I’ve been invited to submit an article on this subject to the Journal of Mental Health Training Education and Practice. To warm up for the writing I plan to do in Paris, I think I'll start with it. Hence, as ever, a growing draft entry here.
Why teach the philosophy of mental health?
Abstract
Why teach the philosophy of mental health? Much recent philosophy of mental health has either criticised psychiatry, or attempted to defend it, from an external perspective, which suggests that the philosophy of mental health is at best a peripheral activity and at worst a distraction. A better understanding reveals that philosophical inquiry is continuous with good mental healthcare in response to genuine and deep conceptual complexity. I illustrate this claim both by examining Szasz’s arguments for anti-psychiatry, which reveal much more than a simple attack on psychiatry, and recent work on psychiatry for the person where conceptual problems are raised by the conflicting requirements on good mental healthcare.
Introduction
Why teach the philosophy of mental health? What role does a philosophical understanding have for mental health service delivery and innovation? Why should we put philosophy into mental health practice? The question, however, is not just ‘why?’ but also ‘how?’. Under what construal of the philosophy of mental health, or the philosophy of psychiatry, is it clear that philosophy has a practical role to play? I will thus approach the first question via an examination of the second.
When one discipline examples another, it typically falls into one of two roles: either debunking or uncritically validating. In the history of science, for example, uncritical Whig histories from the early part of the twentieth century were replaced in the later half by social constructionist approaches many of which, at least, took their remit to be a critical challenge to the assumption of scientific rationality and objectivity. This oppositional stance was even given the name ‘the science wars’.
The philosophy of mental health, or the philosophy of psychiatry, like other ‘-ologies’ of mental health or psychiatry, naturally fits this kind of oppositional model. But the danger of this dichotomous approach to the options in this case is that it threatens to alienate a significant voice in debates about good mental health care. The philosophical critique of psychiatry – anti-psychiatry – threatens to alienate clinicians and others for whom, whatever past abuses of some patients there may have been, scientific psychiatry is the best hope for mental healthcare. On the other hand, a philosophical articulation of the virtues of evidence-based medical care or a defence of psychiatry against anti-psychiatric arguments threatens to alienate at least a proportion of mental health service users. Either way, the possibility of dialogue is undermined and only half the story is heard. But given that the promotion of dialogue is one of the key virtues of philosophy, this is disappointing. As I will argue, however, there is another option. Philosophical reflection grows organically in response to the genuine conceptual complexity of mental healthcare flowing from the confliting requirements placed upon it. It is not imposed from without but continuous with such healthcare.
Background
A century ago, the father of psychopathology, Karl Jaspers, combined psychiatric and philosophical expertise. Since then, within the English speaking tradition, philosophy and psychiatry have gone their separate ways throughout most of the twentieth century. But towards the end of that century, the rise of the anti-psychiatry movement has prompted a resurgence of interest in psychiatry within broadly analytic, Anglo-American philosophy.
The reason for this is that a key element of the anti-psychiatric criticism of mental health care has turned on a contentious claim about the nature of mental illness: that mental illness does not exist; it is a myth. Such a sceptical claim is paradigmatically a philosophical claim and psychiatrist Thomas Szasz, as one of the main proponents of anti-psychiatry, put forward a number of explicitly philosophical arguments in support of it. (His arguments were not the only resource for anti-psychiatry. But they were both well known and pithily philosophical.)
This in turn has spurred a philosophical response by both psychiatrists and philosophers putting forward analyses of mental illness to undercut the sceptical argument and thus, partially at least, to justify psychiatric practice. In a recent article in the AAPP (Association for the Advancement of Philosophy and Psychiatry) bulletin, Jennifer Hansen advocates just such a justificatory view. In ‘There Are No Philosophers in Foxholes! But Maybe There Should Be...’ she describes teaching a student – Samantha – whose mother was ‘battling with bipolar disorder’ and whose cousins are psychiatrists.
