethics, culture, science, and national security, and has published seminal works on the history, sociology and politics of biology and medicine. He is an elected member of the National Academy of Medicine.submitted on January 27, 2023Accepted on January 30, 2023Copyright © 2023 Johns Hopkins University Press... (shrink)

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

In lieu of an abstract, here is a brief excerpt of the content:The Limits of Self-ConstitutionJames Phillips, MD (bio)I am in general agreement with the authors that a psychoanalytic or psychodynamic approach is a good response to simple pruning procedures. That said, however, I do have questions about how they develop their argument.I was surprised at the very notion of pruning, and quite surprised that it is as popular as the authors suggest. The idea that Pete should deal with his (...) inappropriate outbursts by erasing or pruning that aspect of his personality seems so ridiculous that it beggars belief. It leaves one wondering whether Pete, or anyone agreeing with this argument, is credulous enough to think you can just prune away an undesirable part of yourself.The authors write:Importantly, this expulsion is often thought to be a good thing not simply because the undesirable elements are morally wanting but because in some important sense, they are not really a part of the agent proper. This point many seem extravagantly wishful, but is intuitively plausible.Really, “intuitively plausible” that personality traits are not part of the agent? I can understand that the agent may not grasp his or her involvement in the undesirable trait, but to argue that the trait is in reality not part of agent is a very odd claim on the part of the authors.When the authors write that “It would be difficult to exaggerate the prominence of the pruning view of agential self-constitution in philosophy,” they are strongly connecting the notions of pruning and self-constitution. I am aware that self-constitution is a major theme for philosophers like Korsgaard. The authors strongly embrace this principle in drawing out their arguments.In a footnote to their article the authors claim that various notions of a “true self” imply a pruned self. For Winnicott, an originator of the “true self,” this note of pruning does not hold. Winnicott contrasts the true self, a sense of self based on spontaneous authentic experience and a feeling of being alive, with a false self, a defensive veneer without the vivacity of the true self. The notion of pruning simply does not belong in this discussion.What the authors and their supporting philosophers leave out are two limitations to self-constitution. For the first, let me invoke another philosopher, Martin Heidegger, and his notion of “thrownness”—Geworfenheit. We are “thrown” into the world in the particular circumstances of our birth. We do not self-constitute our beginnings; we are plunged into them. The question then becomes what we make of these beginnings. [End Page 209] If they are undesirable, we can brood over them, or we can attempt to overcome them. And as we all know, if the beginnings are bad enough, we may not be able to overcome them.The second limitation to self-constitution resides in the “self.” Does the individual constitute him or her self, or is it more a matter of the self developing out of dialogic relationship of self and other? Here I invoke another philosopher, Paul Ricoeur, who has addressed this issue from a number of perspectives. At a deictic level, the “I” or the self is a shifter that takes on a different meaning depending on its context. At the level of pragmatics, the individual is engaged in illocutionary speech that is addressed to another person, implying, in simple terms, that we live in dialogue. Still more pertinent to this discussion, Ricoeur notes that self-knowledge is not straightforward: “the self does not immediately know itself, but only knows itself indirectly by way of the detour through the cultural signs of all sorts that make us say that action is symbolically mediated” (Ricoeur, 2016, p. 240). And finally, Ricoeur argues for the priority of alterity over reflexivity. “Pushing further yet the primacy of alterity over reflexivity, some will emphasize the dependence of personal identities on identifications with... heroes, emblematic characters, models and teachers” (p. 248). To clarify this statement, Ricoeur is contrasting self-constitution through reflection with a self-other relationship in which the self needs the other to constitute itself—and, of course, he is making a case for the latter.Although I am questioning the authors’ concepts of... