Tuesday, December 30, 2008

Review of Dominic Murphy: Psychiatry in the Scientific Image

This review is forthcoming in Philosophy in Review, Vol. 28 no. 6.

Dominic Murphy. Psychiatry in the Scientific Image.
Cambridge, MA: MIT Press 2006. Pp. 410.
US$36.00 (cloth ISBN-13: 978-0-262-134355-2).

There are many approaches to understanding mental illness; contemporary psychiatry builds on a medical approach. Murphy defends a particular version of scientific psychiatry, with a focus on how it theorizes mental illness, rather than on how it tries to help people. So his book is about the reality of mental disorders, their explanation, and classification. He explores the definition of mental illness, and discusses what a scientific psychiatric theory should and should not aim to achieve. Murphy ends with an extensive discussion of the objectivity of psychiatric classification. For most topics, he illustrates his points by discussing how they apply to one or more kinds of mental illness. Throughout he gives the reader helpful signposts as to what he has argued so far, what he is about to argue, and how that fits in with the overall structure of the book. This will be especially useful for those readers who are not planning to read the whole work, or who will read different parts at different times. This is a dense, scholarly work of over 400 pages that refers to current work in both psychiatry and philosophy, including philosophy of medicine, philosophy of mind, general philosophy of science, and philosophy of biology. There is a short, very incomplete index.

Murphy argues for a revised view of the medical model of psychiatry, which is not tied strongly to existing mental concepts. Especially since Murphy has been a student of, and co-author with, Stephen Stich, it is illuminating to see traces of eliminativism here. Murphy is quite ready to move on from old concepts when necessary, and does not take the primary task of philosophy to be conceptual analysis. He is thoroughly wedded to a scientific approach to understanding mental illness, and he is especially impressed with the success of the cognitive neurosciences. When our ordinary language or standard practice is in conflict with scientific knowledge, he argues for revising our concepts and practices. Thus, for example, he argues that our standard ways of demarcating mental illness from other illnesses and disorders cannot be rationally justified, and so we should embrace a new, initially counterintuitive understanding of mental illness that would, among other disorders, include at least some forms of blindness. In a related vein, he argues that we should abolish the distinction between psychiatry and clinical neuroscience, because cognitive neuroscience is the best science we have to understand mental illness. However, Murphy is not arguing for an extremely reductionist approach to the mind; rather, he embraces a version of the biopsychosocial model that allows different levels of explanation. At the end of the book, he argues for classification of mental disorders based on causal explanation, as found in much of the rest of medicine, but rejected by the widely used manuals of psychiatric classification. He argues that such an approach is both scientifically preferable and pragmatically more useful.

The book’s ambitious and occasionally perplexing middle section attempts to provide a theory of psychiatric explanation. It draws on philosophical discussion of explanation in cognitive psychology and in biomedicine. In Chapter 5, Murphy explores to what extent factual elements can be isolated to ground psychiatric explanation, and to what extent the explanation of mental disorder requires evaluative assumptions about what is normal or rational. He concludes that in much of psychiatry norms will run through the whole explanatory process, so that the prospects for a mechanistic program of the cognitive neuroscience of mental illness are dim. This causes considerable trouble for the scientific project since there is little prospect of getting intersubjective agreement on epistemic or moral norms. He considers in some detail the cases of delusion, addiction, and psychopathy, and in each case, finds that it is impossible to eliminate norms from the explanation of the phenomenon.

These conclusions seem to entail that Murphy’s earlier confidence in the medical model should be rather diminished. Yet he goes on, in a manner reminiscent of Hume in the case of the missing shade of blue, as if these problems are minor and do not create a problem for the whole project. His attitude seems to be that psychiatric explanation will sometimes be slightly incomplete or patchy, with no possibility of a full account of the mechanisms involved in the production of the phenomena of psychopathology, but that the scientific/medical approach is still the best one available. In Chapter 6, Murphy gives an account of causal psychiatric explanation. He coins the notion of an exemplar, which he describes as the idealized theoretical representation of a disorder — its typical course and symptoms. The explanation works by ‘displaying the causal relations among pathogenic processes that produce the symptoms’ (212). He proceeds to sketch how psychiatric explanation can proceed in some fairly simple cases and then in schizophrenia. In the next chapter, he sets out how social factors can enter into the explanation. In
Chapter 8, Murphy addresses the role of evolutionary theory in psychiatric explanation, arguing that many recent attempts at evolutionary explanation of psychopathology are unsuccessful. His analysis of the failures points to what a successful approach to evolutionary explanation should look like.

Together, the chapters in this middle section give a reasonably detailed picture of how Murphy envisions psychiatric explanation. He carries out a difficult project well: his aim is not to make strong empirical claims about which explanations are more successful, but rather to make a philosophical point about the feasible forms of psychiatric explanation. In the setting out
of his ideas, he addresses many particular controversies and debates in theoretical psychiatry and cognitive science. Owing to the nature of the subject of philosophy of psychiatry, which defies neat categorization and exceptionless generalizations, it is very difficult to arrive at one comprehensive theory or to make straightforward, unequivocal claims. Murphy’s discussion is a case study of how many qualifications and diversions are required by an even moderately thorough approach.

The final two chapters are relatively simple by comparison, because their task is simpler. Murphy covers familiar ground in his criticisms of the classification scheme used by most recent edition of the DSM (the Diagnostic and Statistical Manual of Mental Disorders). His advocacy for the merits of a causal taxonomy is powerful. He acknowledges that the lack of corroborated
theories about the causes of mental disorders will place major limits on to what extent a causal taxonomy can be carried out, but urges that it is still possible to make some progress even in the absence of a fully worked out theory. He gives some indication of how the classification would go using exemplars, and he argues that this would be useful not just for research purposes but also clinically.

Murphy’s book is a landmark achievement in the philosophy of psychiatry. Its claims are often plausible and interesting, and the arguments for them are carefully made. It is certainly the most philosophically sophisticated defense of the medical model of psychiatry that has been made to date. It is a challenging book to grasp as a whole, and there are many places where the argument could be clearer or is vulnerable to criticism, yet it deserves attention from philosophers of science and philosophers of psychology.

SEP: Murphy on Concepts of Disease and Health

Dominic Murphy (now at the Unit for History and Philosophy of Science, University of Sydney) has has an entry on Concepts of Disease and Health published in the Stanford Encyclopedia of Philosophy.

It's an excellent survey of the issues, and it discusses some issues related to psychiatry, which is inevitable given that most of the controversial cases are to do with mental illness. He sets up the debate by making the distinction between Objectivist views and Constructivist views of disease. On this divide, Boorse is an objectivist and most other people (such as Cooper, Wakefield, and Reznek) are constructivists. I'm not a fan of the terminology: I think that it is more helpful to distinguish between those who think that the concept of disease is intrinsically value-laden and those who don't. It also lumps together people who have quite different views, but that's just about inevitable in an encyclopedia article. Murphy's article is strong in its bringing together the issue with the philosophy of biology, some discussion of the nature of functions, and the problems faced by the two sides.

On Murphy's view, the main problem faced by the Objectivists is in providing a scientific basis for the distinction between normal and abnormal. For Constructivists, the main problem is in justifying any significant distinction between medical and other forms of undesirable conditions. It seems relatively clear that it would be hard to provide any general justification for our present conception of what counts as diseases or medical condition, and if we were to make our conceptual scheme with regard to medicine more rational, we would have to redraw our existing conceptions of disease.

Thursday, December 18, 2008

NYT on DSM-V


An article on the coming debates over DSM-V in the New York Times. Over at the Neuroethics & Law blog, Peter Reiner (pictured) emphasizes his worries about the influence of money on the decision-making process, and urges that all conflicts of interest should be avoided. Quite right too.
However, I don't envy the architects of DSM-V. They really have an impossible task. How to categorize all those disorders in the absence of any good causal theories? In the NYT article, Edward Shorter grumbles about the process, and he bemoaned the expansion of the DSM and the increase of the number of diagnostic categories over the years. But his solution is to restrict mental disorders to the severe cases of mood disorder and schizophrenia, and if DSM followed his recommendations, many people who currently get treatment for mental disorder would no longer be eligible for it, unless they were ready to pay out of pocket. The DSM architects are in a bind: they are meant to make their manual usable by clinicians, scientifically respectable, and also a tool to help people get help. They are also subject to a great deal of pressure from interested groups. The NYT article mentions parents of children diagnosed with bipolar disorder and sensory processing disorder, who have strong opinions about this. Of course, there are some scientific facts to help make the decisions, but much of the work is political. Whatever decisions the architects make, many people will say they got it all wrong and caved in to the other side. At the same time, it is hard to feel too much sympathy for those poor architects, given that they have insulated themselves from public scrutiny. With even Robert Spitzer outraged at their secrecy, they have given themselves a huge public relations disadvantage.
From a philosophical point of view, it is disappointing that the DSM-V people seem to be distancing themeselves from the intense philosophically informed discussion over DSM that has been doing good work for that last couple of decades. None of the major names in the philosophy of psychiatry seems to have been included in the DSM-V Task Force or Work Groups. Very few of the people in these groups has even entered any dialog with philosophers -- Ken Kendler on the Mood Disorders Work Group) being a notable exception. Of course, the DSM people might be able to put together a rationally coherent manual without the help of philosophers, but they would have benefitted from more philosophical input. Kendler et al argued that there should be a Conceptual Issues Work Group, but so far, it seems that their advice has been ignored.

