The Bloomsbury Companion to Philosophy of Psychiatry

Serife Tekin, Robyn Bluhm

• Publisher: Bloomsbury Academic
• Year: 2019
• ISBN:
  9781350024076
• Edition: 1
• Topic: Philosophy
• Subtopic: Mind & Body in Philosophy

This book explores the central questions and themes lying at the heart of a vibrant area of philosophical inquiry. Aligning core issues in psychiatry with traditional philosophical areas, it presents a focused overview of the historical and contemporary problems dominating the philosophy of psychiatry. Beginning with an introduction to philosophy of psychiatry, the book addresses what psychiatry is and distinguishes it from other areas of medical practice, other health care professions and psychology. With each section of the companion corresponding to a philosophical subject, contributors systematically cover relevant topics in philosophy of mind, philosophy of science, ethics, social and political philosophy, metaphysics, epistemology, phenomenology, and philosophy of medicine. Looking ahead to new research directions, chapters address recent issues including the metaphysics of mental disorders, gender and race in psychiatry and psychiatric ethics. Featuring discussion questions, suggestions for further reading and an annotated bibliography, The Bloomsbury Companion to Philosophy of Psychiatry is an accessible survey of the debates and developments in the field suitable for undergraduates in philosophy and professional philosophers new to philosophy of psychiatry.

Part One

Introduction

1

Introduction to Philosophy of Psychiatry

Şerife Tekin and Robyn Bluhm

Introduction

You are taking a philosophy class in the second semester of your sophomore year at college. The course requires close reading of fairly difficult historical texts, based on which the professor leads lively lectures and debates in class. Your friend April complains to you that she doesn’t understand anything in class. You advise her that she make sure to do the readings line by line, by paying attention to detail, and staying focused on the discussion that takes place in class, as you observe that she is rather distracted. She keeps checking her phone every few minutes, not listening to the professor during the lectures. She never participates in class discussion. You can tell that the professor and other students in class are irritated by her late arrival to and disruption of class. No one wants to do group homework with her especially after she lost one of your classmate’s lecture notes. It was rather surprising for you to see April like this because she took a couple of classes with you during her freshman year and she had performed well.

A couple of months later April leaves class just as you are about to write a test. You wonder why she is leaving. Next class you ask her what happened, and she tells you that she will be writing her tests in a quiet room by herself in the library. After asking you promise not to share it with anyone, she explains why. Her parents took her to a psychiatrist at the advice of few of her professors who had noticed the changes in April’s performance and that the psychiatrist diagnosed her with this illness called attention deficit and hyperactivity disorder (ADHD). It turns out that was why she was as distracted and inattentive in class. April doesn’t want her other friends know because she is worried that they will make fun of her.

You are rather puzzled: as your little brother, too, is diagnosed with ADHD, but his behavior does not at all resemble April’s. Your brother is super active, running around at inappropriate times and places, and talks a lot, even when it is not his turn to speak. He was so disruptive in classes, displaying erratic behavior, that his elementary school teacher contacted your parents and asked them to take your brother to a psychiatrist. You are surprised that both April and your brother have the same diagnosis because they behave completely differently: April is quiet, distracted, and inattentive, while your brother is loud, fidgety, intense, and active. You are also puzzled to witness the change in your feelings about April: initially you had thought that she was being a bad student who doesn’t respect her classmates or professor and disrupts class, but now you feel bad about having thought that way because it was the illness causing her to behave this way.

You also start to wonder how many of the apparently disruptive people who are not very good at what they do actually suffer from a mental disorder. Then you start asking yourself how is it that we distinguish a student who is unmotivated, or just a poor student, from one who is suffering from a mental disorder. If the same illness can express itself in completely different behavior how exactly can doctors detect it? Is April responsible for her behavior in class, or did her illness cause her problems? What can be done to help students like April so that they are not ashamed of their mental illness? How do you prevent others making fun of people with mental disorders? You may not realize it, but when you start asking these questions, you are doing philosophy of psychiatry.

Philosophy of psychiatry is a branch of philosophy that will help you answer, or at least make sense of, some of these questions pertaining to the experience of mental disorder, its scientific research and clinical treatment, as well as various social and political questions it raises. To understand how philosophy of psychiatry will guide you through these questions, we first review what philosophy is and then explain how the fundamental problems of psychiatry connect to the main branches of philosophy.

What is philosophy?

