New York University
Nosology Wars!: The Concept of Disorder and the Future of Psychiatric Classification.
We are living through an interesting and rather tumultuous time in the history of psychiatric nosology. I will provide an overview of how we got here and, I’m afraid, a rather skeptical and conservative assessment of various proposals for where we should go in the immediate future. I will be guided by my “harmful dysfunction” analysis of the concept of mental disorder, which I will briefly explain and defend with some recent supportive evidence. The tumult arises from the widespread perception, which I will argue is not wholly accurate, that the dominant “neo-Kraepelinian” (or better, I will argue, “neo-Spitzerian”) approach to psychiatric diagnosis and classification has decisively failed, leaving psychiatry without a conceptual framework. Keeping in mind Santayana’s aphorism that “Those who cannot remember the past are condemned to repeat it,” I argue that the origins of the current system lie in foundational conceptual issues of psychiatry’s medical legitimacy that cannot be ignored lest psychiatry confront a new antipsychiatry challenge, and that the proposals on offer to replace the current neo-Kraepelinian system fail to adequately address this issue.
Standpoint Theory and the Psy Sciences :
Can Marginalization and Critical Engagement Lead to an Epistemic Advantage?
As participatory research practices are increasingly taken up in health research, claims related to experiential authority and expertise are frequently made. Here, in an exploration of what grounds such claims, we consider how feminist standpoint theory might apply to the psy sciences. Standpoint theory claims that experiences of marginalization and critical engagement can lead to a standpoint which offers an epistemic advantage within a domain of knowledge. We examine such experiences of marginalization and critical engagement in the mental health system, as well as evidence for epistemic advantages resulting from these experiences. This evidence, found in the identification of problematic assumptions and the development of new tools and theories in the field, grounds our argument that standpoint theory is indeed relevant to the psy sciences and that many of those who have experienced marginalization and engaged critically have an epistemic advantage when it comes to knowledge production. The implications of this argument are significant: those who have attained a standpoint within the psy sciences ought to be included in research and given both tools and funding to develop research programs. However, we must be weary of risks of tokenization, cooptation, and essentialization that are likely to accompany such a transformation.
The concept of mental disorder revisited: Robustly value-laden despite conceptual change
Our concept of disorder is changing. This causes problems for projects of descriptive conceptual analysis. Conceptual change means that a criterion that was necessary for a condition to be a disorder at one time may cease to be necessary a relatively short time later. Nevertheless, some conceptually-based claims will be fairly robust. In particular, the claim that no adequate account of disorder can appeal only to biological facts can be maintained for the foreseeable future. This is because our current concept of disorder continues to be laden with ethical and political values in multiple different ways.
University of Texas at San Antonio
Rethinking Objectivity in Psychiatry: Unmuting Patients in Epistemic Practices
One of the central aims of psychiatry is to identify the properties of mental disorders to enable their diagnosis and treatment. As a branch of both science and medicine, psychiatry draws on a variety of scientific and medical practices to glean information about these properties. These practices include scientific research on mental disorders, such as clinical drug trials for depression treatment, as well as clinical research, such as case studies on treatment resistant depression. The ultimate goal is to develop effective interventions into mental disorders. While the first-person experience and reports of individuals with mental disorders provide unmatched resources for investigating the properties of mental disorders and designing effective interventions, dominant psychiatric frameworks have not systematically included patients in the scientific inquiry. Patient communities are rarely considered “subjects” who produce knowledge. Rather, patients are “objects” of investigation, e.g., when they are recruited for clinical trials. This problematic epistemic exclusion is most evident in the creation/revision process of the Diagnostic and the Statistical Manual of Mental Disorders (DSM), i.e., the primary classificatory schema used to expand knowledge on mental disorders. From the publication of the DSM-I (1952) to the DSM-5 (2013), patients were never part of the decision-making process. While there were extensive calls to the APA to include patients and their families in the DSM-5 revision process to make it more democratic, the APA opposed this on epistemic grounds, suggesting patients’ involvement would compromise psychiatry’s commitment to objectivity.