Wednesday, December 17, 2008

What is a 'new' philosophy of psychiatry and why do we need it?


A new review article, just 3 pages long, on "What is a ’new’ philosophy of psychiatry and why do we need it?" in Volume 11 Number 4 of Medicine, Health Care and Philosophy, by Michael Quante (pictured).  It reviews many  recent books in the OUP International Perspectives in Philosophy & Psychiatry series.  I've only seen the preview, but it starts off in a positive tone.  

Neuroscience in Context

Neuroscience in Context

This group is new to me, and looks like it is doing interesting work.  They have a conference at UCLA on Critical Neuroscience on January 30.  They have held a few very interesting workshops already.  It's another sign of the rise of neuroethics, and more evidence that philosophy of psychiatry needs to be building bridges to neuroethics.

Tuesday, December 16, 2008

Weakness of Will and Responsibility for Action

Sarah Stroud has written a helpful summary of the literature on Weakness of Will for the Stanford Encyclopedia of Philosophy, published in May 2008. She sets out the basic philosophical problem -- how is weakness of will possible? -- then sets out Davidson's solution, and some problems with Davidson's view. She moves on to the question of whether weakness of will is always bad, paying attention to Nomy Arpaly's arguments that it can be rational. She concludes with a brief discussion of Richard Holton's refiguring of the debate, where he argues that weakness of will is not acting against one's values, but rather a too easy changing of one's mind and giving up one's resolutions, followed by Alison McIntyre's recent suggestion that when one is weak-willed and acting against one's values, it is better to be clear that is what one is doing, rather than to rationalize one's actions.


Holton (pictured) has extended his work on weakness of will and strength in his forthcoming book, Willing, Wanting, Waiting, (available in pre-print on his home page). His work is wonderfully clear, and is backed up by recent work in social psychology, such as the research by Roy Baumeister on self-control and ego-depletion. In a recent paper, Holton, with Stephen Shute, applies his ideas to a legal context, arguing that loss of self control needs to be taken seriously as a criminal defense. ("Self-Control in the Modern Provocation Defence")


Holton's work here has already given rise to other published discussions. The journal Criminal Law and Philosophy has a couple of accepted articles related to this: Stephen Garvey has a paper on "Dealing with Wayward Desire," and Vera Bergelson has a reply to Garvey, "The Case of Weak Will and Wayward Desire." Garvey, following Holton, argues in favor of the idea that sometimes people are unable to exercise self-control and this should be a valid legal excuse for criminal action, while Bergelson argues that such sympathy for the offender has no place in the criminal law.

Friday, December 12, 2008

Buss on Autonomy in SEP


The entry by Sarah Buss (pictured) on Personal Autonomy in the Stanford Encyclopedia of Philosophy (updated September, 2008) does a very nice job at mapping out different theories and their relation to each other, although you have to read the notes carefull to work out which philosophers hold which theories.) She has a pessimistic and somewhat puzzling conclusion:


Agents can be deprived of their autonomy by brainwashing, depression, anxiety, fatigue; they can succumb to compulsions and addictions. To what, exactly, are we calling attention when we say that, under these conditions, an agent does not govern herself, even if she acts as she does because she thinks she has sufficient reason to do so, even if she has (thorougly) considered the pros and cons of her options, and has endorsed her behavior on this basis, and even if she would have acted differently if there had been stronger reason to do so? Most agents who are capable of asking this question are confident that they are the authors of most of their actions, and are thus accountable for what they do. Nonetheless, as this brief survey indicates, the self-relation they thereby attribute to themselves is extremely difficult to pin down.

How can we be so confident about our own autonomy if we have not worked out the details of our theory of autonomy? More to the point, in the case of people with addictions, compulsions, and even delusions, how can we be sure that they lack autonomy if we haven't worked out our theory of autonomy? The answer must be that there are broad features of autonomous action that we can identify even if we haven't worked out the theoretical details. We can tell if a car is working well or broken down even if we don't know how the engine works.

But aren't the broad features all we need then for a satisfactory theory of autonomy for it to make the distinctions we need it to make, at least with regard to working out who is autonomous and who is not? Do we need to sort out the details of the debates between coherentists and externalists, or how agents authorize their desires, it sorting this out does not help us make the distinctions we want to make? Even further, can't we conclude that whatever these debates achieve, they don't really tell us more about what autonomy is. We might use the car example: we can understand the concept of a functioning car without knowing how the engine works, and furthermore, knowing how the engine works does not add anything to our concept of a functioning car. To be sure, it is useful for other purposes, but not in the basic use of the concept of functioning car. So with autonomy, the sophisticated debates about self-relations are interesting in their own terms, but they don't tell us more about what we mean by autonomy.

I'm not sure I accept this conclusion, but it certainly is tempting.

Thursday, December 11, 2008

Neuroethics special issue on psychopathy and responsibility

Neuroethics Volume 1, Number 3 / October, 2008

Moral Responsibility and the Psychopath
Walter Glannon

Psychopathy and Criminal Responsibility
Stephen J. Morse

Psychopathy Without (the Language of) Disorder
Marga Reimer

Responsibility, Dysfunction and Capacity
Nicole A Vincent

The Cognitive Neuroscience of Psychopathy and Implications for Judgments of Responsibility
R. J. R. Blair

The Mad, the Bad, and the Psychopath
Heidi L. Maibom

On the one hand, I'm thrilled that there's a whole issue on this topic. On the other hand, I wonder when I'm going to have time to read all of these! It's the price of one's area of research becoming popular.

Friday, December 5, 2008

The Philosophy of Mental Illness: What's New?

It is time for me to update my entry in the Stanford Encyclopedia of Philosophy on Mental Illness. I wrote it originally in 2001, and I did some updates in the bibliography in 2005.

It has 3 main sections:

1. Does Mental Illness Exist?
2. Is There an Objective Way to Classify Mental Illnesses?
3. When are People with Mental Illnesses Responsible for Symptomatic Behavior?

I am reluctant to cut these, but it's clear that I could add many topics, and I would want to update the existing sections. But how to prioritize? One of the most obvious missing topics is on making sense of psychosis and delusions; another is on the relation between psychiatry and cognitive neuroscience. But what else?

I'd appreciate suggestions from others on this. One thing to keep on mind is that the topic is philosophy of mental illness rather than the philosophy of psychiatry, and the original idea behind this was that it was a narrower topic, although thinking about it now, it is not so clear to me why this should be so.

Thursday, December 4, 2008

Psychiatric Coercion Not Evidence-Based

A survey of the literature reveals a lack of study and evidence regarding medicating psychiatric patients against their will.

"Coerced medication in psychiatric inpatient care: literature review"
Manuela Jarrett, Len Bowers & Alan Simpson
Journal of Advanced Nursing 64(6), 538–548
http://www3.interscience.wiley.com/cgi-bin/fulltext/121428227/PDFSTART

The BBC reported this as "Psychiatric drugs force queried" which isn't really what the article does. Bowers has written defending psychiatric practices, in his book The Social Nature of Mental Illness. Noting the lack of study of coerced medication and calling for more study is not the same as doubting whether it should be done at all. Doubtless it is an awful experience for the person being drugged, especially at a time when they are feeling vulnerable and possibly paranoid. One of the central issues would be what alternatives are available to health care providers, especially when drugs are relatively cheap and individual attention is expensive.

All in the Mind on Mental Health Blogging

There was a nice piece in the BBC Radio 4 show All in the Mind, Tuesday, Dec 2, 2008, about mental health blogging, with an interview with a couple of bloggers with psychiatric diagnoses.

One of the blogs was http://thesecretlifeofamanicdepressive.wordpress.com/

It has a great list of links to other blogs too. Worth checking out.

New Issue of Disability and Society

At least two articles that particularly interest me in the latest issue of Disability & Society.

"Controlling behaviour using neuroleptic drugs: the role of the Mental capacity act 2005 in protecting the liberty of people with dementia"
Geraldine Boyle
http://www.informaworld.com/smpp/content~content=a906327424
Abstract:
The use of neuroleptic drugs to mediate the behaviour of people with dementia living in care homes can lead to them being deprived of their liberty. Whilst regulation has been successful in reducing neuroleptic prescribing in the USA, policy guidance has been unsuccessful in reducing the use of these drugs in the UK. Yet the Mental capacity act 2005 aimed to protect the liberty of people lacking capacity and provided safeguards to ensure that they are not inappropriately deprived of their liberty in institutions. This article highlights the potential for using this law to identify when neuroleptic prescribing in care homes would deprive people with dementia of their liberty and, in turn, to act as a check on prescribing levels. However, the extent to which the Act can promote and protect the right to liberty of people with dementia is constrained by a lack of access to social rights.

and

"The meaning of autism: beyond disorder"
Sara O'Neil
http://www.informaworld.com/smpp/content~content=a906324659
Abstract
The incidence of autism spectrum disorders has increased dramatically over the past two decades, yet these disorders are still poorly understood. By considering the viewpoints of autistics themselves, together with evidence from the scientific literature, it becomes clear that autism spectrum disorders are not always the debilitating conditions that they are sometimes portrayed as. In fact, they are often associated with a number of strengths. With a focus on the areas of intelligence, communication, social skills and stereotyped/repetitive behaviours, this article calls into question the idea that autism is a traditional disorder and argues that a new inclusive dialogue on the meaning of autism should be considered.

