Review - Nature and Narrative
An Introduction to the New Philosophy of Psychiatry
by Bill Fulford, Katherine Morris, John Sadler, Giovanni Stanghellini (Editors)
Oxford University Press, 2003
Review by Christian Perring, Ph.D.
Jan 30th 2004 (Volume 8, Issue 5)

Nature and Narrative is a collection of 17 articles taking a philosophical perspective on psychiatry.  Some of the authors are well known philosophers such as Gordon Baker and Rom Harré and others are in psychology and psychiatry, including Alfred Kraus and Daniel Robinson. Most of the contributors are located in Europe: Natalie Depraz in philosophy at the University of Sorbonne, Paris, Markus Heinimaa in psychiatry at the University of Helsinki, Eric Matthews in philosophy at the University of Aberdeen, Michael Musalek in psychiatry at the University of Vienna, Paolo Rossi in philosophy at Florence University, Guy Widdershoven and Ineke Widdershoven-Heerding based in philosophy in the Netherlands.  Some authors are from South Africa and Australia.  They have a rich variety of perspectives, and employ diverse methodologies. 

In their introductory chapter, the editors make great claims for the recent renaissance of philosophy of psychiatry, suggesting that it is likely to lead to a long-term partnership between philosophy and psychiatry.  They go so far, at least in the section headings, to claim that the project will give rise to "new kinds" of philosophy, ethics, psychology, phenomenology, and scientific psychiatry.  The articles in this book do not really live up to such an ambitious proposition, and indeed, several of them amount to no more than a rehashing of long-familiar themes in philosophy of psychology, or present questionable and even rather bizarre ideas relating to the nature of psychopathology.  Nevertheless, despite or possibly in virtue of its eclecticism, as a whole Nature and Narrative is a valuable addition to the library of books in philosophy of psychiatry that is especially likely to appeal to an interdisciplinary readership.

In this review, I will give brief summaries and comments on each article. 

In "Towards a psyche for psychiatry," Russell Meares argues that we need to go beyond the present level of conceptualization and practice in psychiatry, we need to turn to the modes of thinking of Hughlings Jackson, William James and Pierre Janet.  Meares seems to think that the problem of current psychiatry is that it treats humans as machines, and thus devalues or ignores the personal world of feelings and imagination.  However, he does little to establish either that psychiatry actually makes this error or that adopting the methods of Jackson, James or Janet is the best way to correct the error.  His paper is more of a rallying call than a philosophical argument.

Gordon Baker has a solid reputation as an interpreter of Wittgenstein.  In "Wittgenstein's method and psychoanalysis," he continues this work to explore how dissolving the puzzles that trouble philosophers can be seen as akin to psychotherapy.  Wittgenstein uses Heidegger's statement that "the nothing noths" to illusutrate his approach.  He does not believe that we need to develop a philosophical theory of the nature of reality to ascertain whether or not Heidegger's statement is true, but rather we need to diagnose what led Heidegger to make this claim, searching for reasons that might even be termed "unconscious."  By bringing back the philosopher to the ordinary linguistic usage, we should be able to cure him or her of the urge to think there was a deep conceptual problem to be solved.  The parallel between Wittgenstein's method and Freud's is interesting, although it's unclear how far the connection between the two illuminates either.  What is clear is that this tells us very little about psychiatry, since it is simply addresses the very general issue of the nature of philosophy.  

Eric Matthews addresses a solidly conceptual question in "How can a mind be sick?"  Matthews tries to steer a course between biological reductionism and Szasz's antipsychiatry: he resists the view that mental disorders must necessarily be physical disorders, but equally resists the view that mental disorders are simply cases of behavior that differs from social norms.  He traces the problem to the difficulty in conceptualizing the nature of mind and its relation to the body.  His solution to the problem is pluralistic, that there are several ways in which a mind can be sick.  But his main focus is on developing a notion of consciousness from Merleau-Ponty as a way of illuminating the concept of mental disorder.  He emphasizes the importance of embodied consciousness and the centrality of the concept of a person rather than a reduction of the person to a mind or body.  Of course, to what extent this approach really solves the mind-body problem is a matter for extensive discussion, and Matthews does not go into much detail concerning the implications of the approach for the nature of mental disorder.  Nevertheless, he does make a strong case that a phenomenological approach could be a productive one when addressing the conceptual puzzles that arise concerning mental disorder. 