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Diagnostic WannabesJennifer Radden, PhD (bio)Saunders explores challenges for the clinician faced with self-styled sufferers from attention deficit hyperactivity disorder, post-traumatic stress disorder, bipolar disorder, autism spectrum disorder (ASD), and fibromyalgia. The diagnostic system was not meant to be used as “a scaffold for identity,” she points out. Yet wannabe patients now step into the clinic wielding self-proclaimed diagnoses as social identities. Saunders explains the context where such phenomena arise, (...) and offers guidelines for clinicians addressing this new reality. To do so, she enlists Rashed’s innovative normative approach to the so-called boundary problem of assigning, and providing justification for, the contested line between normal and disordered. The boundary problem itself seems to rise to prominence during our current era of increasingly dimensional thinking, it is worth noting, with psychiatric diagnoses taken to refer to points on a continuum, rather than to discrete categorical disease entities.On the likely sources of these ‘diagnostic’ social identities, as well as reasons why certain diagnoses attach to them more commonly than others, Saunders points to social trends (including what she asserts to be a “post-stigma” cultural environment), the failure of efforts to identify neurobiological markers for psychiatric disorder, the ubiquity of social media, the algorithms themselves, and the hyperconnected existence of contemporary times. Such narratives also offer the comforts of a sense of belonging and explanations for perceived inadequacies, she rightly observes.Despite today’s virtual and other inducements, the problem introduced here is not an entirely new one. The first part of the seventeenth century in Europe saw an apparent “epidemic” of what was known as “melancholy,” a condition associated with the spleen, whose symptoms loosely resembled those of today’s depression and anxiety. Much of this suffering was undeniably real, but much was a fashionable, identity-conferring pose. “Every distemper of the body now is complicated with spleen,” the poet John Donne ironically observes in a letter dated 1622, “and when we were young men we scarce ever heard of the spleen. In our declinations now, every accident is accompanied with heavy clouds of melancholy”1 (Gosse, 2019). By then, the Melancholic Man (or homo melancholicus), with his surfeit of spleen, was an unmistakable character type—or social identity, as we would now say. Recognized and saluted in centuries-long literary and illustrative traditions, the type was an anchoring element of the humoral medicine which, despite the gradual emergence of more empirical science, had endured since Galenic times.Melancholy’s closest descendants, affective depressive and anxiety disorders, are today less evident among the troubling identities Saunders discusses—somewhat preempted, she points out, by more cognitively-based diagnoses such as ASD. [End Page 279] This is itself an ironic reminder of the vagaries of cultural attitudes, cautioning us to remember the broader context where these particular social identities are selected for emulation and adoption.The lure of the melancholy man’s2 social identity is well understood: already normalized, within the humoral system in which excess black bile afflicted roughly one in four people, it had been valorized for centuries—arguably by Aristotelian writing (in the dubious ‘Problems’), during the Renaissance by Ficino, and Shakespeare—even by Freud in his 1916 ‘Mourning and Melancholia.’ Through most of Western history, the positive attributes and benefits of the dark moods of melancholy have needed no further explaining or justifying. They glow with glamorous associations.Applying Rashed’s conditions for appropriately acknowledging and recognizing the fit of a person’s chosen social identity, Saunders‘ guidance for clinicians clarifies boundary matters. And it illustrates how to understand, regulate and communicate the appropriate norms in ways that can dissuade those whose personal growth and mental health are not served by claiming such identities.With at least some of the popular social identities Saunders describes, I think we can helpfully continue the comparison with the homo melancholicus. For the ‘neurodiversity’ rhetoric of our own times contains forces promoting both the normalization and the valorization of syndromes such as ASD. Pointing to analogies with differences of gender, ethnicity and culture, neurodiversity theorizing argues for a respect for, and appreciation of, difference. Mental or cognitive variations are equally natural and valuable, it is... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Understanding First: Exploring Its Scope and Testing Its LimitsMarga Reimer, PhD (bio)I thoroughly enjoyed reading and reflecting on this provocative, engagingly written, and persuasively argued paper. My commentary focuses on the authors’ “understanding first” principle. I begin by exploring that principle’s scope by appeal to aesthetic analogues to the moral cases of Pete and Jacob; I then explore its limits by appeal to cases involving agents struggling with maladaptive (...) traits that are more self-destructive than antisocial.According to the authors, when attempting to eliminate or reduce a maladaptive trait, it is important that the agent begin with a non-moralizing understanding of that trait’s “root cause.” In this way, the agent avoids some of the epistemically