It's more evidence that great work is being done in disability studies that should be included in both psychiatric ethics and philosophy of medicine. Oh disciplinary walls, how I want to knock you down!

Monday, December 1, 2008

Young People and Personality Disorders

It is strange what the press picks up on. In the latest issue of Archives of General Psychiatry is the following article: "Mental Health of College Students and Their Non-College-Attending Peers: Results From the National Epidemiologic Study on Alcohol and Related Conditions," by Carlos Blanco; Mayumi Okuda; Crystal Wright; Deborah S. Hasin; Bridget F. Grant; Shang-Min Liu; Mark Olfson. The abstract of the article concludes: "Psychiatric disorders, particularly alcohol use disorders, are common in the college-aged population. Although treatment rates varied across disorders, overall fewer than 25% of individuals with a mental disorder sought treatment in the year prior to the survey. These findings underscore the importance of treatment and prevention interventions among college-aged individuals." There's nothing very surprising here. I probably would not have looked at it, but for the headline from the Associated Press on Yahoo News: "1 in 5 young adults has personality disorder." 20%? Good grief!

US News and World Report has a more measured summary. "Among college students, the most common disorders were alcohol use (20.4 percent) and personality disorders (17.7 percent). The most common disorders among young adults not in college were personality disorders (21.6 percent) and nicotine dependence (20.7 percent)." Still, the incidence of personality disorders is very high here, and without having looked at the article itself, and not being familiar with the literature, I can't say if they are using an over-expansive definition. However, this points to the suspicion that the DSM-IV criteria of personality must be too broad, or being applies in too broad a way.

Of course, the media are right in picking out the most surprising feature of the article, which isn't even mentioned in the abstract. And the overall message, that nearly half of college-aged students experience psychiatric disorders, while only one quarter get treatment, is still alarming even if it isn't surprising.

Sunday, November 30, 2008

Swiss voters approve of heroin prescription plan

Apparently the experimental program for medical providers to prescribe heroin to heroin addicts as part of their treatment has been so successful in the last 10 years in Switzerland that voters approved it on a permanent basis. (Source) The scheme has been successful in getting drug users off the street, and people were impressed by that.

It is hard to imagine such a scheme being approved in the USA, because the symbolism of doctors prescribing heroin is perceived as so dangerous -- medically sanctioned addiction. In Switzerland, it seems that heroin has become less cool at least partly because of this scheme -- heroin is less romantic for young people now, and heroin addiction is more obviously a medical problem. I wonder when such an initiative would have hope of being tried in the USA, where pandering to public opinion gets in the way of effective policy.

Wednesday, November 26, 2008

Blog on Teaching Philosophy of Psychiatry & Mental Health.

I've created a blog on Teaching Philosophy of Psychiatry & Mental Health.
It is at http://teachingppp.blogspot.com/

It is primarily a place to put up syllabi for courses. It is possibleto comment on the syllabi -- all comments are moderated.If you know of, or have, a syllabus in an area closely related tophilosophy of psychiatry you would like to be up on this blog, pleasesend it to me. If you know of a syllabus already online that I could link to, please send me the link.

I'm willing to take an inclusive approach, including many differentkinds of courses that raise philosophical and ethical questions aboutclinical psychology and abnormal psychology. So, for example, I would include history of psychology courses that include some considerations of mental illness and raise philosophical questions. I'm also looking for published articles on teaching philosphical issuesin psychiatry and mental health.

Saturday, November 22, 2008

Why Don't People with Mental Illnesses Embrace Disability Identity?

I've only ever been to one disability studies conference, and I should go to more. I gave this paper at the 16th Annual Meeting of the Society for Disability Studies, "Disability and Dissent: Public Cultures, Public Spaces, " held at the Bethesda Hyatt Hotel, June 12-15, 2003. It was different from most other conferences I've been to. I remain interested in the relation between people with mental illness and disability movements.


Why Don't People with Mental Illnesses Embrace Disability Identity?

Abstract
There are legal and financial benefits from identifying as disabled such as protection under the ADA and disability benefits, but despite these, people with mental illness are hesitant about identifying as disabled. This reluctance is especially clear among those with mental illnesses who manage to hold jobs and sustain relationships with significant others. Little empirical work has been done to examine this, so this presentation is speculative in addressing what might explain this phenomenon. Most obviously, people may wrongly believe that the term disability is restricted to those with physical impairments. Furthermore, they may believe that if they are able to hold a job, then they cannot count as disabled. But there may be more subtle reasons. The category of "disabled" may seem disempowering, since it often carries a connotation of being powerless. The Social Model of disability is specifically designed to be empowering, laying the responsibility for disability on society, and portraying people with physical and mental impairments as merely different. There are striking parallels between the Social Model and the antipsychiatry movement of the 1960s and 1970s, which also argued against a medical model. Now antipsychiatry has been largely rejected, and the mentally ill today tend to embrace the medical model, which is promoted heavily by pharmaceutical companies and which seems to reduce the stigma of mental illness. So even the Social Model of disability may not be appealing to people with mental illnesses. If the people with mental illnesses are to be fully included in the disability community, these concerns need to be addressed.


Identifying as Disabled

My first assumption in this paper is that people with mental illnesses are reluctant to embrace a disability identity. I should explain what I mean by this and provide some justification.
Maybe the most obvious way one can identify as disabled is in a rather superficial sense. One can claim financial benefit and get both medical and social services (at least in some countries) by proving that one fits with the official definitions of disability. Parents can sometimes get extra educational resources for their children if they show them to have physical or cognitive disabilities. One can also try to claim legal protection against discrimination through legislation such as the Americans with Disabilities Act.

Whether a significant proportion of people with mental illnesses who could qualify for various forms of disability benefits but do not claim such benefits is a matter for research. Of course, one might claim such benefits without any deeper psychological identification as a disabled person. What kinds of psychological identification are available? One may call oneself disabled and explain one's lifestyle to other people by reference to a disability. One may identify oneself as a member of a group of disabled people who communicate with each other and meet on a regular basis. The group could take on a public role, raising awareness in the rest of society about the nature of disability and the experience of people with disabilities. The group could also take on a political role, lobbying governmental organizations and defending the rights of group members. The group can engage in academic discussion and studies of issues relevant to its disability. An individual participating as a member of the group is at least likely to identify with the group in different ways corresponding to these different activities.

A final way in which one might identify as disabled is in perceiving a commonality between oneself or one's group with other people or groups with other disabilities. It is worth adding here a comment about the social model of disability. On this view, people with disabilities may have physical or mental differences from "normal" or "abled" people but the cause of the disability is understood as society, and on this view one may identify with other oppressed groups such as minorities or women who are disabled by the attitudes and practices of the rest of society.
People with mental illnesses do generally acknowledge that they have those illnesses, although there are of course studies suggesting that many people with psychological disorders either do not acknowledge their problems or else do not seek treatment for them. Some groups exist for people with major mental illness for them to share information with each other about their disorders and ways to get help for their problems. These include formal groups with membership requirements, recovery groups that often insist on anonymity, and many Internet groups that are open to anyone. There are national advocacy groups such as NAMI in the US and MIND in the UK which are especially focused on major mental illnesses which are often chronic.

What is striking is that both individuals and groups of people with mental illness rarely describe themselves as people with disabilities. Sometimes people who are unable to work due to chronic mental illness describe themselves as "on disability" but even in such cases, they often have little inclination to identify as disabled in a stronger sense. People whose mental illnesses make it difficult for them to sustain friendships or loving relationships with others may see themselves as disabled in some ways. For people with mental illnesses who are able to maintain themselves in work and love, it is much easier to "pass" as someone without a mental illness, and such people are rather less likely to identify as disabled.

Why Don't the Mentally Ill Identify as Disabled?
Having clarified to some extent what I mean by saying that people with mental illnesses do not identify as disabled, I now turn to the next aim in this paper, to set out possible reasons why such people are reluctant to identify as disabled.

One of the first concerns may be the widely shared misconception that disability must be due to a physical impairment. While the popular understanding of disability is mainly based on physical impairments such as blindness, paralysis or lack of limbs, or deafness, there's no reason to restrict the category disability to such cases. Indeed, there is probably widespread agreement that severe mental retardation should count as a disability, and since mental retardation concerns intelligence, it is a paradigm of a psychological problem. Of course, mental retardation may well have physical causes -- they are often genetic -- but the effects are mental as well as social. The etiology of serious mental disorders such as manic depression, schizophrenia or unipolar depression is still under investigation, but there is a good chance that they are at least partly physical. So this concern provides no reason to prevent seeing mental illness as a disability.