Samantha blurted out: “You see, it is these silly debates that piss off real psychiatrists. No wonder psychiatrists don’t respect philosophers!” ...the psychiatrists she had been talking to pointed out to her, over and over again, that mental illness was real, that psychiatry was a science, and therefore, any debates over classification or the “reality” of mental illness was wasted breath. Philosophers, in their mind, were pseudo-scientists getting tangled up with unsolvable metaphysical questions... In particular, Samantha found Thomas Szasz’s work offensive; it was, in fact, her disgust with his claim that mental illness is not “real” that predisposed her to agree with her cousin’s colleagues; I feared I had lost her forever. [Hansen 2007: 2]
Hansen’s response to this is to suggest that philosophers can aid psychiatrists by defending psychiatry against its critics. (In the UK, at least, the idea that psychiatry, as a discipline, might seek aid from philosophy may strike some as verging on the ironic.)
The hope is that philosophers and psychiatrists can form a partnership to counteract the growing critics of the field. Philosophers can play a useful role in clarifying conceptual confusions, demonstrate the weakness of some of the arguments made against psychiatry, and the flawed nature of the critics assumptions…
[P]hilosophers play a very important role for scientists in times of crisis. The crisis is generally not generated from within, but rather the product of outside political forces challenging the legitimacy of the entire field. If I can get my students, especially Samantha, to buy into the idea that psychiatrists might need philosophers, and even find them valuable allies, then I will have made one small step toward a happy reconciliation. [Hansen 2007: 4]
The sketch of the origins of recent philosophy of psychiatry in anti-psychiatry and a contemporary philosopher of psychiatry’s call for philosophy to defend psychiatry both chime with a widespread historical ambition for philosophy more generally: to be the queen of the sciences, arbitrating what is good and what is bad science.
But, whilst that was an influential view until nearly the end of the twentieth century, it has fallen from influence. This is partly as a result of the realization of the impossibility of articulating a substantial prescriptive model of good scientific practice [Kuhn 1970]. But it is also the result of criticisms by philosophers such as Richard Rorty, Arthur Fine and John McDowell of the very idea of philosophy acting as an independent judge of the truth claims of other disciplines [Rorty 1981, Fine 1999, McDowell 1994].
Legislation by philosophy over, but from outside, empirical science has been replaced by more organic relationship between philosophy and other disciplines, a relationship that, in the US at least, has been influenced by the late WVO Quine’s advocacy of epistemological naturalism [Quine 1969]. According to the new Quinian orthodoxy, philosophical methods are continuous with scientific methods. I aim here to suggest a less radical position. Whilst philosophical methods are distinct from purely empirical methods – and that is why philosophy has something distinctive to offer – its subject matter is continuous with that of psychiatry.
One way to see a more organic relation between philosophy and practice stems, ironically, from closer attention to the arguments of Szasz which helped motivate the oppositional model within philosophy of mental healthcare.
A different lesson from Szasz?
Let us consider two of Szasz’ arguments. The first is expressed in the following passage. Szasz suggests that the idea that mental illnesses exist is based on the idea that they are some sort of ‘deformity of the personality’ which explains human disharmony or more generally life problems. But, he objects:
Clearly, this is faulty reasoning, for it makes the abstraction ‘mental illness’ into a cause of, even though this abstraction was originally created to serve only as a shorthand expression for, certain types of human behaviour. [Szasz 1972: 15]
Now it is worth thinking about this argument as an exercise in the philosophy of mental health. How does it work? What is the force of the argument. I suggest the underlying argument runs like this:
• Premiss 1: Mental illness is an abstraction from a description of behaviour. So it is defined in terms of behaviour.
• Premiss 2: Mental illness is supposed to be a cause of behaviour.
• Premiss 3: Nothing can cause itself.
• Conclusion: So there is no such thing as mental illness defined this way.
To continue the exercise, how can and should we respond to this argument? Are the premises true? Is the argument valid? Must the conclusion be true? Think about it.
Szasz also offers a second argument based on distinct norms.
