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
Functional neurological disorders : it’s in your head, but not quite.
Amongst so-called « medically unexplained disorders », functional neurological disorders (FNDs) refer to a collection of particularly vexing symptoms for both patients and healthcare providers. From a philosophical perspective, the concern is primarily lexical and ontological: intermittently deemed « hysterical », « somatoform », « psychogenic », « conversion » or nowadays « functional neurological », these symptoms are generally construed as the bodily and cognitive manifestation of mental health disorders rather than of any organic disease. Besides, their clinical presentations can be so diverse and inconsistent over time that it is unclear whether they can appropriately be associated with a single nosological entity. Until recently, the sole criterion was that whereas suggestive of a neurological underlying condition on the surface, these symptoms turn out to be inconsistent with any known neurological illness once thoroughly investigated. As a result, FND has primarily been used as a diagnostic of exclusion, which is arguably neither satisfactory nor helpful. Yet FND is hardly a rare condition: it is estimated that approximately 30% of people who present to neurology clinics suffer from this type of disorders, i.e., distressing motor, sensory and/or cognitive symptoms that cannot be explained by any structural or organic lesion of the central nervous system.
Under the influence of several physicians and patients’ advocates however, FND has received renewed attention since the 2010s. Several attempts have been made to turn it into a positive diagnosis. They generally hinge upon a non-dualistic explanatory model, which involves complex interactions between the structural and functional levels of the central nervous system. Obviously, it is not up to philosophers to decide whether this model is medically sound and likely to prove clinically helpful. But as steadfast efforts are being made to improve both the comprehension and treatment of FND, there are epistemological lessons we can already learn here, especially concerning the development of medical knowledge and epistemic fruitfulness of therapeutic alliance, even in a rather inauspicious context of ignorance, prejudice and power imbalance.
Group Delusion and Folie à Deux
This paper explores the idea that delusions can be attributed not only to individuals but also groups or, in other words, not only individuals but also groups can be delusional. Groups can have beliefs (the “second variety of social epistemology” Goldman 2011), and they can satisfy the definition of “delusion” in DSM-5 or any similar definitions. A plausible candidate of group delusion can be found in shared psychosis or folie à deux where a delusional belief is transmitted from a “primary” individual to a “secondary” individual. A central question of this paper is whether the group delusion that P is summative or non-summative. It is summative if all (or most) members of the group believe that P (e.g. both the primary and the secondary believe that P); it is non-summative if it it is not the case that all (or most) members of the group believe that P (e.g. the primary believe that P but the secondary does not). I will argue that group delusions can be non-summative at least in some cases, in particular in the cases where the secondary’s delusional commitment is fragile in the absence of the primary.
University of Manchester
Mental Dysfunction and the Matching Problem
In the philosophy of medicine, Jerome Wakefield’s harmful dysfunction analysis claims that a condition is a disease or disorder if and only if it is judged to be harmful to the person and involves the failure of an internal mechanism to perform its evolutionarily selected function. Herein, I draw on Subrena Smith’s matching problem for evolutionary psychology to argue that the harmful dysfunction analysis is unable to account for mental disorder. In order for the harmful dysfunction analysis to show that an internal mechanism is failing to perform its evolutionarily selected function, it must be able to demonstrate: (1) that the affected mechanism produces the same sort of effect as some ancestral mechanism; (2) that the affected mechanism is phylogenetically descended from an ancestral mechanism; and (3) that the ancestral mechanism was naturally selected because its effect was fitness enhancing. However, the methodological resources to demonstrate the above are simply not available for the psychological and behavioural features that characterise mental disorder. Therefore, the suggestion that mental disorder involves a failure of an internal mechanism to perform its evolutionarily selected function remains underdetermined by the evidence. I finish by examining the implications for our understandings of the concepts of health and disease in the philosophy of medicine.
University of Montreal
What is the difference between medical assistance in dying and suicide?
In 2021 the Parliament of Canada amended its law concerning medical assistance in dying (MAID). The new law included, among other things, a two year exclusion clause for those seeking assisted dying based on a mental disorder as their sole underlying medical condition.
