Philosophy of psychiatry: theoretical advances and clinical implications

Work at the intersection of philosophy and psychiatry has an extensive and influential history, and has received increased attention recently, with the emergence of professional associations and a growing literature. In this paper, we review key advances in work on philosophy and psychiatry, and their related clinical implications. First, in understanding and categorizing mental disorder, both naturalist and normativist considerations are now viewed as important - psychiatric constructs necessitate a consideration of both facts and values. At a conceptual level, this integrative view encourages moving away from strict scientism to soft naturalism, while in clinical practice this facilitates both evidence-based and values-based mental health care. Second, in considering the nature of psychiatric science, there is now increasing emphasis on a pluralist approach, including ontological, explanatory and value pluralism. Conceptually, a pluralist approach acknowledges the multi-level causal interactions that give rise to psychopathology, while clinically it emphasizes the importance of a broad range of "difference-makers", as well as a consideration of "lived experience" in both research and practice. Third, in considering a range of questions about the brain-mind, and how both somatic and psychic factors contribute to the development and maintenance of mental disorders, conceptual and empirical work on embodied cognition provides an increasingly valuable approach. Viewing the brain-mind as embodied, embedded and enactive offers a conceptual approach to the mind-body problem that facilitates the clinical integration of advances in both cognitive-affective neuroscience and phenomenological psychopathology.

The Dynamics of Disease: Toward a Processual Theory of Health

The following article presents preliminary reflections on a processual theory of health and disease. It does this by steering the discussion more toward an ontology of organisms rather than conceptual analysis of the semantic content of the terms "health" and "disease." In the first section, four meta-theoretical assumptions of the traditional debate are identified and alternative approaches to the problems are presented. Afterwards, the view that health and disease are constituted by a dynamic relation between demands imposed on an organism and individual presuppositions for adequate response is developed. In the last section, the paper takes stock of three possible objections to and clarifies some implications of this approach to the notions of health and disease.

Scepticism of the gentle variety: interview with Derek Bolton, PhD

This interview with Derek Bolton, PhD, goes into a discussion of his philosophical work on the diagnosis and definition of mental disorder, the basis of the standards or norms by which we judge that a person has a mental disorder, and the validity of the distinction between abnormal and normal mental functioning. Bolton argues that the notion that emerges from a conceptual analysis of psychiatry's diagnostic manuals is not a naturalist notion of disorder, but one that is focussed on harm and suffering, and in which the personal, the social and the biological cannot be clearly distinguished. The implications of this thinking with regards to the relationship between the medical model and the psychological approaches are also discussed. His most recent philosophical work reconceptualizes the biopsychosocial model as a philosophical theory of biopsychosocial causal interactions and he argues that there are causal regulatory functions within the psychological domain, and this is so independent of whether they can be captured by a physicochemical description of brain processes.

Harm as a Necessary Component of the Concept of Medical Disorder: Reply to Muckler and Taylor

Wakefield's harmful dysfunction analysis asserts that the concept of medical disorder includes a naturalistic component of dysfunction (failure of biologically designed functioning) and a value (harm) component, both of which are required for disorder attributions. Muckler and Taylor, defending a purely naturalist, value-free understanding of disorder, argue that harm is not necessary for disorder. They provide three examples of dysfunctions that, they claim, are considered disorders but are entirely harmless: mild mononucleosis, cowpox that prevents smallpox, and minor perceptual deficits. They also reject the proposal that dysfunctions need only be typically harmful to qualify as disorders. We argue that the proposed counterexamples are, in fact, considered harmful; thus, they fail to disconfirm the harm requirement: incapacity for exertion is inherently harmful, whether or not exertion occurs, cowpox is directly harmful irrespective of indirect benefits, and colorblindness and anosmia are considered harmful by those who consider them disorders. We also defend the typicality qualifier as viably addressing some apparently harmless disorders and argue that a dysfunction's harmfulness is best understood in dispositional terms.

Health and Reference Classes

In this article, I address two objections developed by Kingma against Boorse’s (1977) bio-statistical theory of health, the objections that choice of reference classes renders the theory both circular and problematically value-laden. These objections not only apply to the bio-statistical theory of health but also to other naturalistic theories, like the dispositional theory of health. I present three rejoinders. First, I argue that the circularity objection arises from excessive methodological demands. Second, I argue that naturalists can resist the normativist claim that health and pathology are differentiated on the basis of personal or cultural values. Finally, I show that it is possible to justify choices between rival theories of health without the interference of evaluative commitments. With these rejoinders, I conclude that the bio-statistical theory, as well as other naturalistic theories of health utilizing reference classes, is not undermined by Kingma’s arguments.