The concept of illness, whether bodily or mental, implies deviation from some clearly defined norm. In the case of physical illness, the norm is the structural and functional integrity of the human body…What is the norm, deviation from which is regarded as mental illness? This question cannot be easily answered. But whatever this norm may be, we can be certain of only one thing: namely, that it must be stated in terms of psychological, ethical, and legal concepts… … [ibid: 15]
The second argument continued
Yet the remedy is sought in terms of medical measures that – it is hoped and assumed – are free from wide differences of ethical value. The definition of the disorder and the terms in which its remedy are sought are therefore at serious odds with one another… [ibid: 15]
Since medical interventions are designed to remedy only medical problems, it is logically absurd to expect that they will help solve problems whose very existence have been defined and established on non-medical grounds. [ibid: 17, italics added]
So, again, here is a summary of the argument:
• Premiss 1: Mental and physical illnesses answer to different norms (bodily function versus social, ethical, legal or otherwise evaluative norms).
• Premiss 2: Treatments which address deviation from one kind of norm cannot address the other.
• Conclusion 1: Because mental illness answers to a different norm it cannot be treated using physical medicine, or ‘medically’ more generally.
• Premiss 3: To be an illness is to be medically treatable.
• Conclusion 2: Hence mental illness (as something can be so treated, rather than as life problems) is a myth.
Again, think whether this is a compelling argument and how, if one wanted, one might try to challenge it.
Stop right there for a second and think about it! Too often arguments about psychiatry and anti-psychitray go too quickly and without careful thought.
Szasz’ second argument can be thought of has having two key stages:
1. Mental and physical illnesses answer to different norms.
2. Because mental illness answers to a different norm it cannot be treated medically and hence mental illness (as such, rather than as life problems) is a myth.
One way to challenge the argument is thus to challenge the first claim. Some philosophers working on the nature of health and illness (such as Jerome Wakefield) have suggested that at least an element in the concept of disease is that of biological disorder, an element that might be shared in both physical and mental pathologies. (Wakefield’s second element is also shared: harm.)
But there is another possible challenge to the argument, this time to the second stage. This is to concede that mental illness is identified via behavioural norms – social, ethical and legal norms expressed in speech and action – but to deny that this implies that illness is identical to that behaviour. Consider this analogy. The assassination of Arch Duke Ferdinand is often described as the precipitating cause of the First World War. Thus the war and its vast social, economic and cultural consequences, including 1.7 million German deaths, were effects of that assassination. But the death of the Arch Duke is not identical with those 1.7 million deaths.
Similarly, it is consistent with the premise that we identify mental illnesses via psycho-social and ethical behavioural norms that mental illness is not identical with such behaviour but merely its cause. And thus it is not logically absurd to expect medical treatment of mental illness. So a model of mental illness that combines these two features – identification via psychosocial norms and medical treatability – need not be mythical. (This response is also available to the first argument from circularity.)
But note that whilst the above consideration undermines Szasz’ conclusion that mental illness is unreal it does not undermine his key claim that it is identified via essentially evaluative norms. And in fact most of the interesting response to Szasz – in their conflicting ways, for example, by Jerome Wakefield and Bill Fulford – take this, rather than the reality or not of mental illness, to be the main question [Fulford 1989, Wakefield 1999]. Is mental illness value-laden or not? Aside from an anti-psychiatric attack there are a number of other substantial issues of importance to psychiatry that would follow from this such as the extent to which we should expect agreement – or reliability – in psychiatry, especially across different cultures. This in turn leads to issues of public policy with regard to mental health care: what model of recovery is there? Is there a notion of mental health that is not merely the absence of illness and so on? It also leads into more explicitly ethical questions such as how a diagnosis of mental illness can ethically justify involuntary treatment. What is it about mental illness that might do this?
The initial question – of whether mental illness is value-laden – is not empirical. It depends primarily on conceptual analysis of the terms involved, although it also depends on the empirical facts about what are taken to be paradigmatic mental illnesses. A self-conscious understanding of a central psychiatric concept thus depends on a philosophical analysis. Within the original debate about anti-psychiatry is a question of continuing interest that is continuous with psychiatric practice although it need not be taken directly to threaten the very possibility of such practice. It concerns how best to understand the central subject matter of psychiatry: the treatment of mental ill health. And the resources required for addressing it are conceptual, and thus philosophical, as much as they are empirical.
