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The Philosophy of PsychiatryReview - The Philosophy of Psychiatry
A Companion
by Jennifer Radden (Editor)
Oxford University Press, 2004
Review by Daniel Callcut, Ph.D.
Mar 1st 2005 (Volume 9, Issue 9)

Philosophy of Psychiatry is a new name for something that is, in a sense, very old. The topic of how best to care for and heal a person's mind or soul has received philosophical attention since antiquity. The professional demarcation of a medical discipline called psychiatry, however, is far more historically recent and the idea of a field of philosophy called Philosophy of Psychiatry is so new that, to my knowledge, this is the first anthology of papers ever to bear the name. The publication of this book is a major event in the ongoing development of the field.

Jennifer Radden has assembled a number of thought-provoking pieces from some of the major figures in the field: the collection as a whole gives a sense of both the philosophical excitement and the cultural and practical importance of this area of study. Radden has divided the anthology into five major parts: Psychopathology and Normalcy; Antinomies of Practice; Norms, Values and Ethics; Theoretical Models; and Circumscribing Mental Disorder. Many of the questions and issues raised in the different sections interconnect in a rich and fascinating way: this means that the standard organizational challenges of assembling an anthology of this kind must have been particularly acute (indeed, Radden alludes to them in the acknowledgements) – how can any piece or part come first, for example, when in order fully to understand any of the pieces or parts one needs to have read one of the other pieces or parts? However, while I can see that any choice in this regard has costs as well as benefits, I think that I would have placed a piece on the topic of how to define mental disorder far closer to the start of the book.

Part I of the book, as it stands, provides a kind of tour of the theoretical issues involved regarding psychopathology and normalcy in a variety of areas: cognition, affectivity, desire, character, action, self-ascription, memory, body, identity, and child and youth development. One has to wait until pp.70–71 before one gets (from Louis C. Charland) the first clear explanation of the evaluative nature of diagnostic categories and one has to wait until chapter 29 out of 30 before one reaches the chapter by Charles M. Culver and Bernard Gert devoted to the issue of defining mental disorder. Now, of course, nothing prevents one from jumping straight to the end of the book: all the pieces work as self-contained contributions. But the issues surrounding the concept of mental disorder – to what extent it is evaluative, nonevaluative, natural, universal, culturally constructed, political, and so on – are so pervasive that I would have opened the book with a piece that simply set out all these issues. John Z. Sadler's helpful piece on mental diagnosis would, in particular, have benefited from a stage-setting chapter on the concept of mental disorder. The same is true of Daniel N. Robinson's piece on the issue of how to respond to the issue of dangerous (or possibly dangerous) patients.

The concern about the placing of the chapter on mental disorder, in a way, raises another question: is this book intended to serve as an introductory guide or to represent the current state of advanced thinking in the field? On the whole, I would say, it both aims at and best succeeds at the latter goal. But there is a definite (perhaps somewhat unavoidable) tension regarding the aims of the anthology here: some of the pieces are quite sophisticated, others speak to the novice; some pieces are highly opinionated, others adopt the more neutral and impartial style of an encyclopedia. To give one example of the contrast: Grant Gillett's explanation of "discursive naturalism" (25) is likely to be impenetrable to those not already familiar with a distinct philosophical literature that aims to synthesize certain elements of Kant and Wittgenstein where as Nancy Potter's piece on gender includes some very basic points of gender theory such as, for example, an explanation of what the term "Gender role" means (237). This tension within the anthology as a whole also shows up in a number of the individual contributions – some of which swing from the rudimentary to the advanced and back again very rapidly. The danger, of course, is that the article is then too obscure for the newcomer but too superficial for the more advanced reader. Tim Thornton's discussion of the reductionism/antireductionism debate is generally helpful but his sketch of John McDowell's philosophy of mind is likely to be too opaque for those not already initiated and unnecessary for those who are. The same point applies to Marilyn Nissim-Sabat's exposition of Foucault (248-249) and to Simon Wilson and Gwen Adshead's overview of the insanity defense (298).