distorting and otherwise counterproductive effects associated with an approach that begins with a moralizing assessment of the problematic trait. They can then proceed with a reason-based “dispensation” of that trait.The cases of Pete and Jacob make these points vivid and lend them considerable credence. Moreover, the authors’ “understanding first principle” arguably exemplifies a more general, and no less plausible, principle concerning the remediation of virtually any problem. Who would deny that an objective, non-normative, understanding of a problem’s “root cause” might be useful in addressing that problem? Who would deny that normativizing a problem before understanding its origin might prevent a deeper understanding of that problem and therewith its maximally effective “treatment”?One way to showcase the intuitiveness of the authors’ “understanding first” principle would be to explore the applicability of an analogous principle to problems beyond those involving “moral matters.” Problems involving aesthetics might prove particularly illuminating in this regard insofar as aesthetics, like morality, is inherently normative and yet it lies beyond the scope of morality proper. If an “understanding first” principle can be shown to be applicable to certain types of aesthetic problems, then the authors’ already strong case for the applicability of such a principle to certain types of moral problems would be further strengthened.In the cases of Pete and Jacob, the problems are unambiguously moral: the patently antisocial behaviors of these two individuals are paradigmatically “bad” and their premature assessment as [End Page 205] such can be epistemically distorting and otherwise counterproductive. Consider now analogous cases involving aesthetic problems. Pete and Lucie are getting ready for the holidays and are expecting family from out of town. But there are a couple of problems. Pete notices an “ugly” stain on the living room carpet and Lucie notices a subtle but decidedly “nasty” odor permeating the entire house. Neither Pete nor Lucie know where the stain came from, nor where the odor is coming from. But both the stain and the odor are “pretty gross” and so they need to “get rid of” them before family arrive. There’s no time for investigative work into “root causes.”Pete scrubs the stain until the portion of carpet beneath it is threadbare; Lucie buys three different deodorizers, all of which eliminate the odor but only temporarily. Had Pete and Lucie understood the root causes of the “ugly” stain and “nasty” smell, their treatments might have been different—and, importantly, more effective. The stain turned out to be caused by red wine, easily treatable without leaving a noticeable “bald spot.” The lingering odor was from an easily fixable plumbing problem, albeit one requiring more extensive (and costly) work.Pete and Lucie’s aesthetic evaluations (“ugly,” “nasty”), coupled with a lack of understanding of “root causes,” have predictable results: their control over some “pretty gross” problems is significantly diminished. Similarly, with respect to moral evaluations of maladaptive traits (“bad,” “wrong”) coupled with a lack of understanding of “root causes.” As the authors show, such evaluations can be epistemically distorting and otherwise counterproductive with the result that the agent’s control over the problematic trait is significantly reduced.Further aesthetic analogues are easy to develop and potentially even more revealing. Imagine that Pete and Lucie, who are expecting family later in the week, are experiencing symptoms, both respiratory and gastrointestinal, that are “kind of yucky.” As with the maladaptive traits of Pete and Jacob, the problematic traits in this case are literally “in” the agent (vs... (shrink)

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

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

In lieu of an abstract, here is a brief excerpt of the content:Past, Present—and Future Perfect?Taking Psychiatry Beyond Its Single Message MythologiesK. W. M. Fulford (bio)I am grateful to John Sadler and his colleagues for their generous invitation to contribute to this collection marking Philosophy, Psychiatry, & Psychology (PPP)'s thirtieth birthday. True to our editorial tradition of "no nonsense" publishing, the "ask" was a reflection on PPP's past, present and future, limited to 500 words. In fact, one word does it (...) for me—collegiality.Collegiality was our watch word from the start. I still treasure a group photo taken at an early pre-meeting of the Association for the Advancement of Philosophy and Psychiatry (AAPP) convened by Michael Schwartz at his home in 1992, when, among other initiatives, PPP was conceived through transferring our then-nascent journal proposal from a small British publishing house to its current international publisher, the Johns Hopkins University Press. Michael and I had met earlier by phone when he had called the Royal College of Psychiatrists in London to enquire about its recently launched Philosophy Group and (by mere chance) I happened to be