The possibility of permitting access to MAID for persons with mental illness was hotly debated during the legislative process and remains a topic garnering considerable attention by scholars and the public alike. In this debate, the use of MAID for suicidal ends has been frequently cited as an area of concern, and one that elicits two opposing views concerning the relationship between suicide and MAID. There are those who believe that MAID requests by persons with mental disorders are necessarily a reflection of suicidal thinking caused by a mental disorder (and are therefore pathological). By contrast, others argue that MAID requests by persons with mental disorders may be – at least in some cases - unrelated to suicidal impulses resulting from a mental disorder. If the latter, this leaves open the further problem of error. If we allow MAID for persons with mental disorder we run the risk of assisting in the death of a person who is really acting upon suicidal thinking. The opposite error is also possible, that a person is refused because we believe she is suicidal rather than making a legally permissible request.
In this paper, I interrogate the relationship between the terms assisted dying and suicide and the acts to which these terms refer. I argue that whether or not there are empirical differences between MAID and suicide is the wrong question. The real problem in this debate is normative rather than empirical, namely, in what circumstances should society intervene to prevent people from taking actions to end their lives? Reframing the problem in this way illustrates the continuity between a decision to request MAID and other types of permissible life-ending decisions that persons with mental disorders might make.
Sanneke de Haan
Self-illness ambiguity & self-medication ambiguity in depression: A case for relational authenticity
Psychiatric disorders pertain to one’s feelings, thoughts, perceptions, and/or actions: the kind of experiences that are narrowly related to who we are as persons. Psychotropic medication can have an impact on those same experiences. How then do you know whether certain thoughts or feelings are genuine expressions of yourself, or whether they are colored by your psychiatric illness, or by the medication you take? As Karp (2006) aptly summarizes the problem: ‘If I experience X, is it because of the illness, the medication, or is it ‘just me’?’. Self-illness and self-medication ambiguity have been reported with regard to various mental illnesses and may affect people’s well-being and treatment choices.
In this talk I will discuss some preliminary findings from a qualitative interview study on self-illness and self-medication ambiguity with people suffering from recurrent depressions. I will also address some difficulties with the notion of being yourself and will argue for a relational notion of authenticity.
On the Roles of False Belief and Recalcitrant Fear in Anorexia Nervosa
The DSM-5 highlights two essential psychological features of Anorexia Nervosa (AN): intense and recalcitrant fear of becoming fat or gaining weight, and body image disturbance, characterized by feeling or judging oneself to be fat or overweight, despite the fact that one is underweight. Of these two features, the literature has focused more on the body image disturbance, and in large part, implicitly or explicitly, grants false beliefs about body weight and shape a central role in the explanation of AN behavior. The talk will offer reasons for thinking that we should abandon the strong explanatory emphasis on false belief, and it proposes instead a stronger explanatory emphasis on recalcitrant fear. Moving emphasis from false belief to recalcitrant fear comes with explanatory gains and can supplement a number of different non-doxastic models of AN.
University of Bordeaux-Montaigne
Debunking the old myth of the psychiatric symptom as a “signifier”
In this presentation, I will first sum up some of the main theses I have carried out in my last book, L’éclipse du symptôme [The eclipse of the symptom] published in French in 2019. After a rapid presentation of the historical and epistemological results I have achieved, I will attempt a deconstruction of an old and long-lasting myth of the psychiatric historiography. This myth, which is still active in the French psychiatric literature and also frequently found in the English-speaking literature, amounts in saying that the psychiatric symptom is equivalent to a linguistic “signifier”. I will examine the origins of this myth in the French psychoanalytical literature and show its spread in the psychiatric literature from the 1960s onwards. Finally, I will highlight the importance of debunking this myth in order to clarify the causal explanatory role of the notion of symptom.
University of Maryland University College
Can Philosophy of Mind Improve Psychiatry?
Psychiatry is an intrinsically philosophical discipline. As a branch of medical science that sets out to improve mental health, it is grounded, unavoidably, in assumptions about the nature of mind and its relation to body.
I begin this talk by articulating, first, the principles that psychiatry takes for granted when it comes to the meaning of mind-body dualism and the importance of avoiding it. Second, I show how these principles misunderstand what dualism is in philosophy – so much so that psychiatry has been effectively shut out of the very meaningful debates about dualism in contemporary philosophy. Third, I suggest that beneath its anti-dualism dogma, psychiatry actually operates on the basis of the benign form of dualism that’s now common in philosophy of mind. As a science-based discipline committed to the reality of experience, psychiatry is implicitly grounded in property dualism – a perspective that accommodates the richness of our inner lives without sacrificing the unity of mind and body.