There are a number of pieces in the anthology that illustrate the potential usefulness of philosophy for psychiatry: Alfred R. Mele's discussion of volitional disorder and addiction is an excellent example of how philosophical sophistication could lead to practical as well as philosophical gains. And there are times here when the philosopher is almost playing therapist to the therapist – ministering, for example, to the potential anxieties of some mental health practitioners regarding the role of values in psychiatry. K.W.M. Fulford's exposition of values-based medicine, among other things, nicely brings out the way in which psychiatry is not the only value-laden area of medicine: the appearance that this is the case is a result of the fact that there is more contestation over values in psychiatry. The silent consensus over value in some other parts of medicine should not lead one to conclude that such areas are value-free. Some pieces raise interesting questions about where, if at all, the line can even be drawn between philosophy of psychiatry and psychiatry proper: consider the claim of Andrew Garnar and Valerie Gray Hardcastle that "Biological psychiatry would do better to approach soma in a different way" (365). Are they writing as philosophers or psychiatrists here? Does it matter? If so, where and how can one draw the lines?

Fulford's piece brings out ways that the differences between psychiatry and other areas of medicine can be exaggerated. Nonetheless, there is no denying that much of the philosophical excitement of philosophy of psychiatry comes from the fact that psychiatry is a field uniquely freighted with philosophical preoccupations. What other area of medicine so profoundly raises questions concerning human identity, well-being, and the relationship between mind and body? Indeed, one could argue that psychiatry is a field in a state of chronic and ongoing philosophical crisis. What is the object of care in psychiatry? Should mental health treatment be aimed at the mind, the brain, behavior, the self, the soul, or the whole person? This is a question which is at one and the same time both a practical concern (what should psychiatrists, clinical psychologists and psychotherapists be doing?) and one of the deepest of philosophical questions (what are we, ultimately?). At times it looks as if the possibility of practicing psychiatry depends in some sense on answering the perhaps unanswerable philosophical question. Thus the working psychiatrist, perplexed by these questions, is left like some character out of Beckett: I can't go on. I go on.

Many of the pieces in the anthology deal explicitly or implicitly with issues concerning the relationship between the epistemology and ontology of mind. The majority of the contributors show sympathy with the idea that there is a fundamental discontinuity between the kind of understanding involved in gaining knowledge of material nature and the form of understanding required to interpret human thought and action. James Phillips quotes Dilthey's pithy expression of this idea: "We explain nature, but we understand psychic life" (180-181). Phillips' marvelous piece explores some of the difficulties (in philosophical theory and psychiatric practice) of sustaining these demarcations but I remain struck by how many of the contributors tend to treat the epistemological dualism as unproblematic. There is little acknowledgement of the major and longstanding debate (or set of debates) in the philosophy of mind concerning whether acceptance of this kind of dualism in epistemology turns out to be a package deal (i.e. you have to buy ontological dualism too). Moreover, as Phillips' piece makes beautifully clear, the epistemological dualism in any case fails to acknowledge the ways in which any neat isolation of the realms of mechanical causation and human intentionality cannot survive close attention to experience. Philips' piece explores these issues via the case history of a patient, Mrs. D, suffering from depression. One passage on p.184 is worth quoting at length:

"On the one hand, Mrs. D's constitutional predisposition to depression, her altered brain state, did nor simply "cause" an altered mood; to some degree her altered brain and altered mood "caused" her to think about the world in a different way, to give depressed meanings to her experiences. Thus, the causal dimension of explanation invades the dimension of meaning. On the other hand, the meanings with which she framed her life experiences themselves had a causal effect on her mood. This is the basis of the cognitive therapy of depression. Thus, while it remains very useful to distinguish the understanding of meaning and the explanation of causes, we must also recognize the deep interpenetration of these two dimensions in our analysis of any human being."

Phillips' piece is a model of how careful attention to actual cases can enrich both philosophy and psychiatry. He lingers over the significance of the fact that a person is "both meaning and natural process" (183) and his rewarding openness to experience suggests that it is better to do justice to our sense of ontological puzzlement than rush to theoretical closure at any cost.