standing next to the person who took the call! PPP, with John and myself its founder editors, was subsequently born as, and has remained, a joint venture between our two groups: and Peter Zachar's recent initiative in building closer links with the International Network for Philosophy and Psychiatry (INPP) has taken us an important step towards the vision shared by Michael, John and myself that PPP should grow to reflect and represent a global open society of philosophy and mental health.As a pointer to the future, this global open society was no mere utopian vision but a joint commitment to what we conceived as a necessary ambition. Contemporary disenchantment with the repeated failures of translation of current narrowly empirical models of psychiatry, points to the truth of our German colleague, Paul Hoff's, characterization of the history of psychiatry as a history of serial collapses into single message mythologies. This disenchantment might seem to offer an opportunity for colonial expansion of philosophy into psychiatry (a re-assertion, perhaps, of phenomenology?). But PPP was born out of the "decade of the brain" and has remained throughout an ally of, not competitor to, the neurosciences. [End Page 3] So, while it is true that, with Peter's initiative, and with editorial and other innovations introduced by John, PPP is actively extending its reach (to new areas of philosophy, and to new voices, informed notably by experience as well as by training), this expansion remains a collegial not colonial enlargement of the field. I need hardly point to the challenges presented by the inclusive ambitions of such enlargement (not least to maintaining the highest standards of editorial and peer review). But PPP's collegiality provides the foundation for the work needed to deliver on these challenges. Even if imperfectly realized, this collegiality will help to take us beyond the single message mythologies by which our discipline has too long been hobbled. [End Page 4]K. W. M. Fulford K.W.M. (Bill) Fulford is a Fellow of St Catherine's College and Member of the Philosophy Faculty, University of Oxford; Emeritus Professor of Philosophy and Mental Health, University of Warwick Medical School; and Founder Director of the Collaborating Centre for Values-based Practice, St Catherine's College, Oxford (valuesbasedpractice.org).Copyright © 2023 Johns Hopkins University Press... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Arguing about PsychiatryNatural Selection, Austinian Conservatism, and Finding Our Way to the BestJoseph Gough (bio)Professors Murphy and Lieberman have offered two generous and interesting commentaries on my article, each very insightful and helpful in its own way, and each offering an interesting alternative characterization of the subject matter of psychiatry. I found each extremely thought-provoking, hence this rather bloated response. I strongly disagree with each. In brief, I disagree (...) with the 'preliminaries' of each commentary, struggle to see the tension between Hull's view of science and my view of psychiatry, reject Lieberman's appeal to the history of mind-like and mental-illness-like concepts, and finally, believe my position neither suffers from the instability of psychiatry, nor blocks the route to best practice, nor counsels despair.Metaphysical Precision and Conceptual Evolution: Response to MurphyMurphy begins by offering some helpful context for the debate, and for our disagreement within that debate. Partly it is helpful because it raises a cluster of questions, which I agree with him, are related to the topic at hand. Partly it is helpful because it lays out Murphy's background metaphysics, with which I broadly agree, but where I think it is important to be more pedantic than Murphy himself is. Murphy and I agree that there are animate objects, importantly different from inanimate objects; we also agree that there is no object in nature that is a mind. However, in that [End Page 45] opening paragraph, there are a few things that look to me a little like conflations—and while I am happy to grant this as pedantry, I am not happy to deny its importance.First, not everything animate is intelligent and unpredictable—a presumably accidental implication of Murphy's use of 'these' throughout the paragraph. Second, intelligence and unpredictability do not in my view cluster in the way that Murphy suggests in the passage—a highly intelligent system may be exceptionally predictable at least so long as its goals and knowledge are fixed, and a highly unpredictable system may, of course, be entirely unintelligent. Of course, when some systems behave other than we expect, we count this as a failing of the system; but this is a feature of artifacts as well as animate systems, and perhaps also of objects that are neither artifacts nor animate (think of a farmer whose crops fail to go—might they not think there is something wrong with the soil?). The class of 'predictions' Murphy identifies is what I would describe as a class of normative expectations, that, of course, must be somewhat in line with the