In this paper, I argue there are epistemic – rather than exclusively social/political – reasons for including individuals with mental disorders in psychiatry’s efforts to identify the properties of mental disorders. In the context of the crisis, controversy, and uncertainty in current mental health research and treatment, individuals with mental disorders can serve as important resources to enhance psychiatric epistemology. I challenge APA’s position by demonstrating the notion of objectivity operant in its reasoning is insufficiently examined. It is reminiscent of positivism which characterizes objectivity as “detached” or “impartial” knowledge. An account of scientific objectivity developed by feminist philosophers is a better fit for psychiatry. As a collective enterprise shaped by a variety of scientific and medical practices that aim to develop effective interventions for mental disorders, psychiatry requires the inclusion of patients’ perspectives if it is to be objective. In what I call the Participatory Intersubjective Objectivity in Psychiatry (PIOP) view, psychiatry represents the activity of an expert community, including those with technical expertise (medical professionals) and those with experience-based expertise (patients). The engagement between different kinds of experts not only allows a diversity of views to go through a process of transformative criticism, enhancing objectivity, but also facilitates the development of effective treatments of mental disorders that will help patients flourish, not just survive.
Mohammed Abouelleil Rashed
Welcome ISSF Research Fellow, Department of Philosophy
Birkbeck College, University of London
Desiderata of a Theory of Understanding for the Mental Health Encounter
In mental health encounters the meaning of certain experiences and behaviours is often contested among the involved parties. Relevant phenomena include voices (auditory hallucinations), unusual beliefs (delusions), and loss of control over one’s thoughts and actions (passivity phenomena). Typically, one party gives an account of their experiences, while the other (e.g. a clinician or family member) contests that account. These phenomena challenge everyday understanding, as we might not know what it is like to have the experience in question, and we might fail to understand it in light of the person’s other mental states. And so, we appeal to explanatory and interpretive accounts, ranging from neuropsychological theories to psychoanalytic interpretations, and from sociological theories to philosophical analysis.
Experience in Delusion
Delusions are the irrational—sometimes bizarre—beliefs that are characteristic of psychosis in psychiatric and neurological illnesses. In recent years, cognitive neuropsychiatrists have attempted to answer two fundamental questions about delusions: How are delusions formed? And why are they retained in the face of their inconsistency with other beliefs and with the evidence? The various answers to the first question universally include a role for abnormal, or “anomalous,” experiences in delusion-formation. In this talk, I review the place of experience in models of delusion and argue that theorists would be better served by omitting it from future models.
Université du Québec à Montréal
Epistemic justice and epistemic authority on autism
Autistic people often face multiple forms of epistemic injustice in many contexts, whether medical, clinical, familial, social, professional, or academic. Epistemic injustice often undermines autistic people’s epistemic authority regarding their own experience of themselves and of the world. In this talk, I identify and argue for criteria that justify epistemic authority on autism and that foster greater epistemic justice for autistic people.
Université du Québec à Montréal
Autism and Epistemic Disablement
The contrast between third- and first-personal accounts of the experiences of autistic persons has much to teach us about epistemic injustice and epistemic agency. This paper argues that bringing about greater epistemic justice for autistic people requires developing a relational account of epistemic agency. We begin by systematically identifying the many types of epistemic injustice autistic people face, specifically in connection to general assumptions regarding autistic people’s sociability or lack thereof, and by locating the source of these epistemic injustices in neuronormativity and neurotypical ignorance. We then argue that this systematic identification pushes us to construe epistemic agency as resulting from a fundamentally relational and dynamic process between an individual, others around them, and their social, cultural, or institutional environment, rather than as a fixed and inherent property of individuals. Finally, we show how our relational account of epistemic agency allows us to introduce the novel concepts of epistemic disablement and epistemic enablement. We argue that these two concepts allow us to more accurately track the mechanisms that undermine or facilitate epistemic agency, and thereby to better understand how epistemic injustice arises and to design more effective interventions to foster greater epistemic justice for autistic people.