The idea that the subject matter of philosophy of psychiatry is continuous with, and develops naturally from, the concerns of psychiatry itself can be illustrated through a number of recent debates as diverse as how evidence based practice is best applied to mental health care; or how brain imaging experiments on the timing of conscious decisions impact on the nature of free will. But I will jump right up to date and outline a conceptual or philosophical issue arising naturally from present concerns within psychiatry, which will have to be addressed over the coming years.
The apparent tension between narrative formulations and validity
Even a casual observer of intellectual developments in psychiatry will have noticed two growing emphases. One is the suggestion that whilst great advances were made in DSM III and IV in increasing the reliability of psychiatric diagnosis, this may have been at a cost of its validity. Thus the task force carrying preliminary research for the next revision – DSM V – have called for validity to be placed at the centre of the revision process.
Those of us who have worked for several decades to improve the reliability of our diagnostic criteria are now searching for new approaches to an understanding of etiological and pathophysiological mechanisms – an understanding that can improve the validity of our diagnoses and the consequent power of our preventive and treatment interventions. [Kupfer, First and Regier 2002: xv].
On the other hand, a recent development within the World Psychiatric Association is the advocacy of a ‘comprehensive’ model of diagnosis. A WPA workgroup charged with formulating ‘International Guidelines for Diagnostic Assessment’ (IGDA) has published a guideline called ‘Idiographic (personalised) Diagnostic Formulation’ which recommends an idiographic component within psychiatric diagnoses. This has been put forward within the context of the development of a model of ‘comprehensive diagnosis’ which is described by Juan Mezzich, President of the WPA, as follows.
The emerging comprehensive diagnostic model aims at understanding and formulating what is important in the mind, the body and the context of the person who presents for care. This is attempted by addressing the various aspects of ill- and positive- health, by interactively engaging clinicians, patient and family, and by employing categorical, dimensional and narrative descriptive approaches in multilevel schemas. [Mezzich 2005: 91 italics added]
Writing in the journal Psychopathology, the psychiatrist James Phillips describes a narrative and idiographic addition to conventional criteria-based diagnosis in this way.
In the most simple terms, a narrative or idiographic formulation is an individual account with first-person and third-person aspects. That is, the patient tells her / his story, with its admixture of personal memories, events and symptoms, and the story is retold by the clinician. The latter’s account may contain formal diagnostic, ICD-10 / DSM-IV aspects, as well as psychodynamic and cultural dimensions not found in the manuals. The clinician’s account may restructure the patient’s presentation, emphasizing what the patient didn’t emphasize and de-emphasising what the patient felt to be important. It will almost certainly contextualise the presenting symptoms into the patient’s narrative, a task which the patient may not have initiated on her own. Finally, the clinician will make a judgment (or be unable to make sure a judgment) regarding the priority of the biological or the psychological in this particular presentation, and will structure the formulation accordingly… [Phillips: 2005: 182]
If psychiatric diagnosis is, however, to include a narrative based and, as far is possible, idiographic ingredient, if the basic classificatory judgement of psychiatry is to include this element, then what of its validity? Might there not be a tension between these two intellectual aims of recent psychiatry.
Note, first, the contrast with classification in chemistry. There, the validity of the Periodic Table is displayed in classificatory judgements which are essentially general. Samples are described as instances of general types which possess a great deal of ‘systematic import’, in Hempel’s phrase [Hempel 1994: 323]. Validity in chemistry is underpinned by the use of general kinds.
The WPA’s suggestion pulls in the other direction: narrative components in a comprehensive diagnosis are tailored to individual cases in a way which seems, by definition, to undermine systematic import. Does this undermine the validity of classifications based on this approach? The difficulty in answering the question is that assessing validity seems to require stepping outside one’s beliefs to measure them against the world, to check that they line up. But that, of course, is impossible. So it seems that one needs a less direct measure of validity. What is this?
I do not here wish to argue that narrative formulations actually are in tension with the aim of increasing the validity of psychiatric diagnosis: that narrative formulations cannot be valid. But what is clear is that standard models of validity will not apply to them. In a nutshell, standard models of validity are nomothetic whilst narrative formulations are idiographic. It is thus a project for philosophical investigation – informed by empirical work on the kind of diagnoses that are actually made – but one which arises naturally from within self-conscious psychiatry rather than being imposed on psychiatry by philosopher outsiders.
