Friday, November 14, 2008

The Rise of Philosophy of Psychiatry

'The Rise of Philosophy of Psychiatry"
This piece originally appeared in Philosopher's Web Magazine 1998 Volume 2.

Last year I gave a talk at a philosophy department in a well respected US university about public concern about the over prescription of Ritalin to children. During the question period one senior faculty member asked me in what way my talk was supposed to be philosophical. Having just discussed whether hyperactivity in boys should count as an illness or as natural behavior, what the rights of parents are in the upbringing of their children, and why the use of technology in the body should be considered any more problematic than the use of technology outside the body, I was surprised by his rather hostile question. But only slightly surprised, because I recognized it as an example of a long-standing resistance to the discussion of psychiatry in philosophy departments.

It is striking that so many issues concerning mental health have received little discussion by philosophers and bioethicists. While the public and popular media have shown great concern over issues such as the huge rise in the use of Prozac and other antidepressants, the classification as alcoholism, drug addiction and sexual perversions as mental disorders, and the use of mental disorders as an excuse or as a mitigating factor in legal trials, they are rarely discussed in philosophy and bioethics journals.

This is changing, however. In the last few years, there has been a steady increase in philosophical interest in psychopathology and mental health. For instance, there has been considerable debate about multiple personalities, in personal identity, philosophy of mind, and philosophy of science. Cases of multiple personality are seen as important test cases for theories concerning the unity of mind or the unity of self, and there is philosophical debate about what the evidence for multiple personality and what belief or scepticism about multiple personalities entails. Kathleen Wilkes, Ian Hacking, Daniel Dennett, Owen Flanagan are just some of the philosophers to have given the issue extensive discussion. A characteristic of the work in this area is its breadth; it includes many different parts of philosophy, including the metaphysics of mind and self, action theory, epistemology and moral psychology. This makes it a rich area for philosophical study.

This surge of interest has led to a new series by the MIT Press, called Philosophical Psychopathology, edited by George Graham and Owen Flanagan. The “prequel” to this series was an edited book of the same name, edited by Graham and Lynn Stephens, and was followed by Jennifer Radden’s Divided Minds and Successive Selves. Within a year two more will be coming out: one by Valerie Hardcastle on psychopathologies of pain; the other by G. Lynn Stephens and George Graham on psychopathology and self-consciousness.

This is not the only sign of a rise in philosophical interest in psychiatry. There has been a variety of developments. Some of the most significant is the formation of the Association for the Advancement of Philosophy and Psychiatry (AAPP) in the USA, the Philosophy Group of the Royal College of Psychiatrists in the UK, the start of the journal Philosophy, Psychiatry and Psychology, and the formation of three master’s degree programmes in the UK devoted to philosophy and clinical psychology.

The AAPP was formed in 1989. It was the result of a meeting arranged to discuss philosophical issues in psychiatry at the San Francisco convention of the American Psychiatric Association. It was arranged by Michael Schwartz and John Sadler, psychiatrists, and Osborne Wiggins, a philosopher now at the University of Louisville in Kentucky. Schwartz had long been interested in the deeper questions of psychiatry, and recollects that he chose to work in New York City, “at St. Vincent's Hospital-New York Medical College (in Greenwich Village) because it was across the street from the New School (all the old European existentialists had migrated there after WW2 -- Hans Jonas, H. Arendt, Schutz, Gurwitsch, etc.).” There he took courses from Wiggins. The two went on to write papers together, “on the nature and methods of medicine, and then on psychiatry. We submitted presentations to organizations like the annual meeting of American Psychiatric Association (APA) but no one ever accepted them.” It was frustration at this marginalization that let them to form the Group for the Advancement of Philosophy in Psychiatry, and hold their first small meeting in San Francisco. The event was a success and attracted interest from several notable psychiatrists. The group soon transformed into the Association for the Advancement of Philosophy and Psychiatry (AAPP), and its membership grew. Today it is an international organization, holding regular meetings in association with the American Psychiatric Association and the American Philosophical Organization, regional meetings in the US, with local groups in the former Soviet Union, Italy, and France.

At roughly the same time, in the UK a Philosophy Group emerged as a special interest group of the Royal College of Psychiatrists. It was started by Bill Fulford and Sidney Bloch, and David Foreshaw. Bloch is a psychiatrist with a long standing interest in philosophy, and is co-editor of Oxford University Press’ Psychiatric Ethics, which is currently being edited for a third edition. Fulford is a psychiatrist and philosopher has worked hard to build interest in philosophy of psychiatry both in Britain and the rest of the world. The Philosophy Group now has over 1200 members, including philosophers, psychologists, lawyers and psychiatrists. Its annual meeting, held this February over 2 days, was on “Psychopathology, Philosophy and Neuroscience.” Next year’s topic will be “Aesthetics and Health.” In Britain local groups meet regularly in Oxford, Birmingham and Portsmouth.