Finally, I show that when we accept property dualism as psychiatry’s foundation, we’re in a position to finally characterize the nature of mental health problems as distinct from purely biological diseases. We’re better placed to consider criticisms of psychiatry’s medical orientation, and to understand alternatives. Most importantly, we can let go of the endless debate between biological and biopsychosocial approaches to practice. Because psychiatry aims to understand and improve subjective experience, its success depends on the coherence of its philosophical mind-body picture.
Dan J. Stein, MD, PhD, DPhil
University of Cape Town
Problems of Living: Practising Psychiatry With Wisdom
Both philosophy and psychiatry are deeply concerned with “problems of living”. Kant asked “What can I know?”, “What must I do?”, and “What may I hope?”; questions that remain central in philosophy. In psychiatry, related questions arise about the nature of psychiatric diagnosis, the causes of mental illness, and the appropriate interventions for these conditions. It may be useful to contrast “Classical” and “Critical” approaches to questions about psychiatric diagnosis, etiology, and intervention; an “Integrative” approach that draws on the best aspects of these positions seems wisest. A number of “paradigm shifts” for psychiatry have recently been proposed, including by those working on clinical neuroscience, public mental health, evidence-based psychiatry, and positive psychiatry; instead an incremental and integrated approach to advancing the field may be optimal.
University of Sydney
Nature and Construction in Psychiatry
Social construction is often treated as an alternative to the reductive explanations that characterise biomedical psychiatry. But there must be some mechanisms by which social forces act on behaviour. Most theories seem to assume that standard psychological theories can describe the mechanisms. I will ask what difference it makes if we try to integrate models of abnormal psychology into a constructionist framework .
Michigan State University
Deep brain stimulation, electroconvulsive therapy, and the self
Deep brain stimulation (DBS) has been associated with alterations in self-related characteristics when
used to treat movement disorders and obsessive compulsive disorder (OCD). Yet there is significant
disagreement about the nature, extent, and frequency of these changes. Moreover, as DBS is being
investigated for use as a treatment for a wider variety of psychiatric conditions, questions about the
relationships among treatment, diagnosis, and self become increasingly important, given the centrality
of self-related characteristics to these conditions. In this talk, I aim to broaden the discussion about DBS
and the self by considering a related phenomenon – memory loss in people treated with
electroconvulsive therapy (ECT). I show that, with both DBS and ECT, it is important to understand not
just the “direct” effects of the treatment, but also the broader social narratives around these treatments
and the conditions they are used to treat.
University of Texas Southwestern
Folk metaphysical assumptions and the generation of formative cultural tropes
in mental health and criminal justice
DSM and ICD psychiatric diagnosis, and indeed diagnosis in the history of psychiatry, has long been confounded by the blending of illness concepts and concepts of immorality and criminality (that is, concepts of ’vice’). For example, consider Antisocial Personality Disorder, Pedophilic Disorder, Intermittent Explosive Disorder, among others. For this lecture I abridge key elements of a large monograph (Vice and Psychiatric Diagnosis, OUP, 2023) to address the intellectual and cultural sources of this confound. The lecture moves in several steps. First, I define the problem of what I call ‘vice-laden’ psychiatric diagnostic categories and provide examples of vice-laden categories and their significance. Second, I very briefly summarize a framework in Western intellectual history, what I call the “ Enlightenment split”, where social deviance associated with insanity/mental illness was culturally assigned to science and medicine, and social deviance associated with the old concept of sin and the newer concept of ‘crime’ was culturally dominated by the Abrahamic religions (Christianity, Islam, Judaism) and the emerging Western common and criminal law. Third, I elaborate the concept of ‘folk metaphysical assumptions’, which are assumptions about the nature of reality that are naively presupposed into our everyday affairs. Fourth, I compare and contrast the folk metaphysical assumptions of post-Enlightenment medicine/science/psychiatry with the culturally prevalent folk metaphysical assumptions in Western common and criminal law, as well as the aforementioned Abrahamic religions. Finally, I relate the insights of these comparative folk-metaphysical assumptions to the issues of vice-laden mental disorders identified in the first part of the lecture. Implications, which are far-reaching, are very briefly mentioned in conclusion.