way things actually are, but are not 'predictions' in the paradigmatic sense of guesses about what will happen.This pedantry matters because this implied (or perhaps less charitably, enforced) alignment between non-coextensive categories in this picture of Murphy's is leveraged, I think, to gesture towards an objection. First, Murphy claims that this class of systems has required a special vocabulary, 'mental' vocabulary. Second, it is, I think, suggested in Murphy's set-up (and perhaps in Murphy's work; Murphy & Stich, 1999) that at some level this vocabulary anchors what we are talking about when we are talking about 'mental illness.'But here, of course, I disagree—or at least, I might disagree if I were clear what is being claimed. Which class of systems is that gives rise to this 'special vocabulary? Several have been mentioned. It should also come as no surprise that I think it is deeply unclear what counts as 'mental' vocabulary. Is it the vocabulary of animacy? Of normative expectation and function-ascription? Perhaps of intentionality? Or of consciousness? Maybe it is defined 'ostensively' with respect to terms like belief and desire?After these preliminaries, Murphy offers an objection to my position, and a brief defense of his own. I would like to begin with his defense of his own position:the best way to think about the claim that mental illnesses are brain diseases … is to see them as committing us to a form of explanation that treats psychiatry as continuous with other sciences of mind, in... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Minding Psychiatric PracticePaul B. Lieberman, MD (bio)In recent discussions of what makes or should make something 'a psychiatric disorder' (if anything does; Lange, 2007), attention and contention have mostly involved problems distinguishing disorder from normal life, expectable suffering, neurological disease, criminality, prejudice, error, religious experience and effects of injustice, but the question of what makes or should make something psychiatric is also important and difficult to answer. It's important (...) because general conceptions of what kinds of things we treat (e.g., disorders of the heart, brain, or mind) guide practice by specifying what constitutes, nurtures or poisons them, ways they may break apart or be repaired and processes that produce change, as well as by helping to draw appropriate boundaries between psychiatry and other fields. It's difficult because psychiatry comprises many kinds of objects, theories and forms of practice (primarily biomedical, psychodynamic and cognitive behavioral), and we don't know which, if any, are 'natural' or valid. It's also not established whether or why all or any should be called, 'psychiatric,' what explains their being so-called (if it is correct to do so), or which may be fundamental or constitutive and which derivative and potentially eliminable.One appealing answer (the Diagnostic and Statistical Manual of Mental Disorders [DSM] an swer; American Psychiatric Association, 2013) to the question of what makes something psychiatric is that it is mental in some essential way. But few psychiatrists could explain what that might mean, nor would many be able to say what a mental disorder is or defend the idea that the conditions they work with are (always?) such things (though many probably wouldn't deny it either; they wouldn't know what to say and most wouldn't think it mattered). But if the idea that 'psychiatric disorders are essentially mental' seems obvious yet unclear to psychiatrists, what's the alternative? And if no alternative leaps to mind, then are psychiatrists practicing without knowing what they're treating?In "What makes a disorder 'mental'? A practical treatment of psychiatric disorder," Joseph Gough (2023) addresses these problems with two bold proposals: first, that we abandon altogether using 'mental' (assuming we understand its meaning) in the definition of 'psychiatric disorder,' and, second, that we, instead, define psychiatric disorders as those conditions best treated by psychiatrists (including psychologists, social workers, nurses and other practitioners).To a psychiatrist, these proposals seem, both, a welcome validation of our work ("At last, someone appreciates us!"), but also a troubling destabilization of how we understand that work ("That can't be right: it's backwards!") In Gough's [End Page 37] wide-ranging and carefully reasoned defense of his two proposals, he offers many novel and provocative insights relevant to problems defining psychiatric disorders. I will consider only a few of the issues he raises, which I think are especially worth emphasis and further thought.Gough initially rejects mentality in the definition of psychiatric disorder by reminding us that it is neither sufficient nor necessary for inclusion in the DSM. Vision is mental but blindness is not in the manual; caffeinism and erectile dysfunction are not mental but are included. Later, he offers two additional reasons for abandoning mentality: it promotes stigma and encourages dualism. I think all these