Philosophy, Psychiatry & Psychology

Published by Johns Hopkins University Press
Online ISSN: 1086-3303
Publications
Past year illicit drug dependence, United States, 2004 (Substance Abuse and Mental Health Services Administration, 2004).  
Philosophers and psychologists have been attracted to two differing accounts of addictive motivation. In this paper, we investigate these two accounts and challenge their mutual claim that addictions compromise a person's self-control. First, we identify some incompatibilities between this claim of reduced self-control and the available evidence from various disciplines. A critical assessment of the evidence weakens the empirical argument for reduced autonomy. Second, we identify sources of unwarranted normative bias in the popular theories of addiction that introduce systematic errors in interpreting the evidence. By eliminating these errors, we are able to generate a minimal, but correct account, of addiction that presumes addicts to be autonomous in their addictive behavior, absent further evidence to the contrary. Finally, we explore some of the implications of this minimal, correct view.
 
Self-administered psychopathology questionnaire scores Note: The Rosenberg Self-Esteem Questionnaire has no normal limits, the higher the score the higher the self esteem to a maximum of 40 points  
This paper explores the ethical and conceptual implications of the findings from an empirical study of decision-making capacity in anorexia nervosa. In the study, ten female patients aged 13 to 21 years with a diagnosis of anorexia nervosa, and eight sets of parents, took part in semi-structured interviews. The purpose of the interviews was to identify aspects of thinking that might be relevant to the issue of competence to refuse treatment. All the patient participants were also tested using the MacCAT-T test of competence. This is a formalised, structured interviewer-administered test of competence, which is a widely accepted clinical tool for determining capacity. The young women also completed five brief self-administered questionnaires to assess their levels of psychopathology.The issues identified from the interviews are described under two headings: difficulties with thought processing, and changes in values. The results suggest that competence to refuse treatment may be compromised in people with anorexia nervosa in ways that are not captured by traditional legal approaches or current standardised tests of competence.
 
Effective treatment of personality disorder (PD) presents a clinical conundrum. Many of the behaviors constitutive of PD cause harm to self and others. Encouraging service users to take responsibility for this behavior is central to treatment. Blame, in contrast, is detrimental. How is it possible to hold service users responsible for harm to self and others without blaming them? A solution to this problem is part conceptual, part practical. I offer a conceptual framework that clearly distinguishes between ideas of responsibility, blameworthiness, and blame. Within this framework, I distinguish two sorts of blame, which I call 'detached' and 'affective.' Affective, not detached, blame is detrimental to effective treatment. I suggest that the practical demand to avoid affective blame is largely achieved through attention to PD service users' past history. Past history does not eliminate responsibility and blameworthiness. Instead, it directly evokes compassion and empathy, which compete with affective blame.
 
A number of concerns have been raised about the possible future use of pharmaceuticals designed to enhance cognitive, affective, and motivational processes, particularly where the aim is to produce morally better decisions or behavior. In this article, we draw attention to what is arguably a more worrying possibility: that pharmaceuticals currently in widespread therapeutic use are already having unintended effects on these processes, and thus on moral decision making and morally significant behavior. We review current evidence on the moral effects of three widely used drugs or drug types: (i) propranolol, (ii) selective serotonin reuptake inhibitors, and (iii) drugs that effect oxytocin physiology. This evidence suggests that the alterations to moral decision making and behavior caused by these agents may have important and difficult-to-evaluate consequences, at least at the population level. We argue that the moral effects of these and other widely used pharmaceuticals warrant further empirical research and ethical analysis.
 
Replies to J. Z. Sadler and G. J. Agich's (see record 1997-07863-001) comments on Wakefield's (see records 79-27354, 79-23607, 80-25744) harmful dysfunction analysis of the medical concept of disorder. Wakefield addresses Sadler and Agich's 4 objections to his attempt to delineate the descriptive component of disorder in terms of functional and evolutionary concepts and argues that they are all invalid. Wakefield concludes by suggesting that without an adequate analysis of mental disorder, including its nonevaluative component, one cannot correctly judge when human interests are covertly influencing diagnostic judgment vs when there is only overt adherence to the correct standard of judgment. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
 
This article presents an overview of schizophrenia interpretations offered by 3 phenomenological psychiatrists: E. Minkowski, W. Blankenburg, and Kimura Bin. Minkowski views schizophrenia as characterized by a diminished sense of dynamic and vital connection to the world ("loss of vital contact"), often accompanied by a hypertrophy of intellectual and static tendencies ("morbid rationalism," "morbid geometrism"). Blankenburg emphasizes the patient's loss of the normal sense of obviousness or "natural self-evidence"--a loss of the usual common-sense background that enables normal persons to cope easily with the social and practical world. Kimura focuses on certain distortions of self-experience: a distinctive splitting of the subjective self, alienated awareness of one's own ongoing consciousness, and profound uncertainty about the "I-ness" of the self. The 3 approaches are also considered in light of a more recent, phenomenological formulation of schizophrenia as a disorder of self-experience (an ipseity disturbance) involving hyperreflexivity and diminished self-affection (i.e., heightened awareness of aspects of experience that would normally remain tacit or presupposed and decline in the feeling of existing as a a subject of awareness). (PsycINFO Database Record (c) 2012 APA, all rights reserved)
 
Comments that C. Megone's (see record 1998-12724-001) natural-kind interpretation of Aristotle's argument that "the function of a human being is reason" does not resolve major puzzles about the argument, specifically the puzzles of why a human being has a function and why reason is that function. I argue that by supplementing the natural-kind account with the doctrine that reason is the master regulatory natural function by which individuals enter into social life. Also, I critique Megone's value account of function and argue for a non-evaluative, causal-explanatory account of function and teleological explanation. Using the "black box essentialist" account of scientific concepts (J. . C. Wakefield, 1997), I provide a new analysis of the logical structure of the concept of a natural function that explains why values are intimately associated with judgments of function and dysfunction and yet why function and dysfunction are not intrinsically value concepts. I conclude by examining Megone's attempt to construct a quasi-Aristotelian approach to the concept of mental disorder. I argue that his value analysis of function does not offer a viable foundation for an adequate analysis of mental disorder that explains our intuitive judgments of disorder and non-disorder. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
 
Comments on the article of P. Zachar (see record 2001-07496-001), which advocates conceptualizing psychiatric disorders as practical, not as natural, kinds. Zachar offers an intriguing and insightful critique of the current conception of mental disorders, using a philosophy of pragmatism in order to comment on psychiatric disorders. However, a critical weakness of his argument is that his presentation of pragmatism and practical kinds does not lead to an empirical research program. No psychiatric categories are likely to be totally accounted for by reference to the biological reductionism associated with simple essentialism. The Diagnostic and Statistical Manual of Mental Disorders shares many of the features of folk taxonomies. As well, cultural context, economic factors, and values are important relevant topics. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
 
J. Wakefield (see records 79-27354, 79-23607, 80-25744) has presented a view of mental disorder in which harm contributes the value element to disorder concepts and dysfunction implies a value-free foundation as long as it is grounded in evolutionary biology. Sadler and Agich critically review Wakefield and others' functionalist arguments for disorder concepts. Functionalists fail to define function and dysfunction independent of value terms, and Wakefield's view of evolutionary biology neglects the goal-directed and evaluative nature of teleological concepts. Also, even if the grounding of the dysfunction concept is accepted as value-free, this effort yields no practical application for psychiatric nosology. Finally, Wakefield's project assumes an ethical subjectivism that cannot sustain its value-neutral aspirations. Sadler and Agich recommend emphasizing the analysis of logical features and value commitments in nosological categories. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
 