Hunter College and The Graduate Center,
City University of New York
Madness as strategy and mad resistance
I present a novel framework for reading the history of psychiatry. I suggest that we read this history not as a clash between proponents of a biological approach to madness and proponents of a psychological approach, but between those who see madness as purposive, as serving a function or goal for the individual (which I call “madness as strategy”), and those who see madness as a failure of a purpose, or as a dysfunction (“madness as dysfunction”). Additionally, I place madness as strategy in dialogue with the movement alternately known as mad pride, mad resistance, or mad activism. What is their relationship, if any? I suggest that madness as strategy can help us to articulate what mad resistance is opposed to, its foil, and that it presents us with one possible way of rethinking mad identity outside of the dysfunction framework.
Universty of Oxford
The Phenomenology and Ethics of P-Centricity in Mental Capacity Law
Under the Mental Capacity Act 2005 in England and Wales (MCA), persons who are not found to lack capacity are free to make one or more of their own decisions regarding their care, treatment, and financial affairs. The liberal commitment to subjective freedom and self-determination guides statutory requirements towards persons with capacity – if one has capacity, one is free to make one’s own decision, no matter how unwise it may be (s.1(4)). By contrast, individuals who lack capacity are subject to best interests decisions and are not necessarily granted the same freedom or right to self-determination. This suggests two normative imperatives of autonomy and welfare that orient obligations owed to individuals within the MCA. These imperatives not only potentially demarcate the treatment of persons depending on which side of the capacity divide they occupy, but also characterise a potential conflict within the best interests standard itself. The MCA’s requirement that best interests decisions must consider the wishes, feelings, and values of P (or protected party) can be dismissed through an appeal to other, putatively ‘objective’ considerations of best interests, suggesting limits to the liberal commitment to subjective freedom in judicial interpretations of the best interests standard. Cases involving significant communication barriers or longstanding / lifelong incapacity due to profound disability illustrate particularly inconsistent interpretations of how best to discharge one’s legal and ethical obligations to P within the best interests standard. Failure to provide moral and legal clarity in terms of what is owed to P is symptomatic of two broader issues within mental capacity law. First is a problem of normative framing, where issues of moral complexity and uncertainty are commonly treated as reducible to a conflict between the values of autonomy and paternalism. Following on from the reductive normative framing of the MCA is the second problem of how its P-centric ethos has acquired an overly subjectivist inflection, thereby rendering unclear the import of this ethos as a way of negotiating the moral uncertainty that characterises much of best interests decision-making. In this stark normative landscape, P-centricity in the best interests standard, and the empowerment ethos within the MCA more generally, is thought to entail a liberal commitment to subjective freedom, where the preferences of the individual are treated as paramount.
These two issues combined have led to an impoverished understanding of P-centricity as a common normative grounding for obligations to all individuals, regardless of where they sit on the capacity divide. In this paper I want to critically examine the concept of P-centricity as a means of clarifying, enriching, and deepening our normative orientation towards persons in best interests decision-making, of which will also have implications for persons not found to lack capacity. The meaning of a P-centric ethos is particularly important to explore in cases that involve persons who have lacked decision-making capacity all their life and/or where communication barriers make it difficult to determine their values in judicial deliberation. Exploration of the common normative grounding across the capacity divide will help reveal that a P-centric ethos in mental capacity law is not reducible to the uncritical accession of P’s subjective wishes, and at a deeper level, involves the phenomenological and ethical stance of moral considerability and recognition respect. This paper argues that this analytic lens can help confront and navigate the moral complexity that is intrinsic to the best interests standard and mental capacity law more generally, even as decisions are often oversimplified to the binary frame of autonomy vs. welfare.
Operational Definitions, Open Concepts, and the Re-emergence of Nonspecific Psychiatric Distress
The DSM has been criticized for adopting a checklist approach to diagnosis. In this approach, psychiatric disorders are constituted by lists of symptoms for which there are multiple ways to meet criteria and two people can be assigned the same diagnosis even though they share few symptoms in common. When the multiple ways to meet criteria criticism was first articulated, it might have been considered a bit silly, but when repeated enough it came be seen as a valid criticism. In part, as the DSM has become more dominant, this criticism accrued some validity while still seeming a little silly to others. In this talk I will take a closer philosophical look at operational definitions and open concepts as partial and extendable in many directions. Some of the criticisms of the criterion approach to diagnosis are not so much identifying flaws as they are describing features inherent to partial concepts. I will describe how non-specific symptoms of distress extend beyond the partial concepts called operational definitions. Such symptoms have recently been re-emphasized in studies of psychosis risk and the factor analytic models of the psychologists. I will briefly explore these studies and describe one implication of non-specificity, namely, that psychiatric distress is sometimes less determinate than our conceptual proclivities demand.
