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Philosophy of Mental Health
ALASTAIR MORGAN
Learning Objectives
ā¢ Understand the importance of philosophical ideas in mental health theory and practice.
ā¢ Understand the four main themes of philosophical controversy in mental health care.
ā¢ Apply these themes to concrete examples in contemporary mental health practice.
Introduction
There is a strong case to be made that the discipline of philosophy should be central to all mental health care and practice. What is it about mental health and mental illness that should lead us to philosophical enquiry? Radden (2004) has articulated the centrality of philosophical questions to any interrogation of the concept of mental disorder. She writes that:
When we think through questions of what it means to experience mental distress we are immediately confronted with a range of philosophical questions. These can be questions about personal identity, ownership of thoughts and experiences and the nature of the self and its relationship to the world and other people. These can also be questions about how we can classify and label mental health conditions and what our evidence is for labelling them as diseases. How do we understand the biological underpinning of mental illnesses and what is the relationship between the mind and the brain? How are we justified in detaining and treating people with mental illnesses against their will?
Furthermore, the very nature of mental distress and the experiences that accompany it raise questions that are often akin to a process of philosophical questioning. Mental distress can be characterised as a set of experiences that are centrally concerned with meaning and the self in a manner quite different from physical illnesses. Although one might question oneās life, identity and relationships when diagnosed with a serious physical illness like cancer, it is not the illness itself that is a repository of such meanings but the impact it has on your life. In contrast, mental illnesses such as depression and psychosis are themselves full of meaning about who one is, how one relates to the world and the significance of oneās life and experience. Fulford et al. (2003) argue that the discipline of psychiatry is unique amongst medical specialities in that its central concepts and categories are not only difficult to define but highly contested. A person experiencing psychosis may not label their disorder in medical terms and may actively dispute any medical description of their experience as schizophrenia. Mental distress is thus a field of complex and contested definitions and an experience which itself is a crisis of meaning, identity and relations with the self and the world, hence the centrality of philosophical questions in mental health care and day-to-day practice (Fulford et al., 2003).
What is philosophy?
The literal meaning of philosophy comes from the Ancient Greek meaning ālove of wisdomā. In the Theaetetus, Plato outlines a concept of philosophy as a fundamental questioning of the basis of the world in an attitude of wonder (Plato, 1987). This fundamental questioning leads philosophy to a desire to uncover the foundations of knowledge. This philosophical project is encapsulated in the work of Descartes who wrote in his Meditations that his philosophical goal was to uncover the solid and certain foundations for all knowledge (Descartes, [1641] 1984). Interestingly, the method by which Descartes attempted to do this was through a radical scepticism; he doubted everything to try and identify a secure and certain foundation for all knowledge. In this project, Descartes united two key elements of philosophy, a critical and sceptical deconstruction of knowledge, alongside the attempt to provide foundational underpinnings for knowledge.
Later philosophers were critical of this attempt to provide certain foundations for knowledge as the supreme philosophical task. They preferred a more modest description of philosophy as a critical reflection upon the possibilities, justification and limitations of thought. This critical reflection may not produce certainty, only plausible beliefs based upon limited evidence. Hume argues that philosophy cannot provide ultimate foundations for thought and that it can only draw plausible and provisional conclusions based on a critical examination of the evidence of experience (Hume, [1739ā40] 2000). This conception of philosophy as critique, as the discipline that outlines the limits and boundaries of rationality became a key task of philosophy in the late eighteenth century and through the nineteenth century.
Philosophy is therefore an abstract enquiry into fundamental questions of existence, knowledge and morality. These areas are often broken down in the following manner as questions of ontology (namely questions about existence ā what kinds of things are there in the world), epistemology (questions of knowledge ā truth, validity, the limits of reason) and questions of ethics (what is right and what is wrong and how do we characterise a āgoodā society). This set of definitions makes philosophy sound very withdrawn from everyday life; however, increasingly philosophers have felt it important to be engaged in applications of knowledge and to try to clarify the concepts underpinning institutions, practices and ways of living.
Philosophy of mental health
Philosophy is characterised as the threefold investigation into questions of existence, knowledge and ethics. Therefore, philosophy of mental health can be characterised as an enquiry into these questions as they apply to mental health care (Thornton, 2007). In this chapter, I will focus on four main areas of interest for the philosophy of mental health. As Banner and Thornton (2007) argue that any philosophy of mental health needs to be oriented around practice and become a philosophy of mental health care, I will outline a contemporary issue that applies these philosophical questions in practice in each one of these areas.
The four areas for philosophy of mental health are as follows:
ā¢ The question of human consciousness, and particularly the relationship between mind and brain. How do we characterise the fundamental nature of human consciousness and what is the relationship between conceptions of the human mind or psyche and its biological underpinning in neurochemical processes in the brain? Can we reduce experiences that are attributed to a person to neurochemical reactions in the brain, or are these fundamentally different levels of explanation?
ā¢ The question of mental illness as a disease. Can we classify mental distress as a form of disease or is it better understood as a response to societal and individual pressures rather than a form of illness? Should we classify and label forms of mental distress and can these classifications be validated, or should we dispense with all classification and attempt to understand distress in individual or narrative terms?
ā¢ The question of understanding the subjective experience of mental distress. How is it possible to understand and empathise with a mad experience? Should we try to explain it through biological processes or is it possible to empathise and understand the content of madness?
ā¢ The ethical issues in psychiatry, particularly the question of coercion and care. The ethical underpinning of mental health practice will be addressed in detail in a later chapter of this book, so here I will just consider briefly a contemporary contested ethical issue in mental health practice.