The second sort of reason that could be a factor is the belief that an illness cannot count as a disability. This in turn may be based on different possible ideas. One source may be that it is thought that disability is a static condition while an illness is a process. The central idea behind this seems right -- short-term illnesses and maladies do not seem to count as disabilities even if they are serious. A person with a broken arm may be temporarily disabled, but it would be odd to apply the label of "disabled person" or "person with a disability" to her. But as has been argued by Susan Wendell,[1] it is a mistake to exclude chronic illness from the category of disability. Paradigm disabilities are not always static but in fact can develop and change with time. Furthermore, chronic illnesses can be relatively static and permanent conditions. So this sort of concern provides no real barrier to understanding many mental illnesses as disabilities.
Some may think illnesses cannot be disabilities because illnesses are not serious enough in their effects. However, as a strict universal claim, this is obviously false -- one need only look at the suicide rates associated with mood disorders and schizophrenia. Such a consideration might be worth considering seriously is if we restrict our focus to cases of illnesses with which people can still work and have long-term relationships with other people. Indeed, this sort of reason seems right to exclude many minor illnesses and maladies from the category of disability. But even this restriction is implausible, since many people with paradigm disabilities such as blindness or deafness are able to both work and love while still remaining in the category of the disabled. So we might move to a second, greater restriction: maybe the central idea here is plausible in the case of people who with treatment or technological aids is able to compensate completely for their illness. For example, people with manic depression (in ideal cases) may be able to keep their condition under complete control through the use of medication and psychotherapy. Would this in itself mean that they are not disabled? Again, this is implausible. For example, if a person who is missing a limb has a prosthetic limb that is fully functional, would this mean that person was no longer disabled? This is not clear, and opinions or intuitions may differ. The US Supreme Court has in several decisions apparently concluded that such people do not count as protected by the Americans with Disabilities Act.[2] So maybe there is some plausibility to this view, with this major restriction, but it deserves further discussion, for which I do not have time. Since the second restriction does not apply in most cases of major mental illness, I will set this point aside.

The final reason people with mental illnesses might have for being reluctant to identify as disabled is not so much conceptual as emotional. They might feel that the stigma of mental illness is enough in itself, and they do not want to take on the extra burden of risking the stigma of disability. I can illustrate this with an example from Lucy Johnstone's Users and Abusers of Psychiatry.[3] She describes the case of a person who calls himself John Baptist, from an episode of a 1995 BBC documentary series called Minders. John is a black man who believes he was born white, that he is descended from the British royal family, and that his sister has been cannibalized. He does not believe he has a mental illness and does not want psychiatric treatment, because he has had unpleasant and unproductive encounters with psychiatry in the past. However, the authorities go to a tribunal and assert that he is "angry, irritable, shouting at people, verbally aggressive" and has inappropriate beliefs. He is forced to take medication, which he hates, and this changes him to a sad and hopeless man, although he never abandons his unusual beliefs. In one of the final scenes of the documentary, one of his treatment team encourages John to sign a form to confirm that he is "permanently and substantially disabled" by mental illness, in return for a bus pass. Johnstone uses the example to illustrate her claim that young black people are highly suspicious of mental health services, but it also shows how identifying as disabled can be a blow to one's self-confidence. This is not to say that this is always or even often the case, and of course it should not be the case. Naturally, there should be no stigma attached to mental illness per se, nor to disability per se.

The Relation between the Social Model of Disability and Antipsychiatry
Now that we have some grasp on possible reasons why people with mental illnesses may be reluctant to identify as disabled, we can move on to ask how it could be helpful to make this identification. The most straightforward reason is that it can entitle one to financial benefits, subsidized or free medical care, and social services, as well as legal protection against employment discrimination. These are important benefits that should be conferred by enlightened societies.

However, there are other sorts of benefits. First, there could be benefits from joining groups of people with disabilities in sharing information and learning from other people how they negotiate a rather hostile world. Second, identification as disabled could have benefits of reducing a sense of isolation both through solidarity with others and increasing possibilities of friendships with other people. Third, being part of a group of disability studies can expand ways of understanding mental illness. In the remainder of this paper, I want to discuss the relation between debates over the conceptualization of disability in disabilities studies and the debates over the conceptualization of mental illness.

In the US, people with severe and chronic mental illnesses are in many ways some of the most disenfranchised members of society. People with schizophrenia and manic depression are not well organized into political groups. There is a very familiar stigma attached to mental disorder and the rights of the mentally ill are often under attack when they are portrayed as potentially dangerous and a menace to society. Over the last quarter of a century at least, it has been thought that the most effective way to combat stigma has been to insist that mental illness is as real as physical illness, and indeed, it has been thought politically important to argue that mental illness is at root a physical illness. (For example, NAMI and parity.) It is striking how the situation has changed since the 1960s and 1970s there was a very active movement inspired by the work of thinkers such as R.D. Laing, Thomas Szasz, Michel Foucault and a number of feminist theorists such as Phyllis Chessler and Kate Millett, which argued against a medical model for mental illness. This view has to a large extent ceased to play a significant role in contemporary debates. It is plausible that there are important parallels between this movement, loosely collected under the term "antipsychiatry" and the current social model of disability. So there may be lessons to be learned on both sides from seeing the connections between these two approaches.

Those who have been called antipsychiatric theorists have held a wide variety of different views, and it is problematic to lump them all together. In this presentation, I do not have the time to make careful distinctions between the different strands of thought within the movement, but it is at least worth setting out some of the basic ideas. All these theorists shared a deep suspicion of the use of psychiatric technology and power to make individuals conform to the values of society, through enforced treatment and hospitalization. Works such as Erving Goffman's Asylums showed the shocking conditions in which thousands of long-term patients in state mental hospitals were kept. Movies such as One Flew Over the Cukoo's Nest and Ken Loach's Family Life brought such views to a wide audience, and these ideas fit well with a wider distrust of the uses of the power of the state to crush other points of view that was especially prevalent in the 1960s and 1970s with the rise of the civil rights movement, the anti-war movement, women's liberation, rock music and the growth of the recreational use of drugs.

One strand of antipsychiatry has been set out by the libertarian Thomas Szasz. He argues that mental illness does not exist because the very idea is a conceptual mistake. He has argued consistently that not only does the state infringe on the rights of people when it forces treatment on them, but also that people diagnosed with mental illness should receive no special status or protection from the law. He places responsibility for coping with the world on the individual and criticizes all forms of state help for the mentally ill.

An opposing strand of thought within antipsychiatry is maybe most closely associated with R.D. Laing. Laing was influenced by a rather more sophisticated understanding of existentialist philosophy than Szasz's individualist libertarianism. Laing argued that people with mental illnesses such as schizophrenia were genuinely suffering and were in need of help. However, he was very critical of the medical solutions that were in use in the 1950s and 1960s, and he linked the suffering of individuals to both their dysfunctional families and the broader alienation inherent in modern society. He experimented with various attempts to provide people with psychological problems with more tolerant living conditions, although these experiments had little success.

The social model of disability has been set out by such theorists as Constantina Safilios-Rothschild, Gerben DeJong, Deborah Stone, Wolf Wolfensberger, Paul Abberly and currently advocated by well-known activists such as Colin Barnes and Tom Shakespeare. It is surprising to me, as a relative outsider to the field of disabilities studies, that the histories of the field pay almost no attention to antipsychiatric thinkers or even to the wider cultural movement associated with the criticism of psychiatry.

The most obvious parallels between a Laingian antipsychiatry and a social model of disability lie in the placing responsibility on society for its failure to accommodate itself to the needs to people with physical or psychological differences from the norm. In some interpretations of Laing, it is society or parts of society that in fact cause the psychological problems in the first place. A familiar example today of this sort of view would be the social valorizing of thinness causing young people to become anorexic. Another potential example would be if the alienation of modern capitalist societies cause depression and schizophrenia, as some interpreters of cross-cultural studies have suggested is the case. But the causal claim is not essential to the social model of disability. Whatever the original cause of the differences in the individual, on this model, society causes the disability in the sense of making it impossible for the individual to function as well as normal people. For example, a person who needs a wheelchair is prohibited from fully participating in society if public buildings are inaccessible to people in wheelchairs. When it comes to mental illnesses, it can be pointed out that more rural and more mystical societies are able to find a place for people who hear voices and who are not able to engage in normal social relationships. For example, they might be revered as having special mystical abilities, or they might be integrated into society despite their differences, rather than being locked away in hospitals or medicated with powerful tranquilizers. Our society, with its strong emphasis on the need to work in a conventional job and conform to rigid social norms, has no place for people whose behavior is unconventional or bizarre according to its standards.