University of Melbourne
Concept creep and mental illness
The boundaries of psychiatric conditions and of ‘mental illness’ itself are widely acknowledged to be indistinct or even arbitrary. This recognition has grown with the rise of dimensional accounts of psychopathology and enduring concerns about diagnostic inflation. I will explore the shifting boundaries of mental illness from the standpoint of a research program on ‘concept creep,’ the progressive broadening of harm-related concepts. This program documents historical shifts in psychiatric concepts (both lay and professional), clarifies the cultural determinants of those shifts, and points to some of their implications for stigma, help-seeking, diagnosis, and the construction of illness-based identities. A concept creep framework sheds light on Hacking’s ‘looping effects’ – which I illustrate using the creeping concept of trauma – and on possible ironic effects of the rising public attention to mental illness.
St Catherine's College, University of Oxford
Linking Neuroscience with People: a Case Study in Values-based Practice and Person-centred Psychiatric Care
This presentation highlights through brief interactive exercises and a case study the role of values-based practice as one of the practical cutting edges of philosophy and psychiatry. The presentation is in two parts. Part I introduces values and values-based practice and describes how they underpin contemporary models of person-centred care based on shared clinical decision-making between clinicians and patients. Part II explores through a case study (of delusion and spiritual experience) the special challenges presented by these models for psychiatry focussing on the roles of values and values-based practice. The growing range of resources (both clinical and philosophical) for tackling these challenges is described. The presentation concludes with a ‘mental health first’ bottom line, arguing that psychiatry, just in virtue of the special values challenges presented by it, has a potentially leading role to play in establishing this model of person-centred care across medicine as a whole. The ‘next generation’ of philosophers and psychiatrists is already delivering on the promise of the model for twenty-first century person-centred clinical care.
University of Western Ontario
University of Southern California
Gould Law School
This talk will discuss my life-long relationship with schizophrenia. Although it may seem counterintuitive to think of one's psychotic illness as a "friend," I have found that my relationship with schizophrenia bears similarities to other important relationships in my life. My remarks will address how discovering and nurturing this life-long relationship—that is, "making friends with my schizophrenia"—has helped me find a life worth living. In this talk I will describe how I experience psychotic symptoms, the trajectory of my illness, how the use of state-sponsored force has threatened to destabilize fundamental aspects of my autonomy and identity in my journey toward recovery, and how the integration of medication and talk therapy has brought me to where I am today such that I no longer view myself as deeply at odds with my illness.
The University of Adelaide
Pain Suffering and the Self
The neuroscience of pain has moved a long way in the last few decades. The classic modular accounts distinguish “sensorimotor pain” and emotional suffering and associate them with different neural substrates. On these accounts some conditions such as “social pain” (of ostracism or humiliation) empathy and chronic pain are the result of activity in systems associated with distress, not primary sensory (nociceptive) processing. Recent “matrix” accounts of pain offer a different explanation. Complicating these questions is the degree of overlap between neural activity in conditions such as observation of another’s injury and injury to the self. Leading some to claim that empathy and pain experience depend on activity in the same systems. This is not quite right but it is suggestive.
I offer an Active Inference account of pain and suffering that reconciles tensions between different accounts. While active inference can be a highly technical theory in biophysics or neurocomputation we can detach the basic principles from the formalism. The core idea is that processing across the mind is anchored by a multidimensional self-model that co-ordinates regulatory activity for the organism’s benefit. The dimensional structure of pain and suffering reflects the dimensional structure of that model. I show how the patterns of association and dissociation between pain, suffering and self awareness can be explained by this model.
Some recent papers :
A vessel without a pilot: Bodily and affective experience in the Cotard delusion of inexistence
Alienation and identification in addiction
Self unbound: ego dissolution in psychedelic experience
University of Western Ontario
Sheffield Institute of Education
On Neurodivergent Power
In this talk I propose the concept of Neurodivergent Power as a liberatory tool for our theory and praxis for Neurodivergent and/or Mad social movements. I begin by considering how Mad and Neurodivergent people have historically been associated with deficiency, lack, and vulnerability. I go on to consider how, in recent decades, conceptions of Mad and Neurodivergent Pride have been developed as an alternative – and antidote – to this. I distinguish between two different conceptions of pride: individual “strength based” conceptions and collective, historically and culturally informed conceptions. I suggest that the collective conception has important benefits over individual approaches. At the same time, there are limits as to what even collective conceptions of Pride can achieve in terms of the liberatory aims of these movements. I end with a preliminary proposal for a concept of Neurodivergent Power, which draws on theorisations of Black Power as well as examples from Mad history and neurodiversity theory.