In the present paper, it is argued that examining the fundamental conceptual organization of psychotic and mystical mental states not only elucidates the observed similarities between them, but can highlight the differences, and the processes by which negatively evaluated pathological features can be seen to emerge. Oriental philosophical systems such as Tibetan and Zen Buddhism, and Tantric Hinduism, provide conceptualizations of mystical states of mind, from which a model can be drawn, while the epistemologies of these systems provide an illuminating metaphysical perspective on both psychotic and mystical experiences. It is concluded that mystical and psychotic experiences can be distinguished not only by emotional and behavioral consequences, but by real differences in the states themselves; certain features, such as loss of subject/object boundaries and loss of the relative dimensional structure of perception, are common to both processes. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
 
Suggests that psychiatrists have at least 2 ways of speaking about persons: the language of mechanism and the language of ordinary life. Elliott explores L. Wittgenstein's (e.g., 1989) suggestion that when one looks at something mechanistically one takes a fatalistic attitude. Psychiatrists are inclined to take up a similar attitude when they look at certain types of patients. Both biological and psychodynamic explanations of human behavior embed deterministic assumptions, which may further undermine ordinary notions of moral responsibility. A thought experiment by Wittgenstein suggests that to undermine conventional notions of moral responsibility it is not enough to show that all actions are compelled; rather, one must undermine the distinction that we ordinarily make between action that is compelled and that which is not. This supports the practice of holding persons with personality disorders morally responsible for their actions. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
 
In recent years, a number of contemporary proponents of psychoanalysis have sought to derive support for their conjectures about the dynamic unconscious from the empirical evidence in favor of the cognitive unconscious. It is our contention, however, that far from supporting the dynamic unconscious, recent work in cognitive science suggests that the time has come to dispense with this concept altogether. In this paper we defend this claim in two ways. First, we argue that any attempt to shore up the dynamic unconscious with the cognitive unconscious is bound to fail, simply because the latter, as it is understood in contemporary cognitive science, is incompatible with the former as it is traditionally conceived by psychoanalytic theory. Second, we show how psychological phenomena traditionally cited as evidence for the operation of a dynamic unconscious can be accommodated more parsimoniously by other means. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
 
Towards an Intelligent Agent Architecture 
Philosophy, Psychiatry, & Psychology 3.2 (1996) 101-126 We do not claim that this architecture is part of the causal structure of the human mind; rather, it represents an early stage in the iterative search for a deeper and more general architecture, capable of explaining more phenomena. However even the current early design provides an interpretative ground for some familiar phenomena, including characteristic features of certain emotional episodes, particularly the phenomenon of perturbance (a partial or total loss of control of attention). The paper attempts to expound and illustrate the design-based approach to cognitive science and philosophy, to demonstrate the potential effectiveness of the approach in generating interpretative possibilities, and to provide first steps towards an information processing account of "perturbant," emotional episodes. The human mind, and its underlying engine, the brain, are incredibly complex collections of mechanisms of many kinds, produced over millions of years of evolution. As a result of its origins there are several levels of control, of varying degrees of sophistication. Some, like reflex arcs, are shared with many other organisms. Some, like the mechanisms involved in arousal of various kinds, e.g., those involving the limbic system, seem to be shared with many other mammals. Some, like cortical mechanisms involved in the ability to long for recognition, the ability to enjoy the admiration and respect of others, the ability to be thrilled by a mathematical discovery, and the ability to grieve at the death of a friend, require sophisticated cognitive capabilities, which may be unique to humans. Because many researchers into emotions do not clearly distinguish the different types of phenomena, there is much confusion about what is being studied and what is explained by various theories. Our concern is primarily with mental processes that are typically to be found in human beings, which involve high-level cognitive functions and which often have social consequences. They may also, in fact, involve older, more primitive mechanisms, though those are not the concern of this paper. (A complete theory of the human mind would have to include them.) This paper has two main goals: (a) to illustrate the design-based approach to the study of some "higher level" human mental processes; and (b) to make theoretical progress towards a design-based account of certain emotional episodes, namely those that involve a partial or total loss of control of thought processes. Our work derives ultimately from suggestions in Simon (1967), although we have extended and generalized Simon's ideas. We try to show how a certain sort of information processing architecture, extending ideas in artificial intelligence, can serve as a new explanatory ground for some well-known emotional phenomena. Whether the proposed outline architecture is correct, how it might be implemented in neural mechanisms and what the implications of further refinements will be, remain questions for future investigation. The architecture certainly does not yet account for all aspects of grief, and it also leaves unexplained other important mental phenomena. This points to the need for extensions to the architecture, which we shall continue to explore. Section 2, which follows this introduction, is primarily theoretical: subsection 2.1 introduces key ideas of the design-based approach to the study of mind, including the idea of a "broad but shallow" architecture. Subsections 2.2 and 2.3 sketch our high level design for autonomous agents, including the distinction between highly parallel "automatic" attention-free processing and resource-bound "management" and "meta-management" processes (Beaudoin 1994). Allocation of "management" resources is one aspect...
 
Drawing on metaphors of travel and tourism, I distinguish between epistemological stances that clinicians can adopt when attempting to understand how patients experience their world and their illness. I argue for a particular stance, called world traveling, that involves a shift in clinicians' own commitments, perceptions, and values. I identify barriers to this model but also suggest ways a version of world traveling may be implemented. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
 
Reviews historical and cross-cultural aspects of suicide and euthanasia and changes in attitudes toward them in physical and psychiatric medicine. The 1991 case of Dr. Chabot in the Netherlands illustrates issues related to the concept of psychiatric euthanasia. Three cases from clinical practice in which a psychiatrist had to make difficult decisions when faced with a patient expressing a wish to die are presented. The bioethical literature concerning voluntary death, which has been developed mainly with regard to physical medicine, is described and applied to a psychiatric context. It is concluded that the suicidal wishes of psychiatric patients are not always the result of an easily treatable and reversible mental illness or of any mental illness at all; there are situations in psychiatry morally comparable to cases of terminal illness in physical medicine; and that the bioethical literature concerning voluntary death in relation to the terminally physically ill, is often not applicable in psychiatry. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
 
This volume of Philosophy, Psychiatry, & Psychology is devoted to questions about the unconscious mind. The philosophical complexities and difficulties associated with the unconscious are many and, despite widespread confusion and disagreement as to the nature of the unconscious mind, it is used as a concept informing psychotherapy. The aim of this introduction is to ask and try to answer a question that logically precedes those raised in the articles in the light of the therapeutic use of the unconscious. When dealing with psychoanalysis or psychoanalytic concepts in an Anglo-American context, the struggle that psychoanalysis has had and continues to have in a psychiatric domain ruled by science is never far from the spotlight. In psychotherapy, the therapist and the client together construct a story that explains why the client is having some form of difficulty in his or her life. The stated aim is to enable the client to overcome this difficulty by gaining an understanding of what has generated it. Doing so may be a first step to dealing with that conflict. None of the papers in the issue see science as playing a central role in the concept of the unconscious. Nor do they explain this, which might seem an oversight. Specifically we show why the seemingly relevant enterprises of neuroscience and cognitive science are both unsuited to the discussion of the unconscious. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
 
This article discusses some philosophical accounts of common sense and considers several ways in which common sense can be altered or disturbed in psychopathology. Obsessive-compulsive patients show relatively mild disturbances of common sense. Patients with major affective psychoses, in their premorbid personality structure, are overly attached to common sense. In schizophrenia, however, there seems to be a true abdication of common sense involving a loss of "natural self-evidence." Even in premorbid states, such persons often lose both the sense of tact and the ability to "take things in their right light." Although logic, and the ability to engage in theoretical discussion, may be preserved, there is a loss of interpretive skills and the "faculty of judgment"; this results in an inability to cope with everyday practical and social activity. There is also a characteristic sense of perplexity, a sense of amazement before that which would normally seem self-evident and a frequent tendency to reflect upon the conditions of possibility of existence that other wise remain concealed. The author suggests that the fragility of common sense should not be seen as a mere deficiency state. Rather, it derives from a basic vulnerability inherent in the very structure of being human. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
 
A popular approach to monothematic delusions in the recent literature has been to argue that monothematic delusions involve broadly rational responses to highly unusual experiences. Campbell (2001) calls this the empiricist approach to monothematic delusions, and argues that it cannot account for the links between meaning and rationality. In place of empiricism Campbell offers a rationalist account of monothematic delusions, according to which delusional beliefs are understood as Wittgensteinian framework propositions. We argue that neither Campbell's attack on empiricism nor his rationalist alternative to empiricism is successful.
 