In "Psychiatry and the law," Daniel Robinson steers the same course as Matthews between biological reductionism and antipsychiatry, but his topic is the moral standing of people with mental illness, and especially when they can be legitimately coerced into treatment.  He throws in his lot with the conservative political theory of Robert George as set out in his book Making Men Moral, as opposed to the liberal theory of Robert Dworkin.  However, it is hard to find a clear statement of a specific position that Robinson is arguing for.  He does say that, "it should be a principal commitment of psychiatry to develop and express as generous a disposition toward the dignity of the person as is found in the law itself," but it is hard to imagine who would disagree with this proposition.  It seems that Robinson's general outlook is to be wary of the use of state powers to deprive people of their liberty, but he gives very little detail about exactly how he would draw the line. 

Widdershoven and Widdershoven-Heerding propose a hermeneutic alternative to the predominant neuroscientific causal model of dementia.  One might expect this to be a replay of the long-standing debate between psychodynamic and "brain disorder" interpretations of bizarre beliefs, but they link their ideas to Gadamer rather than Freud.  In their paper "Understanding dementia: a hermeneutic perspective," they present a case of a woman on a psychogeriatric ward, who accuses her daughter of taking her money.  They suggest that all odd behavior becomes meaningful and even acceptable on their view.  They relate this to adopting a caring stance towards people, and say that one should "abstain from judgements about the adequacy of the person with dementia's perceptions."  This suggests that the primary aim of their project is not to find the correct explanation of the person's beliefs, but rather is about how to interact with her and her family in order to provide the best standard of care, and indeed the authors make an Aristotelian claim that ultimately understanding dementia is a practical matter connected with looking after the patient.  Their practical suggestions about how to help dementia patients make good sense, but it seems that their ideas could be summed up by saying one should be sympathetic and non-judgmental, and the heavy philosophical artillery used to justify their approach is unnecessary. 

Derek Bolton provides a more satisfactory discussion of the nature of explanation of mental disorder and human behavior more generally, in his article "Meaning and causal explanations in the behavioural sciences."  He summarizes the well-known split between causes and meanings in the history of psychiatric theory, and argues that this gap has been bridged with the new cognitive sciences.  Bolton argues that these show that meaning is encoded in the brain, and that the understanding of human behavior is firmly grounded in evolutionary theory, developmental psychology and the cultural sciences.  We can explain the symptoms of schizophrenia, for example, using multiple interacting levels of explanation, including neurosciences and systems of meaning.  He suggests that the "deconstruction" of the old dichotomies between physicalism and hermeneutics is an essential step for the progress of an integrated biopsychosocial science.  Bolton's chapter is programmatic, but those interested in a deeper exploration of these issues can look forward to the forthcoming second edition of the book he wrote with Hill, Mind, Meaning, and Mental Disorder.

In "Subjectivity and the possibility of psychiatry," Rom Harré synthesizes a number of philosophical perspectives into what he calls a discursive, constructionist approach heavily influenced by Wittgenstein and Goffman.  He emphasizes that the social is prior to the individual, and thus is unsympathetic to explanations of people's behavior that suppose they can have private languages.  With this approach, he briefly proposes that one of the problems of people diagnosed with multiple personality is that they incorrectly use pronouns, and they should use pronouns in way that acknowledges their own actions.  He makes the rather bizarre claim that "repairing grammar is repairing the mind."  He moves onto note that in the case of Alzheimer's patients, their use of personal pronouns is robust, and makes the even more surprising claim that, "According to Wittgenstein's 'expressive' account of the uses of language, the personal pronouns express one's sense of self in relation to others."  While paying attention to language is certainly important in interpreting other people, Wittgenstein is not often interpreted as providing a psychological theory.  If there are any studies that show that one cure mental illness or even relieve suffering through correcting people's grammatical mistakes, one would expect them to be better known.  Harré does not cite any.  Nevertheless, his claims are provocative, and he allies his project with other work in psychology so it might be counted as part of a productive research program. 

Grant Gillett and Harré jointly wrote a book entitled The Discursive Mind, so Gillett's article "Form and content: the role of discourse in mental disorder" can be seen as continuation of the discursive approach.  He emphasizes that conceptualizing the world is an interactive process.  Our conceptualizing of ourselves at least partly constitutes our own natures.  Gillett engages in the familiar debate between psychological and biological science, but he disagrees with Bolton and Hill's claim that mental explanation is a form of causal explanation, and suggests that the discursive view provides a better alternative account of mental explanation.  As he puts it, "Discursive explanations, in a way that differs from causal explanations, put the self-forming relational subject at the center of all mental explanations."  Gillett expresses sympathy towards Ian Hacking's well-known account of "the looping effect of human kinds," although he does not note that Hacking has used this account to express some skepticism about categories such as multiple personality and abused children.  While Hacking surely agrees that he need to use human kinds in the human sciences, he is less enthusiastic about their inevitability than Gillett seems to be.  Gillett proceeds to apply his account to the case of anorexia, which is exactly the kind of phenomenon Hacking's approach applies well to.  Gillett focuses on rather more biological details than conceptual, and he argues that a young woman's feelings about her gender and her development into womanhood can cause her to reduce her eating, which stops her menstruation and causes other physical changes in her body. 