Mind and brain
The background to the mind/brain problem in psychiatry is the question of the biomedical model in psychiatry. The biomedical model remains the dominant model in mental health care, but it has been contested right from the origins of psychiatry as an academic and clinical discipline in the mid-nineteenth century (Double, 2003). Fulford et al. (2006) outline the origins of present-day psychiatry in what is often termed its āfirst biological phaseā from 1850 through to 1910, when the first professor of psychiatry, Wilhelm Griesinger, famously wrote that all mental illness is a disease of the brain (cited in Fulford et al., 2006: 146). The goal of psychiatry was to define an area of illness for mental disorders that could be analogous with that of physical illness. Therefore, the idea was that all mental illness could be shown to have a biological underpinning in terms of a brain disease, and that the underlying basis of mental illness would be either some form of inherited genetic abnormality or a pathological alteration in neurochemistry. Underlying this belief was a larger philosophical claim for biological reductionism. This is the idea that all experiences of the person can be reduced to their determinants in the brain. A strong reductionism will argue that mental illnesses should not be understood as experiences occurring in a person, but only explained as biological abnormalities. The German psychiatrist Kurt Schneider gave a very succinct outline of this form of reductionism when he argued that when we assess a person experiencing psychosis:
Schneider, here, expresses a central belief of biological psychiatry. Engagement with the content of experiences is of limited importance. These are just surface expressions of an underlying disease process that is ultimately biologically determined and driven.
A variant of reductionism, which could be termed a weak reductionism, will argue that biological vulnerabilities interact with environmental stressors and personal experiences to produce illnesses. The stress vulnerability model in mental health care is a variant of a weak reductionist approach, in that it hypothesises a biological vulnerability that is then only later expressed or developed due to the stresses the person faces (Zubin and Spring, 1977).
The reductionist approach to human consciousness is based on a philosophical argument that all states of human consciousness can be fundamentally explained by their reduction to neurological states. A prominent exponent of such a view is the philosopher Patricia Churchland. She argues that when we want to explore what it means to think, feel and decide then we should not explore the meanings that a person attributes to such activities. Rather we should look at the neural underpinnings of the activities, and it is these neural underpinnings that ultimately explain our behaviour. Churchland (2004) writes that:
This reductionist argument leads to an emphasis on altering our neurochemical makeup through psychiatric drugs to ameliorate problems in our mental health (Moncrieff, 2008). However, many philosophers are critical of reductionist arguments and want to argue that complex human experience cannot be reduced to brain states and that it does make sense to talk about the mind rather than the brain. The philosopher Alva Noe has written that consciousness can only be understood in terms of an interaction between brains, bodies and environments. The term āmindā then can be used to refer to what Noe terms a āliving activityā rather than reduced to neural states (Noe, 2009: 7). Neural structures are of course necessary for consciousness to occur, but they are not the whole picture, and consciousness cannot be understood separately from human history, activity and culture, according to this argument. The biomedical model in psychiatry can therefore be seen to reduce minds to brains and to downplay the centrality of experience and society in the construction and causation of mental distress (Double, 2003).
Mind and brain: contemporary issues in neuroscience
One of the key contemporary interfaces where issues of mind and brain have come to the fore is through the growth of neuroimaging technologies. This is an area which is increasingly being used in mental health research if not in practice. Often subjects of research are asked to perform specific activities whilst having their brains scanned and then the results of such scans are produced and attempts are made to correlate brain activity with specific dysfunctions in people labelled with mental illness. These neuroimaging techniques are termed fMRIs (functional Magnetic Resonance Imaging). The use of the term functional relates to the notion of a research subject performing an activity whilst being scanned. The philosophical basis of much of this research is reductionist; the notion that you can reduce a complex set of behaviours, experiences and meanings to a specific activity that can then be correlated with levels of blood flow in the brain. These technologies that function through the production of images produce a powerful force for reductionist philosophies. As Johnson (2008) writes, these images function through producing a representation of a host of activities as reducible to brain states. These images of āactive brainsā are powerful cultural icons of our time. As Fernando Vidal (2009) has pointed out, we are replacing a concept of āpersonhoodā with a concept of ābrainhoodā, an identity that ultimately refers all meaning to patterns of activity at a neuronal level. Cohn (2004) has indicated how such neuroimaging remains tied to a notion of reductionism due to its isolation of all activity to a specific, calculable and repeatable set of functions that are then, themselves, only loosely mapped on to the production of chemical activity in the brain. The philosopher and physician Raymond Tallis has termed the dominance of neuroscientific discourse a form of āneuromaniaā (Tallis, 2011).
A central irony of this reductionist approach is that it has occurred at the time when biological science is moving away from reductionist models. This is particularly the case in genetics where the idea of defined heritable diseases through specific genetic abnormality is increasingly questioned in what has been termed the āpostgenome eraā (McInnis, 2009). Following the complete mapping of the human genome in the early twenty-first century, scientists were shocked to discover that there were far fewer human genes than had previously been hypothesised (McInnis, 2009). This has moved research away from the pursuit of discrete genetic abnormalities that could underlie mental disorders and towards the complex relationship between how genes are expressed and the interrelationship between environment and gene expression. As McInnis (2009) writes, this is a move away from the possibility of reducing complex mental disorders to singular genetic causes.
What this brief survey of current controversies in medical research in neuroscience demonstrates is the continuing relevance and importance of philosophical discussions of consciousness to current understandings and conceptualisations of mental distress. Do we understand mental distress as simply the byproduct of a neurochemical misfiring, or as the complex unfolding of human experience in response to interpersonal and societal stresses? Ultimately, in the absence of clear pathological underpinnings for most mental illnesses, this debate becomes one of philosophical argument and justification.
Can we classify mental distress as an illness?
A central philosophical question for the practice of mental health care is the ontological status of mental illness itself. When we talk about mental distress are we discussing a disease process that is akin to physical illnesses, or is it better to conceptualise mental ...