Philosophy, Psychiatry, & Psychology 11.4 (2004) 309-312 In their thoughtful commentaries on our essay, "Knowing your own strength: Accurate self-assessment as a requirement for personal autonomy," George Agich, Ruth Chadwick, and Dominic Murphy (2004) provide both criticisms and insights that give us a context in which to clarify further our claim that one's autonomy is impaired when one is unable to appreciate whether one has the capacities required for tasks one is undertaking. We focus on two issues: the extent to which our account of autonomy suggests a problematically "externalist" or "objective" approach and the issue of whether our talk of accurate self-assessment entails an overdemanding requirement that one know numerous facts about oneself to count as autonomous. For many, the idea that specific regions of the brain might be relevant to a person's autonomy evokes nightmarish, startlingly reductionist visions of a world in which informed consent is decided on the basis of neuroimaging. In arguing that a capacity for self-assessment is essential for autonomy and also presupposes executive function that is often impaired by prefrontal damage, we do not wish to engage in such reductionism by suggesting that there is any straightforward, one-to-one mapping comparable to that presupposed by the nightmare scenarios. Given what we know about the brain's plasticity, the prospects (although limited at present) for neurorehabilitation, the multiplicity of the instantiation of autonomy-related capacities, and, especially, the constitutively moral/normative dimensions of these capacity concepts, such mappings are clearly problematic. This is true even in the easy cases, which, as Murphy points out, include our case of "John." This is all the more true with regard to the more complicated psychiatric cases, including disorders such as depression where the normative dimensions and the greater interpretive leeway in diagnosis preclude reductionist solutions (See Anderson 2004). For these reasons and for independent philosophical reasons, we are uncomfortable with the label "externalist," although we acknowledge and confirm our view that externally applied neuroscientific notions—and evidence—can inform these matters. Nonetheless, we do not wish to argue for a fully externalist point of view, especially when paired with the idea that we are advocating a "smooth naturalistic picture of the cognitive basis of autonomy" (Murphy 2004, 303). Murphy puts us in some terrific company with the likes of John Doris, Shaun Nichols, and—we would add—himself, and this is welcome and flattering. But, to avoid any misunderstanding of an issue that we do not actually take up in our essay, we should caution that we do not endorse a program of naturalizing the normativity on which many of central autonomy-related concepts are based. The notion, for example, of what it is to assess competently one's chances of success cannot be replaced with a set of nomological regularities or a self-applying list of necessary and sufficient conditions. One of the central challenges we face in presenting our approach is to distinguish our requirement of "accurate self-assessment" from an implausible requirement that one have no false beliefs about one's capacities. In different ways, all three commentaries make it clear that our argument would benefit from further clarification of this distinction. In her commentary, Chadwick suggests that our approach may commit us to requiring too much self-knowledge, specifically, that it seems to require accurate knowledge of things like our genetic makeup as a requirement for autonomy. To begin with, it is worth underscoring again that the requirement we have introduced is explicitly task specific: we are focused here on whether an agent has an understanding of things that are relevant for undertaking an intended task, and declarative knowledge of facts, genetic or otherwise, about oneself is relevant only insofar as they bear on that understanding. But Chadwick's point clearly goes deeper. In that regard, it is particularly important to underscore that ours is actually a requirement that has less to do with knowing facts—even task-specific ones—about oneself and much more to do with having the ability to incorporate available facts about oneself into one's decision making...
 
Autonomy is one of the most contested concepts in philosophy and psychology. Much of the disagreement centers on the form of reflexivity that one must have to count as genuinely self-governing. In this essay, we argue that an adequate account of autonomy must include a distinct requirement of accurate self-assessment, which has been largely ignored in the philosophical focus on agents' ability to evaluate the desirability of acting on certain impulses or values. In our view, being autonomous (i.e., self-guiding) involves understanding the extent to which one has the capacities required for one's intended actions. On both clinical grounds (drawn from cases of frontal brain injury) and conceptual grounds, we argue that one's autonomy is diminished to the extent to which one's ability to assess one's capacities is impaired. Autonomy is one of the most contested concepts in philosophy and psychology. Much of the disagreement centers on the form of reflexivity that one must have to count as genuinely self-governing. In this essay, we argue that an adequate account of autonomy must include a distinct requirement of accurate self-assessment, which has been largely ignored in the philosophical focus on agents' ability to evaluate the desirability of acting on certain impulses or values. In our view, being autonomous (i.e., self-guiding) involves understanding the extent to which one has the capacities required for one's intended actions. On both clinical grounds (drawn from cases of frontal brain injury) and conceptual grounds, we argue that one's autonomy is diminished to the extent to which one's ability to assess one's capacities is impaired.
 
Tan and her colleagues (2006) reported that persons with anorexia nervosa typically manifest no difficulty satisfying the criteria for abilities associated with competence to consent to or refuse treatment. Their results led them to conclude that these patients generally had no problem grasping the nature of anorexia and its possible consequences (understanding), typically did not have difficulty processing information when making treatment decisions (reasoning), and usually neither denied that they had a disorder nor manifested distorted beliefs about the potential consequences of treatment for the disorder. Nevertheless, these authors found, some anorexia patients said that they knew they might die and that they would rather die than suffer the alternative consequences (e.g., loss of identity, feeling of being disgusting). They point out that these beliefs, suggesting questionable competence, were not identified by the usual criteria for competence to consent to treatment. Therefore, they propose that we should consider a modification of the criteria for competence to consent to treatment. They argue for inclusion of "pathological values" as the basis for a finding of incompetence. Their notion of a pathological value (as we summarize it based on their Discussion) includes (a) a personal value (b) on which treatment refusal is based, that (c) is not authentic, and (d) is due to a mental disorder. Second, Tan and colleagues were concerned that the MacArthur Competence Assessment Tool for Treatment (MacCAT-T), currently used widely to assess competence to consent to treatment, did not seem to take values into account when examining deficits related to lack of appreciation or reasoning. They point out that most patients with anorexia nervosa in their study had "pathological values" that influenced their thinking about treatment, yet they did not obtain poor scores on the instrument's appreciation scale, which assesses whether patients deny that they have the illness or offer reasons for accepting or refusing treatment that are based on delusional premises or a serious distortion of reality. Moreover, almost all of the anorexia patients in the study obtained adequate scores on reasoning, which examines the ability to process options and consequences when weighing a treatment decision. A fundamental step in considering Tan and her co-worker's proposal is to examine whether it is necessary to add a concept of "pathological values" to the legal construct of competence to consent to treatment. Modifying the legal doctrine of consent is important if that is needed to improve its validity or reliability. But modifications of the doctrine would have considerable costs, including a long process of producing logical and empirical evidence for its necessity, developing methods to assess the new concept, and then a process of debate, persuasion, and education to change laws, ethical guidelines, and medical training. Moreover, principles of theory building urge parsimony. A theory should employ no more concepts or assumptions than are required to account for the phenomena that the theory seeks to organize or explain. So one must be sure that modifications are truly necessary before adding complexity to the theory of decisional competence. In addition, there is an inherent danger in altering a concept like competence to consent to treatment on the basis of the study of any one mental disorder. It is not at all clear how the modification might influence findings of competence when applied to other disorders. Using a study of patients with anorexia nervosa as the impetus for changing the competence concept runs this risk. For example, anorexia is one of a class of mental disorders that is characterized by a failure to abstain from behavior (here, limiting food intake and other behaviors designed to reduce weight) that has negative consequences for the person. Other conditions in this category might include substance abuse disorders and impulse control disorders (e.g., pathological gambling). Even if one concludes that revised criteria for competence would reduce false-positive findings of competence in this group of disorders, one would have to consider carefully its impact on the full range of disabling mental conditions. Moreover, the sensitivity of an assessment process (i.e., the likelihood that it will accurately identify as incompetent those persons who truly are) is far from the only relevant consideration...
 