A second, related parallel between some forms of antipsychiatry and the social model of disability concerns the medical status of the individual in question. In at least some forms, the social model denies that the differences of the individual need medical treatment. Similarly, in some of its extreme forms, antipsychiatry has denied that there is any such thing as mental illness or that the individuals in question need psychiatric treatment. It is probably this aspect of both approaches which causes most controversy -- whether it be the claim that deafness is simply another way of being in the world or that schizophrenia is not a disease but is rather a psychospiritual crisis.

While there are some people who still defend antipsychiatry in its most extreme forms, it is a movement that has basically died. In its wake are left two rather disparate groups. On the one hand there are academics who defend "critical psychiatry," which tends to be more sophisticated in its criticisms of traditional psychiatry, suspicious of its individualism, sexism, classism, racism, its medicalization of normal conditions, its alliance with the interests of the multinational pharmaceutical corporations, and critical of society for not making a place for people with mental illness. On the other hand, there are groups of patients, ex-patients and "survivors" of the psychiatric system which tend to advocate conspiracy theories, and condemn psychiatry wholesale. These groups have proliferated with the advent of the Internet. Neither group holds much appeal to the majority of people with mental disorders: the "critical psychiatry" movement is at a rather too abstract and academic level to be accessible to members of the general public, and the conspiracy theorists tend to be too far on the fringe and have nothing in terms of substantial help to offer. Furthermore, now with direct-to-consumer advertising and sponsorship of groups such as the National Alliance for the Mentally Ill in the US, the pharmaceutical companies have a powerful grip on the popular thinking about mental illness, and most people are led to believe that it has been scientifically proven beyond reasonable doubt that mental illnesses are disorders of the brain. Many conclude from this, with the implicit encouragement of the pharmaceutical companies, that the best treatment for the illness is medication. It is generally thought, with no good evidential support, that this approach will help to reduce the stigma associated with mental illness.

Given this situation, there is a great deal of room for a modest revival of an antipsychiatric approach taking its inspiration from the social model of disability. It seems to be a major error to insist that there is no such thing as mental illness, not so much because it is an indisputable fact that mental illness exists , but more because such a denial is going to alienate many people who would otherwise be sympathetic to some form of antipsychiatry. The real value of an antipsychiatric approach is to emphasize the responsibility of society to accommodate people with psychological differences and problems and integrate them into the fabric of everyday life. We can debate whether we should try to eliminate mental illness or to value it, and this is certainly an interesting question, but the current state of treatment is so far from curing mental illness that this debate will be of only peripheral concern to most people with mental illnesses. The best we can do these days is help to reduce some symptoms without causing terrible side-effects, and hope for spontaneous remission of the illness.

Thus, my final proposal is that there is a clear benefit for people with mental illnesses to identify as disabled in a political sense of adopting a social model of disability, and to see their problems as caused by society. The next step is to develop a clear understanding of what it would be to have a society that treated people with mental illnesses in a non-disabling way.

[1] Susan Wendell, The Rejected Body (Routledge, 1996) and her article "Unhealthy Disabled: Treating Chronic Illnesses as Disabilities" (Hypatia 16(4) 2001, pp. 17-33).
[2] See for example, Toyota Motor Manufacturing, Kentucky, Inc v. Williams, 120S. Ct. 681 (2002) concerning carpal tunnel syndrome, Bragdon v Abbott, 524 U.S. 624 (1998) concerning HIV-positive status. Excellent discussion of these issues is in Part B of Americans with Disabilities edited by Leslie Pickering Fancis and Anita Silvers (Routledge, 2000.)
[3] Lucy Johnstone, Users and Abusers of Psychiatry. Second edition (Routledge, 2000, pp. 231-2).

Friday, November 21, 2008

The Limits of Philosophical Knowledge: Implications for Philosophical Counseling

Another philosophical counseling conference paper.

THE NORTH AMERICAN CONFERENCE ON PHILOSOPHICAL COUNSELLING
Morals and Ethics in Philosophical Counselling
Saint Paul University, 223 Main Street, Ottawa, Ontario, Canada K1S 1C4
Date: November 1-3, 2002

It was quite a nice conferece, although I recall people were annoyed with me for not being sufficiently enthusiastic or optimistic about philosophical counseling.

The Limits of Philosophical Knowledge: Implications for Philosophical Counseling

Abstract

The goal of philosophical counseling is to help individuals or groups sort through problems they face in their everyday lives. These problems can be ethical, epistemological, existential, metaphysical or conceptual. There are two central difficulties for the project of philosophical counseling. The first difficulty derives from the open-ended nature of philosophical debate. It is part of the very nature of philosophy that it focuses on areas of disagreement and controversy, and it is extremely rare for philosophers to achieve consensus on any issue. If no philosophical theory is generally accepted, then no philosophical theory will be very helpful to people trying to work out what they should do when facing a real life problem, because we cannot know which philosophical theory is the right one with any degree of assurance. The second difficulty is that of deriving recommendations from philosophical theories. Even if we restrict our attention to a single philosophical theory, one generally finds that when considering real life cases, it is very difficult to derive a substantive implication from the theory concerning the case. This problem has been discussed extensively in the literature on the foundations of medical ethics in the debate between principlism, rule-based approaches, and casuistry. I argue that these two difficulties exist also for anyone attempting to teach a course in "applied philosophy," and I discuss my own experience in attempting to design and teach courses that make philosophy helpful to students. I conclude that philosophers should be very careful in their claims that philosophy can be useful in decision-making when facing everyday problems. The most they should claim is that philosophy can help people to inspect the range of choices available to them, to understand the different points of view on the choices they face, to justify their choices once they start from their assumptions, and to be aware of the contingency of their own choice.



The goal of a great deal of philosophical counseling is to help individuals or groups sort through problems they face in their everyday lives.[1] These problems can be ethical, epistemological, existential, metaphysical or conceptual. There are two central difficulties for the project of philosophical counseling that the literature on the subject has neglected. The first difficulty derives from the open-ended nature of philosophical debate, due to nature of which issues cannot normally be settled by empirical observation or scientific experiment. It is characteristic of most of philosophy that it focuses on areas of disagreement and controversy, and it is extremely rare for philosophers to achieve consensus on any issue. If no philosophical theory is generally accepted, then there is a serious danger that no philosophical theory will be very helpful to people trying to work out what they should do when facing a real life problem, because we cannot know which philosophical theory is the right one with any degree of assurance.

Indeed, even where philosophers have reached a good deal of consensus, the general public may well be reluctant to adopt the view recommended by philosophers. The clearest example of this concerns the metaphysical issue of the nature of the mind. Most participants in the current debate in the philosophy of mind agree that substance dualism associated with Rene Descartes is highly implausible, largely because the suggestion that the mind is composed of a non-physical substance has very little explanatory value and leaves unexplained crucual questions such as the nature of the interaction between mind and body, the justification in our beliefs in other minds, and why there should be one and only one mind associated with each human body. Nevertheless, substance dualism remains a popular theory among the general public, for whom it often associated with religious beliefs about life after death. The philosophical worries about substance dualism make very little difference to ordinary people. When it comes to most other issues, the philosophical debate continues and consensus about central issues is rarely achieved. The foundations of epistemology, ethics, metaphysics, and political philosophy remain disputed, and indeed, the very method by which philosophers should set about solving problems is a matter of deep disagreement. Even listing the five most important philosophers of the twentieth century can lead to fierce disputes. Maybe the only matter on which philosophers and the general public could all agree is that there is the deep disagreement about the fundamentals in philosophical debate.

If people are facing particular problems in their everyday lives, they generally need to come to a decision in a limited amount of time. Then a central question, if philosophy is to be useful to people in such circumstances, is how people can make a decision when faced with such a lack of resolution about the right perspective or theory. A further worry facing both philosophical counselors and teachers of philosophy as applied to the real world, especially when dealing with time constraints, is how to present a balanced and fair picture of the philosophical views on the issues in question, and to what extent it is problematic to openly or implicitly to favor one view over others.[2]

The second difficulty I want to discuss here is that of deriving recommendations from philosophical theories. Even if we restrict our attention to a single philosophical theory, one generally finds that when considering real life hard cases, it is very difficult to derive a substantive implication from the theory concerning the case. This problem has been discussed extensively in the literature on the foundations of medical ethics in the debate between principlism, rule-based approaches, and casuistry. There is in the medical ethics literature a thriving discussion of to what extent it is possible to derive concrete conclusions from general ethical schemes when dealing with the complexities of particular cases. Real life cases typically bring with them a daunting complexity of issues, and many ethical considerations come into play. There is certainly no algorithm that will provide concrete recommendations from very general considerations, and some have expressed doubts whether general ethical theories have the ability to provide concrete answers to real life controversies. (For recent discussions of this topic, see the Iltis (2000), chapters 1 and 9 of Beauchamp and Childress (2001), and chapters 7 and 8 of Toulmin (2001).)