Philosophy, according to its Greek etymology, means “love of wisdom.” Beyond that, however, it becomes difficult to define, in part because there are a number of different, and sometimes conflicting, approaches to “love,” “wisdom,” and thus, “philosophy.” One approach to defining philosophy is to look at its methods and goals, as the philosopher Bertrand Russell does. Russell suggests that philosophy results from a critical examination of the grounds of our convictions, prejudices, and beliefs. It unifies and systematizes the body of the sciences, for Russell (1912). Thus, philosophy uses systematic and critical reflection, to search for truth exempt from prejudices, misconceptions, and falsehoods, and thereby to expand our conceptual framework for developing a true understanding of the world.

Another way to understand what philosophy is to think about its different branches, each of which aims to answer different kinds of questions. In what follows, we take this approach, which allows us to also show how the different branches of philosophy are related to philosophical questions about psychiatry. Specifically, we review philosophy of mind, philosophy of science, ethics, and social and political philosophy.

Philosophy of mind and psychiatry

There is a close link between philosophy and psychiatry. As discussed in detail by Mona Gupta in Chapter 1, psychiatry is the branch of medicine that aims to understand the causes of mental disorders, and to develop scientific intervention techniques to help those who suffer from them. One of the fundamental branches of philosophy is philosophy of mind, and it concerns the connection between the mind and the body by answering questions such as the following: How does the mind connect to the body? In other words, how do our mental states, such as beliefs and desires, or psychological states such as anger, relate to our physical states, such as the physiological processes of the brain or hormonal mechanisms? The answer to this question is intimately relevant to the problems of psychiatry; that is, if we understand how mental states relate to physical states, we can also understand what is going on in the body when, say, a person suffers from mental states such as depressed mood. For example, if you understand how mental states relate to physical states, you will be able to explain how your brother’s or your friend April’s ADHD causes different behaviors in each of them. Or, you would be able to make sense of how medications might regulate their behavior.

Additional questions in the philosophy of mind literature that are relevant to psychiatry include what the self is, that is, what makes someone the person they are. For example, you’ve heard your aunt say that your brother has become a different person since he started taking medication for his ADHD. You understand what she means, but have always thought it sounded strange to say so. Obviously, he is still himself, but what makes him that person? Would he still be the same person if he didn’t have ADHD, or is his ADHD part of what makes him himself? If ADHD is part of who she is, did April become a different “self” in your sophomore year from the one she was in freshman year?

For an accurate investigation of mental disorders, we not only need information provided from a third person perspective on mental disorders through scientific research, but also need an understanding of the first person encounter with mental disorders. The best resource for this is patients’ examinations and descriptions of their experiences of mental disorders. Phenomenology, as a philosophical study of human experience, can also be considered as a branch of, or approach to, philosophy of mind. It offers resources for philosophers of psychiatry to contemplate the “what it is like”-ness of mental disorders. Phenomenologists investigate the essential features of consciousness of human subjects, including selfhood, intersubjectivity, affectivity, and temporality. They explore how a meaningful, lived world is opened up for us, and how we make sense of it. In this respect, one of the best ways for you to understand what it is like to live with ADHD may be to talk to your friend April and your brother about their experiences with the condition, how they perceive their illness, as well as how the diagnosis of illness affects their lives.

Philosophy of science and psychiatry

Philosophy of science asks questions about the nature of things like scientific theories and explanations, as well as the nature of science itself. Increasingly, philosophers of science are also concerned with how best to use the results of scientific investigation to effect change in the world. Psychiatry, and medicine more broadly, is related to science, because scientific knowledge is necessary to medicine. And psychiatric research, for example in neuroscience and in psychology, is clearly an area of science.

It is commonly believed that the central aim of science is to develop an accurate picture of the causal structure of the world. If science helps us to understand causal relationships between phenomena, then we can use this knowledge to act effectively. For example, if we predict the speed of hurricane Irma as well as the locations it is anticipated to affect, we can take precautions so as to prevent damage to human lives. For example, we can encourage individuals who live in the most dangerous regions to evacuate their homes. Psychiatry, as a health science, has similar goals; it aims to offer an understanding of the causes and mechanisms of mental disorders in order to facilitate effective clinical and preventative interventions. One way in which it works toward these goals is to identify the generalizable features of mental disorders. For example, if we learn, through scientific research, what the features of depression are (such as significant changes in individuals’ sleeping habits, or weight, or significant loss of interest in previously enjoyed activities), we would be more successful in identifying a depressed person and therefore helping them receive treatment. Thus, the way in which we classify mental disorders, as say whether someone with psychological distress should rightly receive a diagnosis of ADHD, is crucial for psychiatrists to develop the right strategies for intervention. Going back to the thought experiment above, for example, psychiatrists identify two different types of ADHD, which is the reason for April and your brother having the same diagnosis but displaying different behaviors. The one that April suffers from is called inattentive type, while your brother’s is called the hyperactive-impulsive type.

