Review - Oxford Textbook of Philosophy of Psychiatry
by Bill Fulford, Tim Thornton, and George Graham (Editors)
Oxford University Press, 2006
Review by Mark Welch, Ph.D.
Nov 14th 2006 (Volume 10, Issue 46)

At first blush it is an odd idea to have a "proactive textbook" as the editors announce. A textbook is more often seen as a compendium of received wisdom, an overview, a digest of the field. It is often said that textbooks are outdated before they are written. So something is quite different about a book that propounds to develop or even begin to define an area of scholarship.

In recent times there has been not only a growing interest in the interface of philosophy and psychiatry (as this website testifies), but also a recognition that this something that every advanced student should consider. Indeed, philosophy courses are becoming part of the British MRCPych examinations (for those wishing to qualify as psychiatrists) and in a number of Nursing programs at Masters and PhD level. This is not just an abstract concept, but a very real investigation of the implications, for example, of the move from Positivism to a Post-modern world. But this book is neither solely a philosophy text, nor a psychiatric one. It moves between the two, occupying that ill-defined land that is neither and yet is both; attempting all the time to bring out the history, relevance, links and interdependence of ideas. But, it does so using, in the main, a case study approach, with appropriate exercises, study notes and self-test questions for the student as well as the more casual reader. It gives useful reading guides and synopses and is thoroughly well indexed. It also comes with a CD of 179 seminal readings that are referred to throughout the text, and in this way it could be very usefully employed as a course text for students in a variety of fields.

It is presented in five parts. Part One deals with general core concepts and "puts people's individual experiences of mental distress and disorder on an equal footing with the generalized knowledge and skills of professionals" (italics in the original so we are meant to notice them). It considers the historical context of mental health practice, and asks, with good reason, "What is psychiatry? What is anti-psychiatry? What is disorder? What can philosophy have to say about this?" Sometimes it seems that psychiatry is as psychiatry does; sometimes it appears to have an agenda. Sometimes there is a fallacious syllogism, and sometimes there is analytic rigor. The key arguments of writers such as Jaspers and Szasz are similarly introduced, both for their fundamental positions and also for the questions they pose for daily living. What should be done when a person complains, for example, of feeling so worthless as to be contemplating suicide?

Part Two is a philosophical history of psychopathology and "brings empathetic understanding to subjective meaning back into clinical assessment alongside causal explanations". It begins a brief history of mental disorder, and continues with the issues of phenomenological understandings. It attempts to tease apart a series of binaries such as value/fact, illness/disease, unnatural/natural causes, moral/physical therapies, hermeneutics/brain imaging, anti-psychiatry/psychopharmacology. It also, interestingly, draws one tradition through Plato and Christianity and another through Hippocrates and Islam. And then we end up with the DSM.

Part Three is concerned with the philosophy of science and mental health to enrich our understanding of observational science to show "the importance of subjectivity and judgment (including clinical judgment) based on tacit knowledge alongside objectivity and induction … based on explicit knowledge". By this time the material is getting dense and complicated, and it is to be hoped that the reader has taken a break. Freud, a major figure throughout, and his idea of philosophical fieldwork, is of central importance, not just because he truly wanted to see psychoanalysis accepted as a science, but also because his work is almost the touchstone of all later theorizing. It is suggested that much of late 20^th and 21^st century psychiatry and philosophy is a reaction to Freud. What, it is posed, is data? What is observation, what is interpretation? Can they be distinguished and does it matter anyway? The influence of Logical Positivism and diagnostic categories and practice, and the debates concerning hypothetical particles and unobservables in physics add to a heady mix of doubt and speculation.

Part Four doesn't get much clearer as it broaches the problems of values and ethics in mental health. It introduces the idea of Value-Based Practice. It covers the key concepts in bio-ethics, and some of the issues raised by having laws in these areas. What does it mean to have compulsory treatment? Are we back to the anti-psychiatric position of an illness compared with problems with living? What does consent mean? At what point may it be justifiable to override a person's rights in this way? What can philosophical discourse say to us here? The recent events concerning euthanasia, 'rational suicide' and forced caesarean births are broached at this point, but not explored thoroughly. Nor is the issue of deliberate infection by HIV positive persons; but perhaps that is not a psychiatric concern.

The fifth section looks at the philosophy of mind and mental health. In many ways this returns us to our point of departure. What exactly is the mind? What is the mind and what is the body? Is a disorder of the mind a disorder of the body or not? The section revisits many of the concepts outlined in previous chapters, and many of the familiar names reappear as the circle closes. How to know what is going on in someone's mind, how to understand the individual experience of identity, how to enter into the world of another become principal concerns.

In conclusion it should be said that this is a very fine, deeply impressive addition to both psychiatric and philosophical literature, as well as forging an identity of its own. It has admirable clarity and speaks much good sense. It moves at a steady pace and the large number of reflective exercises helps a reader negotiate difficult terrain. It will be of great value to students (both new and continuing) of a number of disciplines and many of its concerns should be seen as essential to any mental health practitioner. It informs but is never didactic, it encourages reflection, but is not without critique, and it does not make claims above its station. It recognizes that psychiatry is, and always has been, intimately wrapped in philosophical concepts; it does after all concern itself with some of the most fundamental questions of the human experience. It will be of great assistance as we begin to anticipate and comprehend the ramifications and implications of DSM-V. The final sentence in the text is perhaps a fitting way to close: the "genuine scientific advances (of psychiatry) have to go hand in hand with an understanding of the rational pattern that governs minds, a pattern that may well never be codified in a deductive scientific theory". Perhaps it is the process rather than the outcome that matters. But that is another philosophical question.

© 2006 Mark Welch

Mark Welch, Ph.D., Assistant Professor in the Faculty of Nursing at the University of Alberta, Edmonton, Alberta and Co-Director of the PAHO/WHO Collaborating Centre for Nursing & Mental Health