We thank the reviewers for their thoughtful comments that probe shadowy areas in our argument, and we welcome this opportunity to elucidate our position. First, we are not repudiating the natural and social facts of pathologic brain degeneration and the physical and cognitive impairments that manifest in people affected by dementia disorders. We are, however, questioning the epistemology, politics, and persistence by some to harden the construct of mild cognitive impairment (MCI) prematurely as a "natural" precursor to dementia. We suggested insufficiencies in viewing MCI as prodromal to Alzheimer's disease (AD; Graham and Ritchie 2006, 36), and pointed to evidence for the prognostic irrelevance of some MCI subcategories (35). The commentators have read our manuscript as suggesting that AD and MCI are different kinds, and that a diagnosis of AD is more "real" than that of MCI. But AD is also fraught with classification issues, as we describe in the section of our paper that deals with consensus committees, published practice guidelines, and the determination of treatment efficacy. Like MCI, AD is a heterogeneous condition, but unlike MCI, AD is a constructed practical kind that does some "work" beyond essentialist (neural degeneration, brain atrophy) claims. Its criteria identify people with well-defined dementia symptoms and multiple cognitive and functional impairments who are in need of, and benefit from, support. Even with these criteria, however, there have been great attempts to achieve definitional accuracy in dementia diagnoses. Practical refinements to the differential diagnosis of dementia based on solid research evidence have made way for more specific recognitions of vascular dementias, dementia of the Lewy body type, and other subtypes beyond AD. So AD too has been subject to more careful, more cautious operationalization in recent years, with research supporting multiple factors and the comorbidity of several types (kinds) of dementia in any one individual. Our paper takes up concerns that are not resolved for dementia and suggests that the nascent category of MCI is still so insufficiently defined as to be ambiguous, and as such, is in danger of identifying individuals with what will be, and has already been, linked to a debilitating and deeply stigmatizing and fatal disorder (AD). We are not contesting the reality that some people begin to display early signs of cognitive loss, nor are we suggesting that symptoms be ignored; as researchers, we stand behind the careful tracking of symptoms and signs in patients and research participants as an essential clinical and research practice. In a era where the public has been made wary of the potentially fatal effects of new treatments whose more careful scrutiny in specific populations would have saved lives (e.g., Fontanarosa, Rennie, and DeAngelis 2004; Psaty and Furberg 2005), and made all the more popular by what Kramer coined "diagnostic bracket creep" (1993, 15), we are questioning the drivers and value of a premature diagnostic classification whose definitional accuracy is neither sufficient nor effective for specific identification of individuals. That matters of fact are constructed does not take away from their natural fact. Some people have subjective reports or show objective evidence of cognitive decline while having preserved activities of daily living—the construction of this evidence indicates they are not normal and they are not demented. Based on such evidence, where then does the balance of probability for MCI lie? A multidisciplinary international group of experts gathered in Stockholm in 2003 to discuss MCI concepts (Winblad et al. 2004). They acknowledged that the heterogeneous etiology of MCI contributes to "some confusion concerning the specific boundaries of the condition", stating that this "not normal, not demented" condition is nonetheless "useful both clinically and as a research entity" (p. 241). Importantly, they concluded that MCI needs "better definition" (p. 246). It was at this stage that we first wrote our manuscript, and in the subsequent two years we have eagerly awaited new studies, and the recognition of flexible, practical subtypes to evolve. We state "that MCI cannot be considered to be a separate clinical entity" (Graham and Ritchie 2006, 35). That is separate and apart from recognition that MCI is an important clinical issue. But we do ask for useful criteria that are supported by sound evidence and can be used...
 
In this commentary, I highlight some of the difficulties encountered by those working within a modernist paradigm (eg Bayne & Pacherie and Klee) and go on to argue that this paradigm is ill-equipped to conceptualise issues which are essentially moral. Georgaca's suggestion that there is a need for researchers to focus more on the contexts which give rise to judgements of delusions and the assumptions which appear to underlie those judgements is a useful one and there is a need for researchers and clinicians alike to learn from the paradigm shift that is taking place in relation to the phenomenon of hearing voices. I suggest that we need to be open to service users’ own theories of the meaning of their beliefs and see our goal as helping them find better ways of living with them. Published (author's copy) Peer Reviewed
 
The contemporary epistemic status of mental health disciplines does not allow the cross validation of mental disorders among various genetic markers, biochemical pathway or mechanisms, and clinical assessments in neuroscience explanations. We attempt to provide a meta-empirical analysis of the contemporary status of the cross-disciplinary issues existing between neuro-biology and psychopathology. Our case studies take as an established medical mode an example cross validation between biological sciences and clinical cardiology in the case of myocardial infarction. This is then contrasted with the incoherence between neuroscience and psychiatry in the case of bipolar disorders. We examine some methodological problems arising from the neuro-imaging studies, specifically the experimental paradigm introduced by the team of Wayne Drevets. Several theoretical objections are raised: temporal discordance, state independence, and queries about the reliability and specificity, and failure of convergent validity of the inter-disciplinary attempt. Both modern neuroscience and clinical psychology taken as separate fields have failed to reveal the explanatory mechanisms underlying mental disorders. The data acquired inside the mono-disciplinary matrices of neurobiology and psychopathology are deeply insufficient concerning their validity, reliability, and utility. Further, there haven’t been developed any effective trans-disciplinary connections between them. It raises the requirement for development of explanatory significant multi-disciplinary “meta-language” in psychiatry (Berrios, 2006, 2008). We attempt to provide a novel conceptual model for an integrative dialogue between psychiatry and neuroscience that actually includes criteria for cross-validation of the common used psychiatric categories and the different assessment methods. The major goal of our proactive program is the foundation of complementary “bridging” connections of neuroscience and psychopathology which may stabilize the cognitive meta-structure of the mental health knowledge. This entails bringing into synergy the disparate discourses of clinical psychology and neuroscience. One possible model accomplishment of this goal would be the synergistic (or at least compatible) integration of the knowledge under trans-disciplinary convergent cross-validation of the commonly used methods and notions.
 