Andrew Garnar and Valerie Gray Hardcastle suggest in their piece on neurobiology that the philosophical divide between reductionists and antireductionists about the mind is mirrored in the practical realm of psychiatry by the "division of labor between psychopharmacology and psychotherapy" (372). This claim certainly has an initial plausibility to it and it would have been nice to have seen more exploration of some of the questions this raises: for example, must a practitioner of talk therapy take an antireductionist view? After all, as Phillips notes, "neuroscience and its findings of neuroplasticity have also lent support to the notion that psychotherapy and its work with the patient's meaning structures have an effect on the brain" (186). One can imagine a kind of pragmatic justification of psychotherapy that is compatible with a strong form of reductionism regarding the relationship between mind and brain. On the other hand, one can imagine someone supporting the claim that psychopharmacological interventions are the best way to treat psychiatric problems while rejecting the idea that this implies any straightforward identification of mind and brain.

The anthology, for the most part, does a nice job in examining the socio-political dimension of many of these questions. The rise of psychopharmacology in psychiatric treatment, for instance, obviously stems from more than philosophical argument or therapeutic success. Carl Elliott's characteristically trenchant piece, in particular, stresses the role that money and marketing have played in making antidepressants "the best-selling category of drugs in the United States" (432). And Jennifer Radden's introduction notes that part of what has put philosophical and ethical issues surrounding psychiatry on the radar is the growing recognition of "the profound social and political importance of mental health care" (3). I thought the weakest piece in the area of social-political philosophy was the discussion of criminal responsibility by Simon Wilson and Gwen Adshead. They state at the outset of their discussion of criminal responsibility that they will not be discussing "the broader notion of moral responsibility" (296) and yet, not only is it not clear that discussion of criminal responsibility can legitimately avoid dealing with the broader notion, they themselves move on to discuss issues which are clearly in the territory of moral responsibility. Their discussion of "mental responsibility" (301) is a discussion of moral responsibility by another name and it suffers from the tendency to contrast a metaphysically superstrong notion of "real" responsibility with the idea of responsibility as an "artificial social construction" (308). The piece is sorely lacking the kind of philosophical sophistication that underpins, for example, Jennifer Church's elegant overview of social constructionist models of mental illness in chapter 27.

There are many fine pieces in the anthology I haven't mentioned. To single out just three more: George Graham's piece on the phenomenon of thought insertion provides an excellent presentation of the issue and subtle discussion of the relationship between the phenomenological and the neurophysiological; Shaun Gallagher and Mette Vaever provide a valuable presentation of the relationship between mental illness, embodiment and bodily experience; and Dominic Murphy's piece on Darwinian models of psychopathology is an extremely useful and elegantly presented introduction to the issues. The text isn't perfect: there are a few typos ("V.W.O. Quine" is cited on p.193), some erratic prose (see the pronoun roulette at the bottom of p.30) and some references that don't match up (the Boghossian article cited in the footnotes on p.404 has a different title in the references on p. 405). However, I would be amiss if, in closing, I did not reaffirm what a significant accomplishment this is: it simultaneously represents, announces and consolidates the arrival of an exciting new field.

 

2005 Daniel Callcut

 

Daniel Callcut, Ph.D., is Assistant Professor of Philosophy at the University of North Florida.


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Metapsychology Online reviewers normally receive gratis review copies of the items they review.
Metapsychology Online receives a commission from Amazon.com for purchases through this site, which helps us send review copies to reviewers. Please support us by making your Amazon.com purchases through our Amazon links. We thank you for your support!


Join our e-mail list!: Metapsychology New Review Announcements: Sent out monthly, these announcements list our recent reviews. To subscribe, click here.

Interested in becoming a book reviewer for Metapsychology? Currently, we especially need thoughtful reviewers for books in fiction, self-help and popular psychology. To apply, write to our editor.

Metapsychology Online Reviews

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Metapsychology Online Reviews
ISSN 1931-5716