University of Utah
Square Pegs, Round holes: the problem of ‘naturalized norms’ in accounts of well-being
The task of finding the place of the normative in the natural world is of central importance to those working on the philosophical issues surrounding human health and well-being, as they come into contact with our fast-developing human sciences. It is no surprise, then, that Peter Railton’s notion of ‘naturalized norms’ from his 1986 paper ‘Moral Realism’ has recently been taken up by philosophers wishing to naturalize the goodness or badness of various physical and psychological conditions, ranging from diseases like Generalized Anxiety Disorder, to disabilities like Down’s Syndrome, and injuries or degenerative conditions like dementia. The hope is that an empirically and normatively adequate theory of mental illness will be able to help us identify all and only genuine cases of psychological suffering, in order that we can better classify, explain, and intervene on these conditions.
In this paper however, I take issue with Peter Railton’s account of naturalized norms, and with their ostensible place in theorizing about what is known as relational or instrumental good, good for-ness, or what is in our best interest. My primary purpose is to complicate a piece of the puzzle which has all too often been used unquestioningly by theories of health and disease. First, I will closely examine the notion of a naturalized norm as it appears in Railton’s original architectural example (known as the snow and rooves case). I will argue that Railton infers more than what is justified from the facts surrounding the snow and rooves case by overlooking hidden assumptions about what is central and what is peripheral to achieving a particular goal. Then, by introducing my own example (which I will call the pegs and holes case), I will extrapolate on what is and isn’t implied by having a fixed goal in mind. Finally, I will return to thinking about mental well-being in psychiatry, and examine how naturalized norms can and have been used in establishing what ought to be done in the pursuit of health. It is this same confusion about naturalized norms, I argue, which lies at the heart of many crucial debates about disability and disease, as well as how to achieve the good life.
University of Birmingham
The Agential Stance: How to support young people in mental health clinical encounters
In this paper we ask what it takes for a practitioner to support a user’s sense of agency within a mental healthcare encounter. Our emphasis is on users who are also young people and seek help during a crisis, though the themes considered here can as well apply to different clinical populations and, with some qualifications, to personal relationships more widely. In our project we bring together a group of young people, clinicians, and academics from philosophy, psychology, and psychiatry to learn what undermines and supports young people’s sense of agency by using real-life video-recorded mental healthcare encounters. Our question is this: in a mental healthcare context, what does it take for a practitioner to interact with a user in a way that does not undermine the user’s sense of agency? In the paper we plan to provide a preliminary answer to this question by offering a brief explanation and some examples for each of the themes we have identified. In order for a practitioner not to undermine a user’s sense of agency, the practitioner needs to validate the user’s experiences; legitimise the user’s choice to seek help; avoid uncritically labelling or objectifying the user; affirm the user’s capacity to contribute to positive change; and involve the user in the decision-making process. We discuss the implications of the agential stance for the clinical encounter and suggest that the results of our study can inform the training of mental healthcare practitioners.
Jonathan Y. Tsou
Iowa State University, Dept. Philosophy and Religious Studies
Natural Kinds, Projectability, and Levels of Psychiatric Classification
I argue that some mental disorders (e.g., schizophrenia, depression) are natural kinds (i.e., HPC kinds) insofar as they are classes of abnormal behavior underwritten by sets of stable biological mechanisms. The philosophical significance of this view is that classifications of HPC kinds yield robust and ampliative projectable inferences (i.e., reliable predictions) about members of a kind. My account of natural kinds in psychiatry is a defense of a qualified biological essentialism insofar as it suggests that natural kinds are constituted by a partly ‘intrinsic essence,’ which grounds the stability and reliability of projectable inferences (e.g., predictions about prognosis or treatment) produced by their classifications. I argue that systems of psychiatric classification (e.g., DSM, RDoC) should classify natural kinds. I explore questions concerning what levels of classification (e.g., mental disorders, behavioral signs, biomarkers) are suitable for the various contexts (e.g., research contexts, treatment contexts) in which psychiatric classifications are employed.