Dan lloyd (2011) issues a salutary warning against the assumption of what I shall call neural modularity—the view that there is a one-to-one mapping between cognitive functions and distinct brain regions. He shows how the assumption can distort the interpretation of neuroimaging studies and blind researchers to global structures and activity patterns that may be crucial to many aspects of cognitive function and dysfunction. In this note, I want to add a further dimension to the discussion by making connections with the notion of mental modularity developed by evolutionary psychologists. What is the relation between mental and neural modularity? Do the arguments for massive mental modularity also support neural modularity? I offer some preliminary remarks on these questions and their bearing on issues in psychopathology. Modern discussion of mental modularity takes its start from Fodor's The Modularity of Mind (1983). Fodor's conception of a mental module is a strict one, appropriate for peripheral systems, such as vision and language. Modules in his sense are special-purpose computational mechanisms that are to a large extent innate and hardwired, deliver shallow (nonconceptual) outputs, and operate in a way that is typically mandatory, fast, inaccessible, and informationally encapsulated. More recent writers adopt a more relaxed notion of mental modularity, which is applicable to central cognitive processes (e.g., Barrett and Kurzban 2006; Carruthers 2006; Coltheart 1999). Modules in this sense are functionally specialized mechanisms that are dedicated to particular cognitive tasks, such as theory of mind, biological classification, and cheater detection, and that can deliver conceptualized beliefs and desires as outputs. Their key property is domain specificity, and it is an empirical question to what extent a given module possesses the other features on Fodor's list. It is arguable that evolution would have favored the development of such central modules as well as peripheral Fodorian ones. Complex evolved systems are typically composed of specialized subsystems, and it is likely that specialized, domain-specific cognitive mechanisms would be more efficient than general-purpose ones, especially given the wide range of adaptive problems faced by humans and other animals. Building on such arguments, some theorists maintain that the mind is composed wholly, or mostly, of modular subsystems—a view known as the "massive modularity hypothesis" (e.g., Carruthers 2006; Cosmides and Tooby 1992; Pinker 1997; Sperber 1994). My aim here is not to defend massive modularity, but simply to ask whether mental modularity involves a commitment to neural modularity as well, and thus whether the arguments for the former carry over to the latter. It will be helpful to think in terms of three descriptive enterprises: personal psychology, subpersonal psychology, and neurology (compare Dennett 1981). Personal psychology is an idealized competence theory; it ascribes psychological traits to organisms on the basis of their behavior. Talk of cognitive capacities is pitched at this level. Subpersonal psychology posits internal information-processing mechanisms that support personal-level psychological traits. The massive modularity hypothesis belongs to this level. Neurology, of course, deals with the fine-grained biological structures and processes in which the other levels are realized. Now, neural modularity is a claim about the relation between personal psychology and neurology; it is the claim that each cognitive capacity is realized in a localized brain region. And the question of whether massive mental modularity entails neural modularity breaks down into two subquestions—one concerning the relation between personal and subpersonal psychology, and the other the relation between subpersonal psychology and neurology. The first question is whether each cognitive capacity is subserved by a single proprietary module; the second whether each module is realized in a distinct brain region. If the answers to both questions are positive, then mental modularity is equivalent to neural modularity. I take that, for a given organism, the answers might be positive, but I shall argue that there is no reason to think that they must be, or even that it is particularly likely that they are—and thus that mental modularity does not entail neural modularity. Consider first the relation between mental modules and neural regions. Some theorists suppose that mental modules have localized neural bases and that evidence of neuroanatomical localization is required to support claims of...
 
What value is this scholarly debate about the origins of Jaspers' phenomenology to psychiatric clinicians? For one thing, it might help kindle enough interest among scholars and clinicians in Jaspers' General Psychopathology (GP) to warrant its reprinting. This would expand the psychiatrist's appreciation of the relevance of philosophy to medical thinking and patient care. In the GP, Jaspers quotes Kant's opinion that "the psychiatrist's competence is really commensurate with how far his education and knowledge would qualify him to belong to the philosophic faculty" (Jaspers 1963, 36).
 
Wilson and Adhead’s plea that the British Government’s proposed new mental health legislation might entail a misappropriation of psychiatry’s true mission will strike a chord in numerous jurisdictions. Many European countries during the last northern summer will adopt mental health legislation that moves in the opposite direction to the United Nations Convention on Human Rights for persons with disabilities, and will allow for compulsory mental health treatment. In this author’s home state of Victoria, Australia, the Mental Health Act has five criteria that must be met for someone to be made an involuntary patient in an institution or hospital, in the community, or in one’s own home (Victoria 2003, s.6). One of the criteria is that the person is judged to be at risk of danger to themselves or others. Once made an involuntary patient, one looses the right to refuse medical treatment. At present, in various parts of the world, medical practitioners are being required to assess a person’s level of dangerousness with immediate consequences for that person’s liberty. From the point of view of a historian of the human sciences, these events propel psychiatry into a dialogue with its recent past. The project of Western psychiatry is usually characterized as a breaking down of the walls of the old asylum that contained the lunatic in its dark recesses, and the subsequent unveiling of the mental patient thanks to the rational, liberatory practices of medicine. But modern psychiatry has also been shaped by the coming into being of particular conceptions of mental illness that are not all its own making. This entailed the removal over time of the mental defective and the mental deficient, the moral imbecile, the epileptic, the alcoholic, the chronically insane, and so on, from spaces in which psychiatry would seek to define it object—populations that psychiatry would determine to be “not amenable to treatment.” If we were to see this shaping in a Foucauldian sense, we would also want to include earlier eighteenth- and nineteenth-century separations of the lunatic and the criminal (Foucault 1965, 1979). Moreover, we might want to insist that the marking out of the modern mental health patient is first and foremost an administrative act—an act of separation and management within a bounded population—which then serves as a condition of possibility for the emergence of knowledges in psychiatric medicine, with the latter following rather than preceding the arrangement of bodies in the asylum/hospital. The psychiatrist in public medicine may well be encouraged to shape a new mission according to the requirements of an administration concerned with managing dangerousness. A shift in the social vocation of the psychiatric expert has been observed over several decades, and may represent a profound departure from the traditions of mental medicine (Castel 1991). Those “dirty words”—risk assessment—involve new strategies where face-to-face relations between carer and cared are displaced by an activity of calculating abstract factors deemed liable to produce risk—“a transition from the clinic of the subject to an ‘epidemiological’ clinic” (Castel 1991, 282). The broad contours of this shift sees the specialist medical carer take a back seat while the manager/ administrator assumes a more autonomous role of allocating individuals into various categories of risk. It is in this sense that the psychiatrist does not make a diagnosis as such, but rather contributes to a list of factors compiled to measure a level of riskiness. Risk assessment forms part of social surveillance that dispenses with the actual presence of the carer and the cared, and provides for a form of systematic predetection rather than treatment. As Castel (1991, 288) presents it, (t)here is, in fact, no longer a relation of immediacy with a subject because there is no longer a subject. What the new preventative policies primarily address is no longer individuals but factors, statistical correlations of heterogeneous elements. They deconstruct the concrete subject of intervention, and reconstruct a combination of factors liable to produce risk. Their primary aim is not to confront a concrete dangerous situation, but to anticipate all the possible forms of irruption of danger. ‘Prevention’ in effect promotes suspicion to the dignified scientific...
 
Psychiatric interviewing highlights the apparent tension between psychiatry's quest for objectivity and its aim to chart the particular experiences and values of individuals. Neo-Kantian philosophy can help to shed light on this apparent tension. There need be no conflict between an exploration of individual values and scientific inquiry, not least because values play a central role in the selection of facts in scientific observation in general and psychiatric history taking in particular.
 