But given our discussion of philosophy of mind, it’s natural to wonder how such different kinds of behavior are related to activity in the brain. If mental disorders are caused by changes in brain activity, does this mean that both April and your brother have the same underlying brain changes? A major goal of psychiatric research is to answer that question—and there is a lot of debate among both psychiatrists and philosophers of psychiatry over whether the current diagnostic categories used in psychiatry (as outlined in, for example, the Diagnostic and Statistical Manual of Mental Disorders [DSM], which, developed by the American Psychiatric Association, offers the standard criteria for the classification of mental disorder and used widely in North America and around the world, and the International Classification of Diseases and Related Health problems [ICD], which, developed by the World Health Organization, is the international “standard diagnostic tool for epidemiology, health management and clinical purposes”) do reflect a specific physical process. Psychiatry is unique in medicine in that diagnoses are based on psychological and behavioral criteria, rather than on a physical examination and the kinds of laboratory tests used in other medical specialties. There is also a great deal of debate over whether this is a good thing. Some people argue that understanding the biology of mental disorders is the best way for us to develop more effective treatments—and that this might require that we get rid of current diagnostic categories and replace them with more accurate ones. Others argue that focusing on biology will lead us to lose sight of the fundamentally psychosocial nature of mental disorders. How we should classify and explain ADHD and other mental health issues is very much an open question.

Another scientific goal in psychiatry is to depict the underlying causes of mental disorders. For example, if we know the underlying causes of ADHD are, we may develop better strategies to treat it so that people like your friend April or your brother do not suffer. The power of scientific research in psychiatry is that we can develop generalizations that will guide clinicians not only to help one or two individuals inflicted with mental disorders, but develop a systematic understanding, and therefore interventions for a whole population of those with mental illness. If we categorize similar phenomena under the same category, then what we know about one individual under that category may also be valid for another individual in the same category.

Questions about the nature of scientific classification and scientific explanation are central to philosophy of science and these have bearings on the science of psychiatry. Philosophers of science, for example, deliberate on whether there is a single, fundamental level of explanation to which all other explanations reduce. Reductionists accept this claim whereas pluralists maintain that explanations should involve multiple disciplines and span multiple levels. Connectedly, a fundamental debate in philosophy of psychiatry is whether mental disorders can be individuated and explained as a disorder of the brain, that can be delineated as the neuroscience matures (reductionism), or whether mental disorders can and must be explained at the multiple levels, not just the cellular level, but at the individual, social, and cultural levels (pluralism), requiring the cooperation of and collaboration with multiple sciences. Reductionists may argue, for example, that April and your brother’s ADHD will eventually be explained as an anomaly in their brain mechanisms, while pluralists would argue that we need multiple scientific approaches to understand ADHD not just neuroscience.

Ethics and psychiatry

Philosophers of psychiatry also discuss ethical issues related to how we should perceive and treat people who have been diagnosed with a mental disorder. For example, April received accommodations to write her exams after being diagnosed with ADHD. Some of your classmates or you may have thought initially that it is not fair for her to receive this type of special support to do well in her exam, however you may now understand that, from an ethical standpoint, the special features of her illness (e.g., being easily distractible) warrant her receiving support to be able to write her exam in a quiet room by herself. Also, remember how your attitude toward April has changed once you heard that she suffers from ADHD; instead of feeling frustrated with her inattentiveness in class you started feeling sympathy for her. But many people who have been diagnosed with a mental disorder experience stigma: people view them more poorly and treat them more harshly because of their diagnosis.

Another important theme in psychiatry is the capacity of those with serious mental disorders to make rational decisions and their ability to act as rational, autonomous agents, problems that are at the heart of ethics. If someone with a mental disorder lacks rational capacity and ability to act autonomously, then it is not clear whether the person bears the full responsibility for their actions in the spaces of morality and the law. Determination of the agency and autonomy of persons with mental disorders has profound implic...

Table of contents

• Cover
• Halftitle Page
• Title Page
• Contents 
• Notes on Contributors
• Acknowledgments
• Part 1: Introduction
• Part 2: Philosophy of Mind and Psychiatry
• Part 3: Phenomenology and Psychiatry
• Part 4: Philosophy of Science and Psychiatry
• Part 5: Ethics and Psychiatry
• Part 6: Social and Political Philosophy and Psychiatry
• Part 7: Metaphysics, Epistemology, and Psychiatry
• Part 8: Philosophy of Medicine and Psychiatry
• Annotated Bibliography/Further Reading
• Index
• Imprint