Max Planck Institute for the History of Science
Biomedical approaches to psychiatry rely on scientists’ capacities to translate laboratory findings, often from model organisms rather than human subjects, into clinical innovations. Translational research of this sort is infamously challenging, not in one way but in countless ways — new sorts of challenges, in fact, are constantly being discovered as medical research progresses. In this talk we introduce the notion of “scope validity” as a way to describe the extent to which a model can account for phenomena in different contexts and at different levels of analysis in psychiatric research. The first part of this talk will discuss the diverse challenges to scope validity that can arise. The second part of this talk will critically assess ethical arguments that have been used to sustain the agenda of biomedical psychiatry on account of these worries about scope validity. We conclude that epistemic questions about the validity of translational research and ethical questions about the regulation of medical research need to be considered in conjunction with each other. Scope validity presents one way to productively assess the adequacy of psychiatric research in theory, in order to bring medical practice more in line with medical values.
Awais Aftab MD
Clinical Assistant Professor of Psychiatry, Case Western Reserve University, OH, USA
“Disorder” and the Legitimacy of Medicine
In this talk I examine the implications of treating disorder concepts (including less pathologizing alternatives such as “medical problem” or “medical condition”) as a way of referring to our current historically contingent domain of medicalized distress/disability/risk/harm and discuss the questions this brings up with regards to the legitimacy of medicine, especially in the realm of mental health. We have no universal “givens” to fall back on, no foundational truths in the form of “disorder” concepts, but there are legitimate reasons for medicine (and psychology, and social work, and service users, etc.) to take on this domain with tools medicine has at its disposal (and correspondingly, the tools other communities have at their disposal). These reasons arise from and are justified by the norms of the medical community, the particular history in which it exists, and the relationships it has with other communities. Such an understanding of medicine brings up implications with regards to pluralism and standpoint epistemology that I will also briefly touch on.
City University of New York
Etiology, Distress and Disability, and Dysfunction in DSM III-DSM-5
There were three distinctive features of DSM-III and future iterations of the APA Diagnostic and Statistical Manual of Mental Disorders that supposedly distinguished them from DSM-I and DSM-II. DSM III-DSM-5 were advertised as atheoretical in nature, in contrast to the psychoanalytically informed DSM-1 and DSM-II; they offered operational definitions of mental disorders in line with the so-called medical model of mental disorders; and distress and/or disability and dysfunction were included in a new definition of mental disorders. In this talk I suggest that DSM-I and DSM II were less theoretical, and DSM-III-DSM-5 more theoretical, than is generally supposed; that DSM-III-DSM-5 did not offer operational definitions in line with the medical model as traditionally understood; and that the inclusion of distress and/or disability and dysfunction in the definition of mental disorders in DSM-III-DSM-5 created problems and surprising implications for the characterization and explanation of individual mental disorders.
Towards an Ameliorative Account of Psychiatric Disorder
The concept of disorder in psychiatry is as elusive as the concept of disease in medicine. Despite many efforts to analyze the history and present usage of the concepts, we still do not have an understanding that helps with resolving difficult cases. Using an example from medicine (migraine) and an example from psychiatry (grief) I will argue that what Sally Haslanger (2005) calls an “ameliorative approach” is more productive than conceptual and descriptive approaches at getting to the heart of what we want these concepts to do. I will take some initial steps towards such an ameliorative account.
University of Pittsburgh
Exemplars, thresholds and fetishes:
De-politicizing psychopathology within the philosophy of psychiatry
For the past century, a substantial stream of work within the philosophy of psychiatry has focused on psychopathology, spanning both continental and analytic traditions. While not universal, I will argue that the lion's share of this literature has consistently avoided or disengaged from questions regarding the politics, and irreducible political embeddedness, of the objects and subjects in question. Philosophy of psychiatry's distinct role in reinforcing status quo epistemic and clinical hierarchies has also gone largely unacknowledged and unexamined. Given this history, I will ultimately ask--and hope to discuss with attendees--what would need to change and where might we go?
University of Montreal
University of Manchester
University of Montreal
Sanneke de Haan
University of Bordeaux-Montaigne