Philosophy, Psychiatry, & Psychology 10.4 (2003) 347-352 The case histories of Dr. Wells and the comments on them require first of all more conceptual clarity. In this article I will first introduce, with Paul Ricoeur, a distinction between idem identity and ipse identity. Then, I will discuss the merits and pitfalls of applying narrative theory to pathologies of the self. Behind the discussion on the breakdown of narrative unity, deep questions loom, most notably about conceivability and meaning of the notion of breakdown of self-relatedness as such; and about the moral basis for clinical action given the lack of a self to treat. These questions amount to the acknowledgment of a normative component in the concept of self and personhood, which can not be accounted for by idem identity solely. Let us begin with identity. When I identify a tree, at least two aspects, are implied in the act of identification. The first aspect concerns the recognition of the tree as member of a certain class (or family) of living things. In the tree we recognize certain features, or aspects, that are typical for this particular class (or family) of trees. This recognition is based on similarity or sameness. The second aspect in the act of identification consists of the recognition of the tree as this individual tree. We are dealing here with a basic, rather mysterious capacity: the capacity to distinguish one individual entity from the other; or: the capacity to know individuals. Both aspects, the recognition of similarity and of individuality, are interwoven in everyday acts of identification. So, we discern the specific features of a particular tree against the background of an overall (or general) image of trees. At the same time we recognize these general features given our capacity to distinguish one tree from the other. There are, accordingly, two sides in the concept of identity: structural identity and individual identity. Individual identity refers to the uniqueness of a thing and structural identity to the properties a thing shares with others things. This distinction can be applied to human beings, but only in a certain way and to a certain extent. So, John is a human being, and as a human being he has both distinctive and general features. However with regard to John himself, that is, the particular person I aim at when I speak about John, the picture is slightly different. Individuality and similarity (universality) refer here to one and the same person. The uniqueness of John is now commonly referred to as numerical identity. There is only one singular John. Even if there were a John with the same birth date, fingerprint and DNA profile, this would be another John, John 2 so to say. This uniqueness is sometimes articulated in terms of the position John 1 and John 2 occupy in the space-time continuum. Because John 1 and John 2 cannot occupy the same spatiotemporal position, they must be separate, two distinct entities. This is of course a limited view on uniqueness of persons; so, we will have to say more about this in a moment. The structural (or general) characteristics of John, the John-ness of John so to say, is commonly called qualitative identity. Qualitative identity consists of the sum of all those enduring properties which could serve as criterion to distinguish John from other persons in the world. Qualitative identity, however, does not completely coincide with structural identity, mentioned earlier. This is obvious from the fact that the John-ness of John refers to those structural (enduring, general) properties for which only this particular John qualifies, whereas the human being-ness of John refers to the properties John shares with all other human beings. So, in those cases in which the structural dimension of identity refers to only one entity, for instance in the case of the John-ness of John, the emphasis is not on intersubject similarity but on intrasubject similarity. This intrasubject similarity refers to continuity in time and to the sameness of a particular pattern of properties of one individual. In a discussion about the nature of personhood, the French philosopher Paul Ricoeur has criticized the...
 
The present paper constitutes a development of the position that illness, whether bodily or mental, should be analyzed as an incapacitating failure of bodily or mental capacities, respectively, to realize their functions. The paper undertakes this development by responding to two critics. It addresses first Szasz’s continued claims that (1) physical illness is the paradigm concept of illness and (2) a philosophical analysis of mental illness does not shed any light on the social and legal role of the idea. Then, in reply to Wakefield, the aim is to defend the account as an interpretation of Aristotle and to argue that this Aristotelian view of mental illness is preferable to one that rests on a supposed value free account of human function. More generally the discussion points to the fact that both Wakefield and Szasz rely on a number of metaphysical assumptions about the supposedly empirical nature of medical diagnosis, about the relation between facts and values, and about mind and body (among others), which are open to challenge. In particular the paper indicates an aristotelian approach to the fusion, in the natural world, of so-called facts and values, and the relevance of this fusion to the analysis of the concept of illness. This suggests the debate over distinct conceptions of that concept must both illumine and be illuminated by these deeper metaphysical questions.
 
Grünbaum (1984) argues that psychoanalysis cannot justify its inferences regarding motives using its own methodology, as only the employment of Mill’s canons can justify causal inferences (which inferences to motives are). I consider an argument offered by Hopkins (1988) regarding the nature and status of our everyday inferences from other people’s behavior to their motives that seeks to rebut Grünbaum’s charge by defending a form of inference to the best explanation that makes use of connections in intentional content between behavior and motives. I argue that Hopkins succeeds in defeating Grünbaum’s objection as it is presented, but that work in social psychology presents a further challenge. I discuss the extent to which the challenge can be met, and conclude that certain types of inference in psychoanalysis are justifiable, but others, including those which are the target of Grünbaum’s objection, cannot be justified by the methods defended by Hopkins.
 
Philosophy is often caricatured as one of the most disconnected and anemic academic enterprises. Yet in philosophers’ own accounts of what drew them to the problems they have sought to address they answer, typically, in two broad, passionate, ways: wonder or anxiety. As such, philosophy, and philosophers’ self-understanding of themselves and their enterprise, can serve as a way to address some of the important topics raised by Rosfort and Stanghellini. Even for philosophers, the emotional experience of moods and affects is employed in narrativity, or at least, employed when one is called to give an account of oneself. One could envisage a party conversation along these lines: So why did you become a philosopher? Well, I wanted to go to university but wasn’t interested in science or in the humanities and I’ve always been dreadful at languages. (Laugh) But you must like something about it as you wouldn’t have become a professor? You know how it is . . . you drift into things. I did well as an undergraduate, my tutor suggested I should do a PhD. Found an excellent supervisor, and got a few papers published and then a teaching post. . . . You must be very committed to the subject. Ummm—I guess so. I thought about joining the civil service after my PhD, but always managed to find work and the hours are much more flexible at universities! Well I think it is amazing: to think and teach about such important things. Do you? There is something slightly baffling here that may simply be part of the inherent irony and self-deprecation of some academics. The philosopher's interlocutor is asking about what philosophy means to the philosopher: why he has given his life to it. As such, she is alluding to a deeper, philosophical question that, after decades of falling out of favor, is returning to the attention of philosophers: namely, how has philosophy given your life meaning? The philosopher responds with possible irony, banality, or superficiality and invokes luck rather than meaning in his narrative. He serves as Nietzsche's feared nihilist. The account offered also seems to fail to meet normative standards, and depending on how the philosopher carries it off, this gap between expectation and reality in the conversation may generate humor. However, the greater likelihood is that the conversation engenders perplexity and disappointment in the interviewer. Rather like the characters in Evelyn Waugh's early novels, the philosopher is buffeted passively by life and luck and eschews agency or meaning. In Waugh's skilled hands this becomes tragic comedy; for the philosopher and his interlocutor we have disconnection and sadness. The crucial reason for this is that we need to use terms referring to moods, affects, meaning, and emotion when we offer an account of ourselves and when we try to understand ourselves. Otherwise, something is missing and the reason a person gives for their actions either look like poor reasons or not reasons at all (Bortolotti and Broome 2008). Further, agency, rationality, and self-knowledge may themselves be dependent upon reason-giving. In invoking moods and affects in one's narrative the practical understanding (or ‘affordances’) of the world one inhabits are laid open in clear view. Hence Aristotle's account of wonder as the stimulus for philosophy. Aristotle says: ‘For it is owing to their wonder that men both now begin and at first began to philosophize; they wondered originally at the obvious difficulties, then advanced little by little and stated difficulties about the greater matters’ (1984, 1554). Conversely, given the experience of transcendence, of ambiguity, of finitude rather than wondrous awe, the philosopher may be motivated by anxiety (Kant's awakening from his dogmatic slumbers, Heidegger's battles with ‘Crisis’ and the flight of the gods). Either manner of accounting for one's interest seems to work normatively in the giving of reasons and in generating a narrative, and, moreover, a philosophical narrative. Our fictional dialogue and discussion aims to reinforce the important link between narrative, reason-giving and moods and affects argued for by Rosfort and Stanghellini. To make our accounts carry weight, we need to invoke feelings, affects, moods, meaning, and purpose. However, we would seek to...
 