Quinn Hiroshi Gibson
Two Kinds of Depression, Two Kinds of Normativity
In this talk, I aim to bring together two things for the sake of drawing an important lesson about the normativity of mental disorder: (i) an argument for the importance of the distinction between what I will call endogenous and exogenous depression and (ii) general consideration of the metaphysics of disease literature. Endogenous and exogenous depression should be distinguished (even if they share a 'final common pathway') because they involve being in different relations to bad states of the world. Exogenous depression bears an intelligible relation to the badness that is its cause; in endogenous depression there is no such relation. As such, endogenous depression involves a kind of dysfunction that exogenous depression does not. What do the available views in the metaphysics of disease literature have to say about this? Typically, there are thought to be four available views: naturalism, normativism, hybridism, and eliminativism. I will argue that naturalism and normativism should be rejected (on familiar and novel grounds) irrespective of what they have to say about depression. Then I will argue that eliminativism better captures the different forms of badness in endogenous and exogenous depression, and their relation to one another, than hybridism can.
University of Massachusetts
“immature faculties”: Anorexia Nervosa in the developing mind
Much psychological and neurobiological research has been focused on deficient cognitive capabilities in those diagnosed with Anorexia. The age of most sufferers has received less attention. Yet recent research revises what we understand of the years at which AN first arises, with their own distinctive cognitive features. The cognitive development of most diagnosed with AN arguably assigns relevant aspects of their cognition and related behavior to the status of age-appropriate – perhaps even design-appropriate – rather than disordered, indicating that attributions of disorder to this condition when first diagnosed must be sought
Why would I want to stay in this world? The impact of the environment on severity, management, and motivation.
In this talk, I will bring together two themes I’ve previously written about: the impact of external environmental factors on neurodivergence and madness, and how madness can be alluring even when it’s terrifying.
It’s commonly recognized that neurodivergent people with conditions like autism and ADHD may need adjustments in, e.g., the school or workplace to be productive and flourish. However, the focus is often on small, local, and relatively cheap tweaks. Moreover, the importance of environmental factors is often overlooked in favour of more biological approaches when we move from common neurodivergencies to “serious mental disorders”.
However, there’s lots of research on how large-scale, structural and societal problems like poverty, racism, precarious job markets, etc., both give rise to and exacerbate psychiatric conditions across the board – “serious” conditions included. A person’s environment – and that includes everything from family life to workplace conditions to society in general – can trigger outbreaks and exacerbate the severity of existing conditions, make an already existing problem harder to manage, and may also affect the person’s motivation to manage.
Some bipolar people experience a kind of grand, cosmic madness in their manic phases. This kind of madness can be very tempting. Less obviously, prima facie terrifying types of madness may nevertheless offer an escape when reality becomes too hard to handle. Of course, people don’t choose to go mad in the same way as people may choose to go down to the pub and have a beer. Nevertheless, we may, at least to some extent, choose methods of self-management and how much effort we put into these. Self-management may be hard and therefore require a strong motivation to sustain – and one’s environment may seriously affect motivation.
Kennedy Institute of Ethics
at Georgetown University
Healthism, Elite Capture, and the Pitfalls of an Expansive Notion of Health
Many theorists and organizations have moved towards an expansive conception of health, modeled on the WHO’s definition of health as “a state of complete physical, mental and social well-being, and not merely the absence of disease and infirmity”. While there are advantages to this kind of flexible definition, in this presentation, I will explore the ways in which an expansive conception of health can be weaponized as a tool of oppression, surveillance, and social and embodied discipline. I look at four case studies, in which this weaponization has been especially striking: healthy eating, mental health, healthy sexuality, and healthy gender identity. I argue that health is a concept that is especially vulnerable to what Olufemi Taiwo has called “elite capture,” wherein elites are able to hijack the meaning of socially important concepts, and use them to serve their own social interests.