Philosophy as a set of investigative tools
If, however, philosophy is not simply concerned with attempting to debunk or to justify psychiatric practice from outside, and if the philosophical work that is continuous with and relevant to psychiatry has been carried out by psychiatrists as well as by professional philosophers, how should it be best understood? What kind of thing is the philosophy of psychiatry? Where does it fit with psychiatric practice? I think that the most promising approach is to take philosophy of psychiatry to be less a body of results or theories evolved over the last hundred, three hundred or two thousand years (depending on one’s perspective) and more a set of tools and abilities for analysis.
Note first that the philosophy of mental health and philosophy of psychiatry is not akin to a ‘natural kind’. There is not an established set of closely inter-related problems with familiar, if rival, solutions. It is not like philosophy of mind or epistemology which have achieved the status of Kuhnian normal science with a settled role within the academic philosophy syllabus [Kuhn 1998]. Published work in philosophy of psychiatry is much more heterogeneous. It is generally drawn from different parent sub-disciplines within philosophy - such as philosophy of mind, philosophy of science and ethics - in response to specific issues or phenomena raised by or within mental health care. The range of issues covered – eg by the recent OUP series International Perspectives in Philosophy and Psychiatry – is great and without a single common ingredient or focus.
Secondly, unlike some areas of philosophy, philosophy of mental health can have a genuine impact on practice. It is a philosophy of, and for, mental health care, providing tools for critical understanding of contemporary practices, of the assumptions on which mental health care more broadly, and psychiatry more narrowly, are based. Thus it is not merely an abstract area of thought and research, of interest only to academics and insulated from everyday concerns. In providing a deeper, clearer understanding of the concepts, principles and values inherent in everyday thinking about mental health, psychiatric diagnoses and the theoretical drivers of mental health policy, it can impact directly on the lives of people involved in all aspects of mental health care.
This suggests that philosophy of psychiatry is best understood as a set tools and techniques to aid analysis and investigation. It is that rather than a set of established theories and results. Of course, there are philosophical theories or models that are relevant to psychiatry. Three centuries of discussing the relationship of mind and body have furnished philosophers with a variety of subtle models (from forms of dualism, through gradations of physicalism, to eliminativism with modern alternatives such as enactivism) which can help in the interpretation of psychiatric data. Equally, substantial ethical theories have informed both medical and psychiatric ethics. But whereas in some areas of philosophy both the problems and their attempted solution seem to be specifically philosophical, isolated from the concerns of everyday life (cf. the relation of radical scepticism to everyday practical certainties), that is not and should not be so for philosophy of psychiatry. Substantial theories have a role within philosophy of mental health when they are borrowed from their usual more abstract setting to be applied in the analysis of concrete practical issues.
This view also chimes with my own experiences of teaching the subject at masters level (at the University of Central Lancashire). The students have mainly come from practice - psychiatry, mental health nursing, social work and the service user movement – rather than from pure philosophy. They choose to work on issues that arise naturally within practice settings and of which they have at least some experience. Thus they might examine the nature of evidence based practice as it applies to talking cures. Or they might look to ethics of the treatment of sufferers from anorexia. Or they might go back to Jaspers to think again about the role of empathy in mental health care but perhaps in response to the established position of criterial DSM style diagnosis.
What such students gain from a masters degree in philosophy and mental health is not so much a snap shot of the present state of debates about evidence, values and the place of mind in nature as applied to psychiatry. Rather, they gain standing abilities to examine and critically analyse conceptual issues that are raised by or underpin psychiatric theory and practice.
If psychiatry itself – and mental health care more generally – were fixed and unchanging, a self conscious understanding of it would be an intellectual virtue, a desirable end where possible. But given the rapid changes in psychiatry in recent years and the continuing outside pressures on it from both public expectation and changing government policy the analytic abilities that make up a self-conscious practice of mental health care are not just desirable, they are necessary.
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