Philosophy, Psychiatry, & Psychology 12.1 (2005) 49-54 Church Is "deeply" puzzled by "the idea that we can be ignorant of our own rea-sons" (2005, 31). I was, at first sight, puzzled by this puzzlement. There is no question that we, indeed, are ignorant of many of our reasons. In cases of routine behavior, for instance, we are often not, or only dimly, aware of the reasons for doing something. When I use the indicator when taking a turn to the left with my car, I have no conscious reason for doing so. It has become routine behavior, acquired during my lessons in car driving. My non-awareness may even be considered as sign of my excellence as a driver. This non-awareness is most noteworthy in all those cases in which we, again routinely, withdraw from a particular action. Education and training not only teach us how and why to perform certain activities, they also give us reasons to refrain from all sorts of other actions. There are many reasons to do certain things; there seem to be many more reasons for not doing other things. To suppose that having reasons would by necessity involve conscious awareness of these reasons would life make impossible to live. So, ignorance seems to be very common, not to say trivial. This raises the question whether there is anything nontrivial in the attempt to make sense of ignorance of our reasons. What element or aspect of ignorance is it that may evoke philosophical interest? Jennifer Church seems to have in mind different overlapping concerns. In the first part of her paper, she addresses The first question can be discussed without reference to a self; the second question cannot. In the second part of the paper there arise new concerns: Let me try to recapitulate some of the main issues. Church makes, first, a distinction between having access to one's reasons and recognizing one's reasons as reasons. She proceeds by discussing the no-access problem in terms of a functionalist metaphysics of mental states. Then she suggests that ascribing unconscious content (or reason) to a person, in fact, boils down to the evaluation of the appropriateness of the ascription of a specimen of practical reasoning to the subject. Practical reasoning involves the structured connection and interaction between beliefs and desires. This structure can be studied at the level of animal psychology; however, there are some important differences between humans and animals: humans can withhold assent, they can lie, and they may recognize mistakes, whereas animals cannot. The possibility of being mistaken about one's reasons leads from the issue of legitimacy to the issue of normativity. For a reason to become my reason, the belief–desire network should make sense, I should feel normatively compelled in some way. So the issue of normativity cannot be studied apart from the possibility of recognition. To recognize a reason as one's reason, one has—at some level of understanding—to assent with its content, even if this occurs implicitly. In the second part the conditions for recognition are investigated in the form of an analysis of unconscious reasons that are strange. Strange reasons are not recognized because they function in some different way compared to normal conscious reasoning. Strangeness is defined here in terms of a different way of processing beliefs, and not, or not only, in terms of (un)familiarity of content. The focus is on norms of reasoning that are uncharacteristic for conscious thought. Church, then...
 
behavior analysis, Aristotle, good life, B. F. Skinner For this reason also the question is asked, whether happiness is to be acquired by learning or by habituation or some other sort of training, or comes in virtue of some divine providence or again by chance. Now if there is any gift of the gods to men, it is reasonable that happiness should be god-given, and most surely god-given of all human things inasmuch as it is the best. But this question would perhaps be more appropriate to another inquiry; happiness seems, however, even if it is not god-sent but comes as a result of virtue and some process of learning or training, to be among the most god-like things; for that which is the prize and end of virtue seems to be the best thing in the world, and something godlike and blessed. Natural scientists (i.e., physicists, chemists, and biologists) can claim to have contributed significantly to the improvement of the human condition through such technological advances as electricity, the steam engine, antibiotics, vaccinations, semiconductors, and gene therapy, to name a handful. Unfortunately, with very few exceptions, psychology cannot boast similar claims. In fact, as I argued several years ago, psychology has not kept its promise to become a science. Specifically, “psychology has produced very few noteworthy discoveries: it has offered few if any satisfactory explanatory concepts and, therefore, has not advanced in the same way as the other sciences” (Schlinger 2004, 124). I further argued that the main reason psychology has made such little progress is its continued emphasis on mental or cognitive events; in other words, psychology has not escaped the philosophical dualism from which it sprung. Additionally, psychology has relied on research methods that have precluded the discovery of cause-and-effect relations, which are necessary for technological innovation and application. A notable exception to psychology’s failure to become a science, and one that can claim to have significantly improved the lives of humans by offering practical solutions to behavioral problems, is the discipline of behavior analysis. Furman and Tuminello (2015) argue specifically that the applied branch of behavior analysis—applied behavior analysis (ABA)—has enabled some people diagnosed with autism to recover and, thus, to flourish in Aristotelian terms. I would go further and suggest that ABA has enabled a much wider range of individuals to flourish by reducing problematic behaviors and increasing healthy, productive behaviors. This has happened because Watson’s (1913) prescription for behaviorism as “a purely objective experimental branch of natural science” (p. 158) came to fruition. Specifically, beginning in the 1930s, behavior analysts discovered a set of basic principles or laws governing the relationship between environment (defined broadly as all the stimuli that affect behavior at a given moment) and behavior. In the 1960s, these laws began to be applied to ameliorate a wide [End Page 267] range of behavioral problems in both typical and atypical populations. In this commentary, I would like to suggest that behavior analysis can be applied even more widely in society to create conditions that will encourage people to flourish as Aristotle defined it. According to Furman and Tuminello, for “Aristotle, human flourishing requires performing certain sorts of actions—acts that fulfill our function as humans” (2015, 253). Although many actions could be said to fulfill our function as humans, according to Aristotle, reason, which distinguishes humans from nonhumans, and which led to what eventually became Cartesian dualism, is central among them. Furthermore, the two realms in which reason operates are matters of character (e.g., courage, friendliness, modesty, patience, temperance, and truthfulness) and matters of thought (e.g., intuition, scientific knowledge, craftsmanship, prudence, and wisdom). Thus, for Aristotle, for humans to flourish, they must live virtuous lives of both character and thought. Although the natural science of behavior analysis might seem at first glance to be incompatible with Aristotelian philosophy, they have at least one feature in common: the emphasis on behavior or action. For Aristotle, flourishing requires performing certain actions, and behavior analysis is the science that can explain why we act...
 
The best known model for case formulation in the last 50 years was George Engel’s Biopsychosocial model. It expanded the compass of medical investigation and it promised a scheme by which to organize clinical information for more adequate understanding and more effective interventions. Despite its claimed advantages, it has not been adopted by clinicians. This article examines reasons for this failure. It argues for the therapeutic value of case formulation (as a complement to diagnosis), and presents an alternative schema by which clinicians can organize information into the four moments of a clinical problem: its origins (preconditions), precipitating factors, perpetuating factors, and protective factors. Unlike Engel’s hierarchically organized, synchronic schema, the 4P schema is developmental, diachronic, and clinically intuitive. The 4P schema encourages ‘thick’ case formulations as the basis of wise treatment interventions. The last section describes two seminar series in which the structure and elements of the 4P schema were presented to third-year psychiatry residents.
 
I am very grateful for the opportunity provided by the editor of this journal, Dr. Sadler, to read and respond to the comments of colleagues. Their observations on the article come from inside clinical medicine outward and outside inward. This makes them immensely valuable to those of us who reflect on what it is that physicians do at work. I am especially grateful for the comments of Drs. Brody and Lewis who I am lucky to have had as teachers. Rather than respond to each commentator individually, I consider themes to their responses. I was sorry that some commentators detected a dismissive tone to my examination of Engel’s work, as I, along with Lewis, consider Engel to be a hero in the history of modern medicine. His critique of biomedicine has had enduring value. The fact that, despite Engel’s direct warning to psychiatrists in his 1977 article, we continue to have to respond to those who would limit our attention as psychiatrists to biological derangements and who assert that these derangements are sufficient to define treatment and prognosis (as Porter rightly detects in Guze, Kupfer and others) suggests that each generation seems to have to have its own Engel. It is the spirit of Engel’s resistance to the biomedical model that I would like to celebrate, while reconsidering the form that his actual argument took. My argument mostly considers the model that Engel developed to help clinicians to make sense of illness episodes. As Perring notes, Engel’s writings contain an implicit model of disease. He argued that disease is a disturbance of levels of organization. He placed great stock in the concept of isomorphy, that is, similar organization at different levels of organization, although somewhat confusingly he allowed that each level of organization has ‘its unique characteristics and dynamics.’ Presumably, isomorphy is the basis for the communication of signals up and down the levels of organization, either in disease or health (Tyreman 2014), and this would be the basis of a solution to the Humpty Dumpty problem. Here is not the place to fully explore whether isomorphy is true, and how well it accounts for emergent properties, such as consciousness. If it is true, then it would offer the basis for a model of disease, as described by Perring (2014). I think that clinicians can be allowed to remain agnostic on this aspect of the theory, at least for now until more of the patterns are elucidated. In the meantime, the 4P model of case formulation allows clinicians a way to ‘carry on. A related issue is whether, as physicians, we are disease hunters only or disease hunters and something else as well. I do not deny the existence of diseases, although defining disease is actually quite difficult, as Perring points out. I do, however, deny that what we encounter in the clinic is disease only, or that we should limit our ‘gaze’ to disease. Diseases do not walk in, people with problems walk in, and not all of their problems are best made sense of as diseases, and not all of their requests of physicians are to (medically) treat the disease (Lazare et al. 1975). Fundamentally, I agree that devising a case formulation for a patient involves constructing a story. I also agree with Lewis (2014) that the 4P model is one way of telling a story, and that this way of telling a story can have value for patients. However, the 4P model is unavoidably a physician-centered narrative device. It provides a structure by which to organize clinical information in a way that is useful to the physician. It is also problem-focused. With full respect to Tyreman’s (2014) salutogenic focus and related efforts to focus on growth and health (e.g., ‘positive psychology’), physicians and most clinicians are first and foremost asked to do something about problems that the patient has. I am sympathetic to the benefit of physician and patient negotiating a story (see Brody 2014 and Lewis 2014). However, to do this in a substantive way...
 