My aim here is to discuss how these features of moral philosophy can be dealt with in teaching courses of “applied ethics” to undergraduates, and to explore the extent to which they could be dealt with in philosophical counseling. It is worth noting the extent of my interest and expertise in philosophical counseling: I have over ten years experience teaching courses in ethics and applied ethics, and I have a strong research interest in philosophical issues in clinical psychology; I have attended various conferences on philosophical counseling and have written on the topic (Perring 1998, Perring 2000, Perring, 2001, Perring forthcoming), but I have no experience of working as a philosophical counselor. Indeed, while I wholeheartedly endorse the aim of using philosophical skills and knowledge to help people, I have concerns about the very project of philosophical counseling. As in much of my other writing on the topic, my goal here is to suggest that the problems faced by philosophical counselors have already been worked through in other areas of philosophy, and philosophical counselors would do well to learn from what has gone before. But here my focus is on the lessons learned in the classroom, and philosophers have rarely discussed in print the problems faced by teachers trying to show the ways that philosophy can help people in their everyday lives. So I will turn to my own experience in the classroom.
I have taught undergraduate classes on medical ethics, death and dying, philosophy of psychiatry, genetic ethics, general ethics, critical thinking, and many courses of introductory philosophy organized both by philosophical topic and by historical period. My aim in teaching is to provide students with an understanding of the philosophical debates about the topics on hand, and with skills to express their understanding in debate and in writing, and to form their own opinions on those topics. When a topic has clear relevance to everyday life, I emphasize the process of decision-making and suggest that philosophical training can enable more rational decisions.

Of course, students rarely sign up for such courses in order to help them with immediate problems in their personal lives. They generally take them because they have a prior interest in philosophy or they are required to take them as ways of fulfilling degree requirements. They frequently start out with an assumption that philosophy has little relevance to the “real world” and have very little conception of how a focus on philosophy could help them either professionally or personally. Although I hope that they benefit from taking my courses, and sometimes receive positive feedback from students, I have no solid evidence that these courses do actually improve my students’ decision-making abilities. Indeed, I know of no attempt to measure the beneficial effects of philosophy courses on students, nor of any attempt to measure the effects of philosophical counseling.

Nevertheless, an experience shared by many teachers is that exposing students to a variety of perspectives on controversial issues together with the main approaches to ethical theory can often lead to student confusion and even bewilderment; far from helping them to form opinions, exposure to philosophy can lead to greater indecisiveness. This is an unsatisfactory result for students, although it is probably a good thing to induce greater epistemic humility in some students who previous had strong convictions but little justification for their beliefs, one hopes using philosophy to help students to enable them to come to some decision.

Therefore, when teaching such courses, it is important to address the fact that rational and informed people will come to different conclusions and will form different decisions. There is a strong element of contingency in ethical decision-making, and while this should be a fact that leads to further discussion and investigation to pinpoint the sources of differences and the rational evaluation of each person’s decisions, it does not vitiate the whole decision-making process. Or at least, since the contingency of ethical decision-making is a feature shared by almost all approaches to ethics and seems to be an inescapable feature, only those inclined to skepticism about the possibility of ethical knowledge will find this contingency a highly problematic feature.[3]

It is striking that in the few available descriptions of philosophical counseling, little or no mention is made of the problem of the uncertainty of moral and philosophical knowledge and the contingency of ethical decision-making. For example, Lou Marinoff and Shlomit Schuster both discuss their approaches to problems with clients and give the impression that the application of philosophy to real problems is a relatively simple affair. In Plato, Not Prozac!, Marinoff (1999) outlines his PEACE process, which has the following stages:
1. Identify the problem
2. Take stock of the emotions provoked by the problem.
3. Analyze the available options for solving the problem.
4. Contemplate the entire situation
5. Reach equilibrium.

Marinoff gives very little discussion of the move from stage 4 to stage 5, or of the uncertainties that bedevil difficult decisions. Furthermore, from the clinical vignettes offered in the book, one has strong reason to doubt that clients were offered a comprehensive survey of philosophical discussion that might be relevant to their problems. Often the conclusions the clients reached seem somewhat arbitrary; the main effect of philosophical counseling seems to be the conferring of an arguably bogus sense of justification concerning the conclusion reached. Certainly, it is clear that if a teacher offered such one-side approaches in the context of a philosophy course, the approach would be highly problematic in its incompleteness and possibly biased approach.[4]

It is worth illustrating my point with an example. Marinoff describes a case of a client named Sean (seen by the philosophical counselor Richard Dance). (Marinoff, 1999, p. 106). Sean was concerned whether he should marry his fiancĂ© Patricia: “his underlying themes were having strong opinions, seeing the world in black-and-white, and seeking control. He also tended to overanalyze things yet not quite trust his own decisions (taking, as just one example, the eight-year trial period he found necessary before deciding that Patricia was the woman for him).” (p. 107). In counseling, he learned a meditation technique where the client replays a recent event in which strong feelings occurred, and to look on the event without emotion, analysis, or judgment. Sean learned to restrain himself from expressing strong opinions and criticizing Patricia. The counselor also recommended that Sean evaluate whether his experience bore out the wisdom of Lao Tzu and Heraclitus about the coincidences of opposites, who held that opposites are interconnected, relying on one another to complement their mutual existence. Apparently this assignment was very helpful to Sean in coming to terms with his relationship and reduced the number of arguments the couple engaged in. Setting aside possible reservations about whether there was anything particularly philosophical about the form of counseling provided here, it’s clear that the counselor was extremely selective in his choice of which philosophers to mention in his counseling. From Marinoff’s telling of the exchange, it seems to be a particularly one-sided approach. Philosophy was used in getting the client to become more settled in his choice and happier in his relationship, but one wonders about the application of the idea of the complementarity of opposites to this sort of case. Nothing in the telling of the case assures that reader that the counseling included discussion of the limits of this approach or any evaluation of its rationality. It did seem to provide the client, Sean, with a new way of looking at the world and his relationship, and this apparently was helpful, although one may well wonder whether it wasn’t the effect of pronouncement of the names of some ancient philosophers and the ring of appealing “words of wisdom” that had the beneficial effect rather than Sean’s learning anything new. There’s no question that philosophical counseling may leave some customers pleased with their encounter: my concern is that in passing over the uncertainty of the claims made, the counselor risks misleading the client and offering radically incomplete understanding.

At this stage, I can briefly address a potential objection that may be raised by some philosophical counselors, who insist that philosophical counseling is very different from teaching philosophy. For example, Peter Raabe has surveyed the views on this topic, coming to the conclusion that, “the philosophical counseling relationship may be substantively didactic but that it is not procedurally pedagogic” (2001, p. 24). It is clear that it may be inappropriate in counseling to assign the client reading of philosophical texts, to demand that she write essays or take tests, or to lecture to the client for substantial periods of time. But these differences between classroom teaching and philosophical counseling are irrelevant to my point here. The uncertainty of philosophical knowledge and the difficulty of applying abstract principles to the complex details of real life remain important considerations whenever one is trying to apply philosophy to everyday life, regardless of whether one is using traditional pedagogic methodologies or innovative counseling approaches. Indeed, the problems I am focusing on may be even more pertinent to the morality of philosophical counseling as compared to teaching philosophy. A standard course in philosophy in a north American college involves at least 30 hours in the classroom, with an expectation that students will spend at least another 20 or 30 hours outside the classroom working on homework and preparing assignments. This sustained exposure to philosophical debate nearly always has the effect of driving home the difficulty of fully justifying one’s point of view, and showing students the epistemic problems inherent in the field. But if a philosophical counselor sees a client for only a few sessions, as apparently is typical, there will be far less time to fully explore more any philosophical ideas, and there is far more danger that the client will grasp onto one suggestion or idea mentioned by the counselor and adopt it because it seems to make sense at the time.

The problem I am highlighting has a clear solution. Teachers and counselors should never promise or hint that philosophy can provide certainty or definitive answers to difficult problems. There may be some cases where philosophers manage to substantially agree on answers to philosophical problems, but there is no reason to think this is a general rule. Philosophers should be very careful in their claims that philosophy can be useful in decision-making when facing everyday problems. The most they should claim is that philosophy can help people to inspect the range of choices available to them, to increase sensitivity and understanding of the different points of view on the choices they face, to justify their choices once they start from their assumptions, and to be aware of the contingency of their own choice. This may disappoint some prospective students and clients, but it is necessary if philosophers are to give an honest assessment of what they can provide to the general public.