There are some obvious difficulties in the discursive view defended by Harré and Gillett.  One immediately raised by Gillett's discussion of anorexia is how the view differs from standard psychosocial explanations of people's behavior.  Although they put more emphasis on the role of language, when it comes to particular examples, the kinds of theories they use when explaining human behavior come very close to those provided in standard psychological accounts.  More generally, it is not clear to what extent the discursive view is a collection of empirical claims and to what extent it makes conceptual, metaphysical, epistemological and methodological claims.  The fact that it is hard to be clear about these issues is a sign of vagueness in the discursive view.   We should welcome competition between approaches to mental disorder which steer the path between biological reductionism and antipsychiatry, and the debates between proponents of the phenomenological, discursive and integrated biopsychosocial approaches should lead to productive dialog, but the points of disagreement between the theories need to be more sharply defined and there needs to be more discussion of particular examples to see how the different approaches compare.  The articles in Nature and Narrative do contribute to this dialog but one wishes that there were more sharply defined interaction between them. 

Michael Musalek provides a thorough discussion of "Meaning and causes of delusions," but while he does refer to a number of philosophers in his article, it is far from clear what philosophical debate he is participating in.  He mentions the debate over the definition of delusion, this is not his primary topic.  His conclusion sets out the various kinds of meanings that can be investigated when presented with delusions, and his earlier discussion elaborates them at greater length.  His final sentence says that more research is needed to "clarify the significance of the various meanings of delusions in the pathogenesis of delusional states and their effects as disorder-maintaining factors."

There is more of a philosophical argument in Katherine Morris' "The phenomenology of body dysmorphic disorder: a Sartrean analysis."  She explains that she uses phenomenology as a method to find the essence of what is experienced by people with the disorder, and makes great use of Katharine Phillips' book about BDD, The Broken Mirror.  Morris distinguishes between the body-as-physical-thing, the body-as-physiological/biological-object, the body-of-the-other, the lived-body-for-itself, and the lived-body-for-others.  She identifies various elements in BDD: longing for invisibility, nausea or self-revulsion, alienation, inapprehensibility meaning that the BDD sufferer wants to know with certainty how others view him, and responsibility without control.  Her conclusion is that BDD is "a specific disorder of the 'lived-body-for-others,'" and she recommends that this result should be inform the DSM categorization.  Controversially, she suggests that it is phenomenologically misguided to provide a sociological explanation of the occurrence of BDD.  She agrees that the content of the disorder is influenced by culture, gender and the media, but says the occurrence is essential to humans living among others.  Her argument against the sociological approach is brief, and many will be puzzled how there could be an a priori argument to demonstrate such a conclusion. 

Continuing the phenomenological side of the book, Natalie Depraz contributes a chapter on, "Putting the époché into practice: schizophrenic experience as illustrating the phenomenological exploration of consciousness."  She uses the case of schizophrenic experience to call into question the common distinction used by those in the philosophical phenomenological tradition between ordinary experiences shared by most people and limit-experiences that are difficult to communicate.  She argues that the schizophrenic époché combines a transcendental disturbance of familiarity with a radical existential disturbance.  Depraz's discussion is admirably sophisticated, and does a wonderful job at showing the richness of a phenomenological approach to the understanding of experience.  However, it is somewhat surprising that in a paper that highlights the importance of understanding of experience, there is so little discussion of actual cases of schizophrenia.  For example, Louis Sass in his groundbreaking Madness and Modernism and many of his articles makes far clearer exactly what aspects of schizophrenic experience he is talking about.  Depraz briefly refers to four cases in a long footnote, and her bibliography does list a number of other works about schizophrenic experience.  One might hope that her recent book, co-authored with Varela and Vermersch, On Becoming Aware: The Pragmatics of Experience, take the opportunity to discuss actual experiences in far greater detail. 