In Defense of Madness: The Problem of Disability

At a time when different groups in society are achieving notable gains in respect and rights, activists in mental health and proponents of mad positive approaches, such as Mad Pride, are coming up against considerable challenges. A particular issue is the commonly held view that madness is inherently disabling and cannot form the grounds for identity or culture. This paper responds to the challenge by developing two bulwarks against the tendency to assume too readily the view that madness is inherently disabling: the first arises from the normative nature of disability judgments, and the second arises from the implications of political activism in terms of being a social subject. In the process of arguing for these two bulwarks, the paper explores the basic structure of the social model of disability in the context of debates on naturalism and normativism, the applicability of the social model to madness, and the difference between physical and mental disabilities in terms of the unintelligibility often attributed to the latter.

The intersection between Descriptivism and Meliorism in reasoning research: further proposals in support of 'soft normativism'

The rationality paradox centers on the observation that people are highly intelligent, yet show evidence of errors and biases in their thinking when measured against normative standards. Elqayam and Evans’ (2011) reject normative standards in the psychological study of thinking, reasoning and deciding in favor of a ‘value-free’ descriptive approach to studying high-level cognition. In reviewing Elqayam and Evans’ (2011) position, we defend an alternative to descriptivism in the form of ‘soft normativism,’ which allows for normative evaluations alongside the pursuit of descriptive research goals. We propose that normative theories have considerable value provided that researchers: (1) are alert to the philosophical quagmire of strong relativism; (2) are mindful of the biases that can arise from utilizing normative benchmarks; and (3) engage in a focused analysis of the processing approach adopted by individual reasoners. We address the controversial ‘is–ought’ inference in this context and appeal to a ‘bridging solution’ to this contested inference that is based on the concept of ‘informal reflective equilibrium.’ Furthermore, we draw on Elqayam and Evans’ (2011) recognition of a role for normative benchmarks in research programs that are devised to enhance reasoning performance and we argue that such Meliorist research programs have a valuable reciprocal relationship with descriptivist accounts of reasoning. In sum, we believe that descriptions of reasoning processes are fundamentally enriched by evaluations of reasoning quality, and argue that if such standards are discarded altogether then our explanations and descriptions of reasoning processes are severely undermined.

Naturalism about health and disease: adding nuance for progress

The literature on health and diseases is usually presented as an opposition between naturalism and normativism. This article argues that such a picture is too simplistic: there is not one opposition between naturalism and normativism, but many. I distinguish four different domains where naturalist and normativist claims can be contrasted: (1) ordinary usage, (2) conceptually clean versions of "health" and "disease," (3) the operationalization of dysfunction, and (4) the justification for that operationalization. In the process I present new arguments in response to Schwartz (2007) and Hausman (2012) and expose a link between the arguments made by Schwartz (2007) and Kingma (2010). Distinguishing naturalist claims at these four domains will allow us to make progress by (1) providing more nuanced, intermediate positions about a possible role for values in health and disease; and (2) assisting in the addressing of relativistic worries about the value-ladenness of health and disease.

How (not) to draw philosophical implications from the cognitive nature of concepts: the case of intentionality

Philosophers have often appealed to intuitive judgments in various thought experiments to support or reject particular theses. Experimental philosophy is an emerging discipline that examines the cognitive nature of such intuitive judgments. In this paper, we assess the methodological and epistemological status of experimental philosophy. We focus on the Knobe effect, in which our intuitive judgment of the intentionality of an action seems to depend on the perceived moral status of that action. The debate on the philosophical implications of the Knobe effect has been framed in terms of the distinction between the competence and performance of the concept of intentionality. Some scholars seem to suggest that the Knobe effect reflects the competence (or otherwise, the performance error) of the concept of intentionality. However, we argue that these notions are purely functional and thus do not have philosophical implications, without assuming normativism, which we see as problematic in a psychological methodology. Finally, focusing on the gap between competence and rationality, we suggest future directions for experimental philosophy.