I want to finish by comparing philosophical counseling with psychotherapy. One might ask whether I am holding philosophical counseling up to a higher standard than psychotherapy normally requires of itself. For it can very plausibly argued that the theories underlying the practice of psychotherapy are in a far sorrier state than philosophical theories, and there is very little good evidence that psychotherapy is more effective in helping people who do not have major mental illness than talking with someone with no specific training or knowledge of psychotherapy. The controversies over the scientific status of psychoanalysis are well known, and other major psychotherapeutic theories have equally problematic foundations. Even for approaches that seem to have the best evidence of effectiveness, such as cognitive behavioral, one might argue that there is limited evidence that the approach will be helpful for a particular individual. Yet psychotherapists do not agonize about the uncertainty of their claims to understand their clients or their suggestions for clients about how to solve their problems. It follows from my arguments that psychotherapists should more openly acknowledge in the therapy that they don’t have strong evidence for the effectiveness of their discipline. An obvious concern this raises is that such a declaration of uncertainty might undermine the therapeutic bond and make the therapy less helpful. That is to say, the client’s belief in the psychotherapist, while maybe not a necessary condition, is at least an enhancement for the beneficial effect of the therapy.[5] However, this concern raises obvious ethical problems: it is a commonplace in medical ethics that patients should always give their informed consent to any medical procedure, and I see no reason why this should not apply equally to psychotherapy. This requires being open about the known efficacy of the treatment, or lack of it. It is also worth entertaining the possibility that one of the reasons that psychotherapy is sometimes viewed with some suspicion by the general public and medical professionals is not so much the weak foundations of psychotherapeutic theory as the fact that psychotherapists have been reluctant to be open and honest about the certainty of their claims to be able to help people. Indeed, being open with a client about the limitations of the evidence for the beneficial effects of therapy might not undermine the therapeutic project, since a great deal may depend on the manner in which this information is conveyed. Indeed, openness and honesty could inspire greater trust in the therapist on the part of the client.

Similar points can be made about honesty within the relationship between philosophical counselors and their clients. If counselors are straightforward with clients about the fragility of philosophical knowledge, then far from undermining the enterprise, this could enhance the relationship. Finally, an open humility about the experimental nature of the burgeoning profession of philosophical counseling would, I suggest, be likely to win it more allies among professional academic philosophers.

References
Beauchamp, Tom L. and James F. Childress. Principles of Biomedical Ethics. Fifth Edition. New York: Oxford University Press, 2001.
Iltis, Ana Smith (editor). “Specification, Specified Principlism and Casuistry.” The Journal of Medicine and Philosophy. 2000: 25:3.
Jopling, David A. “‘First do no harm’: Over-Philosophizing and Pseudo-Philosophizing in Philosophical Counselling”. Inquiry: Critical Thinking Across the Disciplines, Vol.XVII, No.3 (Spring, 1998) pp.100-112.
Kymlicka, Will. “Moral Philosophy and Public Policy: The Case of New Reproductive
Technologies,” in L. W. Sumner, (ed) Philosophical Perspectives on Bioethics. Toronto: University of Toronto Press, 1996.
Luborsky, Lester et al. Who Will Benefit from Pschotherapy? Predicting Therapeutic Outcomes. New York: Basic Books, 1988.
Marinoff, Lou. Plato, Not Prozac! Applying Philosophy to Everyday Problems. New York: HarperCollins, 1999.
Marinoff, Lou. Philosophical Practice. San Diego: Academic Press, 2001.
Perring, Christian. Reviews of Essays on Philosophical Counseling, edited by Ran Lahav and Maria da Venza Tillmanns, in Perspectives: A Mental Health Magazine, Vol. 2. Issue 4, September - October, 1997. Available Online at http://mentalhelp.net/poc/view_doc.php?type=doc&&id=336
Perring, Christian. Review of Lou Marinoff, Plato, Not Prozac! Applying Philosophy to Everyday Problems, Metapsychology Online Review, August 1999. Available Online at http://mentalhelp.net/books/books.php?type=de&id=119
Perring, Christian. Review of Schlomit Schuster, Philosophy Practice. Metapsychology Online Review, June 2000. Available Online at http://mentalhelp.net/books/books.php?type=de&id=292
Perring, Christian. Review of Lou Marinoff, Philosophical Practice. Journal of Mind and Behavior (forthcoming)
Perring, Christian and Lou Marinoff. "Debate: Who Can Counsel?," The Philosophers’ Magazine, Summer 2002, pp. 23-26.
Raabe, Peter B. Philosophical Counseling: Theory and Practice. Westport, CT: Praeger, 2001.
Schuster, Shlomit. Philosophy Practice: An Alternative to Counseling and Psychotherapy. Westport, CT: Praeger, 1999.
Younger, Stuart J. and Robert M. Arnold. “Philosophical Debates About the Definition of Death: Who Cares?” Journal of Medicine and Philosophy. 2001. 26:5, pp. 527-537.



[1] Peter Raabe (2001, Chapter 1) notes that some philosophical counseling is focused on the interpretation of world views rather than solving concrete problems.
[2] It is worth noting that some philosophers have voiced doubts concerning the usefulness of sophisticated philosophy in formulating policy on controversial issues in medicine (see, for example, Younger and Arnold (2001) and Kymlicka (1996)).
[3] For example, Beauchamp and Childress (2001) write, “Even conscientious and reasonable moral agents who work diligently at moral reasoning sometimes disagree with other equally conscientious persons…. Such disagreement does not indicate moral ignorance or moral defect. We simply lack a single, entirely reliable way to resolve all disagreements” (p, 21).
[4] David Jopling notes these sorts of concerns in his paper on the topic.
[5] Note that I am not saying that psychotherapy proceeds merely by a placebo effect, although I am also not ruling out that possibility. I am not very familiar with the scientific literature on the measurement of the beneficial effects of psychotherapy and I don’t know whether any attempt has been made to measure what difference it makes whether or not a client has a belief in the therapeutic process. Common sense would say it would, if only because without such belief, a client will be unlikely to cooperate fully with the therapist’s suggestions or even to continue in the therapy, especially when the therapy starts to delve into emotionally painful parts of the client’s life. Maybe a useful starting place for investigating these issues is Luborsky et al (1988).

What is it like to be a heteronomist?

Here's a conference paper I gave in 2001. To be honest, I wasn't very happy with it at the time, but I've thought about it since giving it, and there's something here worth developing. I was thinking about the reactive attitudes at the time, and some claims by Strawon in Freedom and Resentment.

What is it like to be a heteronomist?

Philosophy and the Emotions: The Royal Institute of Philosophy Conference 2001
University of Manchester: 11-13 July 2001

Abstract:
Heteronomists believe that humans lack freedom of thought or action. In this paper I examine the moral psychology this commits them to which they there by commit themselves, and in particular, what account they can give of the rationality of emotions. I argue that the practices of praise, blame, the emotions of pride, shame, and resentment normally assume that people are free. Heteronomists are pushed towards giving an instrumental justification of these practices and emotions: they have to say that they are useful as ways of manipulating other people and oneself. There is a tension in the thought of heteronomists between denying freewill and asserting that it possible to affect one’s own behavior, and I pursue this tension by examining what account a heteronomist can give of the practical deliberation. What is the point of deliberating about what to do if the future is not genuinely open? Heteronomists can argue that deliberation is a matter of finding out what one will do. Thus heteronomists can reconstruct an account of the rationality of emotions, and so they don’t need to have a radically different world-view from believers in freedom.


Introduction
I use the term "heteronomist" to mean a person who does not believe in free will or free action. The doctrines of physical, biological, psychological, social or metaphysical determinism hold that the future is determined. Those who do not believe in freedom of will or action generally say that determinism is true, and that determinism is incompatible with freedom. Note that a "heteronomist" in the sense I am using the term may not hold that every action and event is completely determined in advance. What is essential to the heteronomist's doctrine is that people do not think or act with freedom. This doctrine applies to all agents. I will assume that a heteronomists accept that there are agents; i.e., people do perform actions, but they do not do so freely, and people make choices, but again, their choices are not free.

Some heteronomists may hold their views for other reasons than the argument from determinism. For instance, they may hold that the very concept of freedom is confused in some way. They may have theological reasons for their beliefs. Or they may simply be heteronomists because they find the view pleasing. For my purposes here, I am not concerned with the philosophical justification of a belief in heteronomy.

What I am concerned to explore is how a belief in heteronomy would affect one's view of life and one's practices. I believe that philosophers have neglected to examine the implications of philosophy for everyday life, and that the rise of philosophical counseling is leading us to think more about such implications.

I should explain at the start of this paper that I am not a heteronomist, and indeed, the doctrine strikes me as bizarre, largely because I find it extremely hard to imagine what it is like to a heteronomist. I suspect that our ordinary practices presuppose that people can act freely, and thus, that a heteronomist would have to abandon many ordinary practices. The purpose of this paper is to explore these suspicions of mine. Through this exploration, I hope even to discover an argument against the heteronomist.

"It makes no difference."
First I want to examine the view that heteronomists are just like everyone else, except that they hold a different philosophical view. This position would claim that all of one's ordinary moral psychology can remain independent of one's lack of belief in freedom. This view would say that praising, blaming, loving, liking, hating, pride, guilt, and of course, resentment do not depend on any assumption of freedom--either the other person's freedom or one's own freedom. This view might say that one praises a person when she does something good, one feels guilt when one does something bad, and one resents another person when she does something harmful to oneself, without ever assuming that any of the actions involved are done freely.

This "no difference" view has its attractions. For example, it is plausible that pets and children can like, dislike, hate, love, trust and fear others without any beliefs about freedom. Sometimes we even say that young children and pets look guilty when they have done something they know we will chastise them for, and we imagine that they feel guilty too. But this is far more speculative.