arguments are correct. (Although blindness is not the best example because DSM defines mental disorders as disturbances of "thought, feeling and behavior" and blindness is none of these. But many other examples (e.g., encephalopathies) could make the point.)But Gough passes over this issue too quickly: we should pause and consider more carefully possible reasons to keep or even privilege the mental in psychiatry as well as the losses we might suffer if we gave it up. The examples and arguments he offers for abandoning the mental could be contested if one were motivated to do so. For example, one could argue, as Gough does elsewhere, that the DSM is just wrong sometimes and should be revised. Perhaps, as Gough briefly considers, there is a subset of 'mental' disorders that are properly psychiatric (where, e.g., certain favored features such as meaning, agency, narrative, or connection of 'self and world' are preserved, and... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:What Is Psychiatry About?Dominic Murphy, PhD (bio)There are no such things as minds, but there are animate objects who behave differently from other types of natural entity. They move around under their own power, and some of their activity seems to be very different from that of other natural objects. Furthermore, some of our predictions about these objects are disproved in interesting ways; if we make a false prediction (...) we do not revise our best theory about how such things generally behave, but we instead conclude that there is something wrong with the object of the prediction. These intelligent unpredictable things need a special vocabulary, and mental talk has arisen to serve as that vocabulary. But since a mind is not a thing in nature we face the problem of saying what the sciences of the mind are actually about.There are, then, intelligent systems that can be judged pathological, and some of them are our conspecifics. It is fair to say that there is no agreement about how such judgments are made or should be made. The question of what a mental illness is part of this larger picture, and it raises several different issues.First, how should we think about our practices of judging deviance? It would be contrary to accepted practice to wear a swimsuit to a state funeral, but what sort of norms would it violate and what state of mind would we ascribe to somebody who did it? Second, what is the difference between a judgment of deviance and a judgment of pathology? We have many ways of distinguishing between types of deviance, and the lines between criminality, immorality and pathology, to take three examples, are not always easy to discern. Third, what makes an illness a mental illness? This is Gough's topic, and I will get to it in a moment, but it worth situating it within this broader framework which asks what we are doing when we make these judgments of norm-violation.Gough begins by quite correctly pointing out that if we look at the domain of psychiatry as currently understood, we would have a hard time seeing what it is supposed to be the science of. It is customary to see psychiatry as dealing with the mental but, as Gough notes, there are some mental processes that psychiatry does not deal with, and some processes that psychiatry deals with that are not mental. Gough's response to this problem is a very interesting one, which starts from the idea that the point of psychiatry is to help those who need it; how different do things look if we start from this position? Conley and Glackin (2021) argues that the practical and therapeutic aspirations of psychiatry should constrain our understanding of mental illness. Glackin argues that we should [End Page 41] see this 'norms-first' view, as I will call it, as part of a broader liberal-democratic conversation about the ways in which we should live togetherA view that starts with norms is typically opposed to the 'naturalist' position. A naturalist begins with positive facts as the basis for diagnostic concepts, on the grounds that our concepts of disease and health are supposed to answer to facts about the physical and mental constitution of human beings. Gough's view is neither a norms-first view or a naturalist's view. We could call it an institutionalist view, or, if we were being a bit less kind, an ostensive one—"these things here, that's mental illness."David Hull (1988) taught us that every science (indeed, every intellectual formation or tradition) needs to be understood in two ways. First, we have the theoretical commitments that are taken to define it. Second, there are the practices and institutions that separate its practitioners off from others. Contemporary evolutionary biology, for instance, is built on the twin foundations of the modern synthesis—Darwinian natural selection and Mendelian genetics. These two theoretical commitments have been transformed and adapted and supplemented in diverse ways so that their modern forms no longer resemble their originals very closely. Still, they continue as the central undertakings about the nature of the living world that modern... (shrink)