It has been argued recently that persons diagnosed with a personality disorder (PD) ought to be held responsible for their actions because these actions are voluntary (Pickard 2011, this journal). In what follows, I argue that this claim is grounded in a conception of voluntary action that is too coarse grained to provide an adequate understanding of the structure of agency in persons diagnosed with PD. When the concept of voluntary action and that of behaviors typical of PD are examined more carefully, the claim that PD behaviors are voluntary turns out to be tenuous in at least two ways. First, it becomes apparent that the grounds provided by Pickard do not conclusively establish that PD behaviors are voluntary. Second, a more refined conception of voluntary agency helps us to appreciate that, if indeed PD behaviors are voluntary, such behaviors seem at best to be voluntary in an anemic and limited sense—a sense that is quite distinct from the ordinary sense in which we speak of actions being voluntary.
 
Political activity on the basis of a shared identity has been with us for several decades. Race, sexual orientation, gender, and myriad other categories form the centre-of-gravity around which social groups demand recognition of the validity and value of their self-understandings. How should social and political institutions respond to these demands? In contemporary social and political philosophy much of the weight of answering this question has fallen on developing a theory of recognition. That theory would then perform several functions: it could provide an explanation as to the emergence and subsequent contestation of shared social norms; it could offer an account of the motivation that drives people to struggle for recognition; and it could provide normative resources for the justification and adjudication of demands for recognition. With such a theory at hand, we would possess a foundation from where we could deliberate as to the appropriate social or political response to a particular demand. But to engage in the sort of deliberations by which an identity claim can be offered an appropriate social or political response (whatever these turn out to be) is to presuppose that the claim can be considered in that way, i.e., can be considered within the scope of recognition. In the original essay (Rashed 2021), I theorise the limit (scope) of social recognition as it arises from consideration of the capacities presupposed by a theory of recognition: the capacity to determine the nature of the relation between one’s subjective conviction and the social category with which one identifies; the capacity for diachronic unity of self-conception; and the capacity for synchronic unity of self-conception. A demand for recognition that satisfies these capacities can then be considered for questions such as: Should the meaning and range of [social identity] be modified to include this person/group within its boundaries? Is the social identity good/valuable as asserted by the recognisees? In my essay, the focus is not on these questions, but on what can be considered at all in their light.
 
In my paper on moral responsibility and mental health disabilities, I defended the use of the standard of the reasonable person (SRP), adapted from W.O. Holmes’ famous account of responsibility in The Common Law (1881). This theory is meant to be applicable to all cases of moral responsibility assessment, but it is particularly apt for ascribing moral responsibility in cases of mental illness on a realist basis. This is because it has three distinctive advantages over the alternatives, that is, the reasons view and the reflective-self view. Namely, (i) it avoids reliance on subjective data, which research in situationist psychology and neuroethics has shown to be elusive, unreliable, and relatively epistemically opaque. (e.g., see Doris 2002, 2007; Harman 1999; Gazzaniga 2005), (ii) it accommodates our deep-seated intuitions about cases of negligence and peculiarly unfortunately formative circumstances, and (iii) it avoids depersonalizing the subject by exaggerating her incapacities to the extent that she is seen, in Strawson’s (2003) words, as an “object of social policy” (p. 78). I see this view as a natural evolution from traditional, internalist accounts of moral responsibility, advanced by Frankfurt (1971), Watson (1987), and Taylor (1976) in the 1970s (i.e., the reflexive-self view), and Susan Wolf (1987) in the 1980s (i.e., the reasons view). Just as Holmes’ theory emerged to account for cases of culpable negligence, which traditional legal theories were incapable of handling, moral philosophy must evolve, I believe, to explain and justify these kinds of objective (situational) excuses. Holmes’ theory was first used in an English tort law case in which the defendant, Menlove, had built a hayrick near his neighbor’s property, despite warnings that it was likely to catch fire. When the structure ignited and destroyed his neighbor’s cottages as predicted, Menlove was charged with gross negligence. The courts deemed that regardless of his subjective intentions, he should have known better. So far in moral philosophy there is no equivalent criterion that would allow us to judge a person’s behavior irrespective of his subjective psychological constitution. This is why moral philosophers (e.g., Scanlon [1986], Watson [1987], and arguably Wolf [1987]) have struggled with the problem of explaining culpable negligence and the extenuating force of formative circumstances and cultural factors on moral judgment. This explains my main motives for developing an externalistic account of moral responsibility. Now, Perring (2014) and Bedrick (2014) raise some very insightful criticisms of this view, which force me to clarify and enlarge upon these motives, and to defend my methodological preference in more detail than I was able to do in my original manuscript. There are three objections in particular that I see as warranting a fairly lengthy reply. The first is the contention that we do not need, and perhaps cannot formulate in intuitively plausible terms, a coherent theory of moral responsibility. The second, related claim is that an objective/externalist account of moral responsibility is no more practically useful than traditional subjective views. And the third charge is that the SRP is not especially effective at preventing the depersonalization of the psychiatric consumer, and moreover, we may sometimes have good reason to completely withdraw basic empathy and moral consideration. In what follows, I provide answers to each of these concerns. One of the most resonant objections may be Perring’s contention that we do not need, and perhaps cannot formulate, a coherent account of moral responsibility—an argument that reinforces Cartwright’s (2006) position of moral skepticism, to which my original paper was directed. Perring contends that Whatever philosophical theory we come up with is never going to achieve anything like certainty, and so we may come to the conclusion that in a large number of cases, either we can never know to what extent an individual is morally responsible, or to go one step further, there simply is no determinate answer to the question of whether a person is morally responsible in many of the difficult cases. This concern is reiterated by Bedrick, who expresses dissatisfaction at my less-than-conclusive treatment of the Harris psychopathy case. My first reaction is to say that I never meant to imply that...
 
According to an influential view, a thought is pathologically ‘inserted’ when it is not voluntarily caused by the subject, that is, when the subject has not formed it qua agent. Recently, Lisa Bortolotti found this account unsatisfactory: most of our ordinary thoughts are not voluntarily produced by us, and yet they are not regarded as ‘inserted,’ so the cause of thought insertion cannot be a loss of agency. Thus, Bortolotti elaborates an alternative view according to which thought insertion is owing to a failure to ‘endorse’ the thought on the part of the subject. Although I agree with Bortolotti that the Endorsement Model is preferable to the Traditional ‘Loss-of-Agency’ Account of thought insertion, I argue that agency is systematically connected with non-pathological thinking, although not ordinarily in the form of the volitional agentive capacity to produce thoughts intentionally, and that in thought insertion such connection between thinking and agency is lost.
 
Top-cited authors
Thomas Fuchs
  • Universität Heidelberg
Josef Parnas
  • University of Copenhagen
Peter Zachar
  • Auburn University in Montgomery
Shaun Gallagher
  • The University of Memphis
Kenneth Fulford
  • University of Oxford