When it comes to praising and blaming, it is hard to see how these practices could be independent of an understanding of freedom and self-control. If I praise a student for writing a good philosophy paper, I assume that the student has tried hard and has stretched herself. She has not been lazy, and she has taken her assignment seriously. Furthermore, I assume she could have done otherwise, but that she freely chose to put the effort into the paper.

To take Peter Strawson's example of resentment, it seems to me that he is right that our attitude of resentment assumes that a person could have done otherwise. For example, if I resent a cat for scratching me, this seems to be irrational, precisely because the attitude of resentment assumes that the person resented could have done otherwise, but chose to act maliciously. Resenting a cat attributes too much to the cat. However, we normally that resenting the actions of another person is a practice that makes sense. If a woman resents her husband for having an affair, she believes that he could have done otherwise. If I am right, then believing that there is no such thing as human freedom should then make a difference to how one lives one's life.

Attitudes towards others
How then should heteronomists regard other people? It is tempting to suppose that they have to view other people as I might regard a cat or a small child. Of course, it would be unfair to heteronomists the belief that people are childlike or animal life. Clearly, heteronomists can accept that adults have greater intelligence and a greater range of emotions than babies and animals. Nevertheless, it seems that they are rationally compelled to say that it is as irrational to resent another person for her actions as it is to resent a cat.

Heteronomists can give an account of praise and blame. The account is instrumental: one praises a person not because she could have done otherwise but didn't, but instead in order to encourage and promote the good behavior of the person. Praising and blaming are means of manipulating other people. It is an empirical fact that people respond to praise and blame; they like praise and they dislike blame, and so one can influence other people's behavior if they can expect to be praised or blamed for their actions.

To expand this a little, one can even praise the actions of people who will never know they were praised, as a way of influencing third parties. I may praise the actions of long-dead saints as a way of getting other people to try to emulate the behavior of those saints. A heteronomist may rationally publicly blame political figures for their actions even if she knows that the politicians will never learn of this act of blame. The blame might be a way of influencing the opinion of other voters in future elections.

It is also possible to justify private praise and blame, where no one else learns of the act of praise or blame, because it may influence the praiser or blamer. It has been suggested to me that private praise or blame may help to maintain one's own values. For example, if one is watching the news on one's own and condemns the behavior of the president, one helps to remind oneself of one's own values. If one watches the news dispassionately when watching a report of the president's wrongdoing, then one's values may fade. Private praise and blame of others can be a way of manipulating oneself. I'm not sure how true this is of the general population -- it isn't true of me, I suspect, although I do find myself blaming politicians even when nobody else is listening.

Attitudes towards oneself
This last case raises the issue of attitudes towards oneself. The philosophical literature has focused on the cases of pride and shame. One is proud of one's own accomplishments when one has done well, and more tellingly, one is ashamed of one's actions when one has done something one should not have, and, at least arguably, when one could have done otherwise. Certainly it makes no sense to be ashamed of suffering misfortune if one did not bring it on oneself, as it makes no sense to be ashamed of falling ill, and if one had no free choice in doing what one did, then it seems hard to understand how one could be disappointed in oneself.

Perhaps one way for a heteronomist to understand self-disappointment is by using an analogy with disappointment with a material object. One might buy a car with high hopes for it running trouble-free for several years, only to have it break down after a couple of months. One would then naturally be disappointed with the car without believing that it had any freedom. Similarly one could be disappointed in oneself, because one has discovered that one is not as skilled or strong as one had hoped. This view replaces a metaphysically open future with an epistemologically open future. The heteronomist can still believe that we are ignorant about ourselves and that we gradually discover more about ourselves, and this process of discovery can have its pleasant surprises and its disappointments.

Furthermore, there may be a purpose for the heteronomist in self-praise and self-blame. One can praise and blame oneself as a form of self-manipulation. We might equate self-praise with "pride" and self-blame with "shame," although this is more of a substitution than a convincing conceptual analysis. The central idea is that one can affect one’s own behavior as one affects that of other people. One views oneself from a third-person perspective.

There is something suspect about this idea, however. It sounds like it is an attempt of the heteronomist to smuggle in the possibility of self-control (which for my rather crude purposes here, I will equate with autonomy) in the back door. There is a potential logical conflict between asserting that one has no freedom and yet that one can control oneself.

The examined life
I want to pursue this problem by asking what is the point, for the heteronomist, of scrutinizing oneself and one’s life. Indeed, what is the role in one’s life of any practical deliberation?

The obvious purpose of practical deliberation is to decide what to do. A heteronomist can clearly agree that agents deliberate and that this is essential in a person making a decision. What the heteronomist denies is that the deliberation is free. The question immediately arises though, why deliberate if one has no free choice? Isn’t the idea of an open future essential to practical deliberation?

A heteronomist could reply that while the future may be metaphysically determined, the agent still does not know what she is going to do until she has deliberated, so the future is epistemologically open. Maybe this is enough to explain the ordinary sense that one has freedom in making a choice, but it implies that this sense of freedom is an illusion. It seems hard to avoid the conclusion that if the heteronomist is right, then it is futile to try to control one's own life, because one's future is not under one's control.

But we must be careful here. I stipulated at the start of this paper that the heteronomist agrees that people perform actions, and that their actions have effects on the world. Am I not now falling into the trap of accusing the heteronomist of saying that there is no agency at all, and that we are no more than machines or puppets?

In order to avoid this trap, we can say that on the heteronomist world view, the agency involved is not the same as we normally believe we have. Deliberation on this view does not require a genuinely open future. Examining one's life does not mean narrowing down one's options, because one has no genuine alternatives open to one. Rather, deliberation is a matter of finding out what one will do.

Shifts of worldview.
One might regard a move to becoming a heteronomist as one in a series of historical shifts in perspective. Consider this list:
· Theism to Atheism
· Ptolemaic to Copernican astronomy
· A belief in an immaterial soul to materialism.
Each of these is a shift to a more scientific worldview. Maybe one of the great attractions of heteronomy is that it can claim that freedom is a myth of a pre-scientific era, and that while progress may entail abandoning our previously favored myths, it is a move for the better. For those who cling to old conceptions of action and our role in the world, the heteronomist's view seems pale and anemic. But the same is probably true of the shift in the concept of self from a belief in the soul to materialism. Now that we are acclimatized to a materialist worldview, the baggage of the dualist view seems (to most) utterly unnecessary.

So how major is the shift involved in becoming a heteronomist? If it what Kuhnians would call a "paradigm shift" or is it merely a slight shift in perspective? How great a change in our practices does the shift require?

It is fairly clear that heteronomists can engage in the same kinds of goals and projects as ordinary people: they can work in business, plan their careers, go on dates, form families, watch TV, and enjoy nature in similar ways to the rest of us. Their views may not be compatible with some religions, but generally religious debates over freedom (such as in the problem of evil) are part of specialized theology, and one can belong to a religion without worrying about the details of its theology. As I have already suggested, belief in heteronomy probably fits best with atheism -- and certainly all the heteronomists I have met have been atheists.

One might expect that heteronomists would be gloomy people. After all, they don't believe in what is generally held to be one of the most important aspects of our lives -- our freedom. Without any belief in freedom, one could become gloomy, and being a gloomy person in the first place could make one predisposed to the gloomy doctrine of heteronomy. However, this association seems simplistic: one might equally find the doctrine of heteronomy comforting -- after all, Sartre, whose early existentialism is the direct opposite of heteronomy, said that we are "condemned" to freedom. Anyway, there's not much evidence to support a connection between a philosopher's views and her mood. For example, it is implausible to suggest that atheists are more gloomy or even selfish people than other people. A world without a deity promising to punish the guilty and reward the good may seem more tragic and harsh to some, but only to those who believe or used to believe that there is such a deity.

However, to see whether a heteronomist is markedly different from other people, we must still look to her emotional life, and particularly her relationships with other people and herself. We have already examined these attitudes in earlier sections, and we can see that the shift in becoming a heteronomist would be subtle rather than major. So I conclude that the practices of the heteronomist would not have to be radically different from those of other people.

Conclusion
Emotions are central to thinking about everyday life, and one of the central implications of belief in heteronomy concerns emotions. The issue of how free we are is vital in understanding how to live our lives, and thus the doctrine of heteronomy needs full exploration. In this paper I hope that I have managed to set out, if sketchily, some important implications for living one's life of a belief in heteronomy. I do not pretend to be the first person to do this; indeed, Stoic philosophers were for the most naturalists and determinists, and they are famous for exploring the emotional consequences of their metaphysics, and for their focus on integrating philosophy ideas with ordinary life more than most other philosophical schools of thought. For a range of reasons, there has in the last decade been a revival of the idea that philosophy can be a guide to everyday living. This goes hand-in-hand with the longer-standing rise in applied ethics and feminism, which has brought to attention issues such as abortion rights, the right to die, sexual harassment, affirmative action, and the judgment of repellent practices in other cultures. It is notable that the theory that we have no freedom, as with theism vs. atheism, and belief in an immaterial soul vs. materialism, is a metaphysical doctrine with clear implications for our attitude to life. Thus it helps to support a more general idea that when examining the importance of philosophy to life, we need to look as much to metaphysics as to ethics.