Alfred Kraus provides another sophisticated discussion of phenomenology with "How can the phenomenological-anthropological approach contribute to diagnosis and classification in psychiatry?"  He explains that P-A (phenomenological-anthropological) psychiatry makes holistic diagnosis oriented to the person.  He thinks that this approach can complement the S-C (symptomatological-criteriological) approach to diagnosis of the ICD and DSM, using the examples of melancholia, hypomania and hysterical personality disorder.   Controversially, Kraus supposes that one's lived experience can be disclosed without any theoretical presuppositions, and he distinguishes between different approaches to phenomenology: eidetic phenomenology, the phenomenology of constitution, and existential-hermeneutic.  His discussion of these is brief, but fortunately it is possible to follow the main points of his subsequent discussion without worrying too much about these distinctions.  The central idea in his approach, that one needs to understand the person as a whole rather than as a collection of symptoms, is illustrated in his discussion of particular mental disorders, and Kraus also explains how his approach can improve the relationship between the clinician and patient, especially in psychotherapy and rehabilitation.  Given the limits of space, it is doubtful that Kraus has said enough to win over true-believers in the DSM, and he says nothing to compare the P-A approach to other alternatives to S-C diagnosis, but he does at least provide a guide to further reading on the topic.

One of the rising topics in philosophy of psychiatry is that of nonsense, addressed in the paper by Markus Heinimaa, "Incomprehensibility."  Some researchers have suggested that it is part of the essence of some mental illnesses that the words or actions of those with the illnesses are incomprehensible, and this immediately raises the question of what counts as incomprehensible.  Some other approaches to mental illness, especially hermeneutic or psychodynamic, take an opposite stance, showing the underlying meanings of the words or actions of the mentally ill.  Both approaches raise the issue of to what extent it is possible for a clinician to understand a patient.  Heinimaa surveys some of the psychiatric and philosophical literature on the topic, paying particular attention to the work of Wittgenstein.  He argues that "saying that something is incomprehensible is not an explanation at all, but just an expression of despair when our ordinary ways of comprehending people and situations elude us."  He concludes that this insight can be helpful to clinicians when frustrated in their efforts to communicate with patients.  This area of research seems particularly interesting, and Heinimaa's paper should help to spur further discussion.

Gerrit Glas tries to combine biological and existential approaches to psychiatry in "Anxiety -- animal reactions and the embodiment of meaning."  He surveys some common biological theories and the set out different kinds of psychodynamic causes of anxiety, as related to loss of structure, existence as such, lack of safety, unconnectedness, doubt and inability to choose, meaninglessness, and death.  He then brings in the work developed during the 1950s of the Dutch philosopher Herman Dooyeweerd as a way to integrate different perspectives.  Glas concludes that Dooyeweerd's work is very promising in this enterprise.  Given the limited length of the paper, it is inevitable that all he can to is provide a sketch of his project but he does make a case that it is worthwhile.  Since Dooyeweerd is an unfamiliar name for most philosophers and clinicians, others may be reluctant to invest much time in exploring his work until there is more decisive evidence that his approach will help to advance our understanding the relation between the biological and the psychodynamic, but one may at least look forward to Glas' other work in this area to see the strength of the research program.

In one of the more technical pieces in the collection, Werdie van Staden and Christa Kruger discuss "Linguistic markers of recovery: semantic and syntactic changes in the use of first person pronouns in the course of psychotherapy."  They briefly present the results of their empirical study, which shows a change in semantic use of first pronouns after psychotherapy, but no significant change in syntactic use.  They then explore the theoretical implications of this result, emphasizing the way that their study combines the study of meaning with scientific method.  They conclude with some practical consequences of their work. 

The book ends with a paper on "Magic, science, and the equality of human wits" by Paolo Rossi.  Rossi surveys the role of magic in pre-modern thought and the importance of the rise of science in the modern era.  It is hard to see why the editors saw fit to include the paper in the collection, since it includes no discussion of concepts of madness or mental disorder. 

As a whole, this collection is especially valuable for its presentation of more unusual perspectives in philosophy of psychiatry. Many of the papers make a strong case for the value of hermeneutic and phenomenological approaches to psychiatry, and address the issue of how to integrate those approaches with more mainstream psychiatric models.  The book should appeal to those with a background in philosophy and with at least some knowledge of clinical psychology.  The book's subtitle is somewhat misleading, since it is hardly an introduction to the new philosophy of psychiatry.  Despite the admirable attempts of the editors to tie the papers together in their introductory chapter, the most striking feature of the collection is its disunity.  The book would not be appropriate for use as a textbook in an introductory undergraduate course to this field, and it would have to be supplemented by a great deal of more central material if it were used in a course for graduate students or professionals.  Nevertheless, philosophers and mental health professionals who want to get a sense of some of the work being done to understand the debates at the foundations of the study of mental illness should find a provocative assortment of ideas in Nature and Narrative.

© 2004 Christian Perring. All rights reserved.

Christian Perring, Ph.D., is Academic Chair of the Arts & Humanities Division and Chair of the Philosophy Department at Dowling College, Long Island. He is also editor of Metapsychology Online Review.  His main research is on philosophical issues in medicine, psychiatry and psychology.