Indeed, Britain is becoming one of the main centers for the philosophical study of philosophy. It is the only country to have graduate programmes specifically focused on these issues. The longest established programme is at Sheffield University, at their Centre for Psychotherapeutic Studies. Run by Nick Crossley, it is an MA in Psychiatry, Philosophy and Society, and covers a broad range. The section titles suggest the approach taken; they are “Meaning, Truth and Power in the Psy-Complex,” “Current Social Policies and Concerns in Psychiatry,” “Philosophical Issues in Psychiatry,” and “Subjectivity and Intersubjectivity: Phenomenological and Psychoanalytic Perspectives.”

More recently formed is the master’s programme in the Philosophy and Ethics of Mental Health at the University of Warwick, under Bill Fulford. It too has four sections, and the titles suggest a difference in approach from the Sheffield course. They are “Core Concepts and the Philosophical History of Psychopathology,” “Philosophy of Science and Mental Health Practice,” “Ethics, Jurisprudence, Mental Health and Society,” and “Philosophy of Mind, Neuroscience and Descriptive Psychopathology.” There’s less social theory here, more philosophy of mind and neuroscience, and a more analytic approach.

Third is a brand new MSc in the Philosophy of Mental Disorder at King’s College London. Here few social and ethical issues are included. Half the courses will be taken from the existing schedule of the Philosophy Department. The focus is on conceptual analysis, epistemology and metaphysics of mind, psychology and psychopathology, although some teaching will be done by Jonathan Glover, the new director of KCL’s Centre for Medical Law & Ethics.

The variations between these different courses are a hint of the variety of philosophical approaches to psychiatry. As a field still in its birthing stages, its very content is still up for grabs. In the last fifty years philosophy has approached psychiatry from a few different directions: philosophers of science have long argued over evidential status of psychoanalysis; in the 1950s and 1960s philosophers of mind discussed whether psychoanalytic explanation made a category mistake in treating reasons as causes; social theorists and existentialists entertained antipsychiatry, according to which there is no such thing as mental disorder, and the medicalization of human behavior is an exercise in social control; and most recently bioethicists have discussed ethical issues such as the rights of mental patients to refuse treatment. Each of these discussions has had its day, without prompting a more cohesive philosophical approach to mental health.

This raises the important question whether philosophy of psychiatry can be seen as a distinct subfield of philosophy, or whether it is just a ragbag of assorted topics collected under one rubric. There is some dispute about this and the usefulness of the categorization of philosophy of psychiatry. Michael Schwartz, who has worked for decades to increase the philosophical discussion of psychiatry, believes that so far philosophy of psychiatry is too small to be a subfield unto itself. He adds, “in a way, the whole idea of a philosophical approach to psychiatry goes against the notion of "subfields" and "subspecialization".”

But others encourage the trend. Stephen Braude, a philosopher at the University of Maryland who has written extensively about multiple personality disorder, thinks there is some use in the consolidation of interests into one field. He compares it to philosophy of history or philosophy of biology or philosophy of music. “In each case we're dealing with the abstract assumptions (metaphysical, epistemological, and methodological) underlying various kinds of activities (e.g., an ostensibly empirical inquiry, or the way we conceive of certain of our activities, such as music). That's why philosophers get to play deep nonsense police with regard to what people say about the sciences or the arts. There is always room for conceptual housecleaning, and ... while philosophy has its share of incompetents, it's still good to have a specialist when you need one.”

John Sadler, who last year organized a conference in Dallas on philosophical issues in psychiatric classification of mental disorder, is also positive about the categorization, but emphasizes its interdisciplinary nature. “It obviously shares ground with other “philosophy of” fields (medicine, psychology, science, language, bioethics to name a few) but what makes it unique is the particular concatenation of clinical-conceptual problems, on the one hand, and the particular ranges of human experiences, on the other, to which pose distinct challenges to perennial problems in philosophy (e.g., mind/body, interpretation, personal identity, erklaren/verstehen issues, etc.).” Bill Fulford who co-edits the journal Philosophy, Psychiatry and Psychology (PPP)with Sadler, agrees. He argues, “The raison d’ĂȘtre of the Philosophy Group in The Royal College of Psychiatrists and of AAPP, is to establish the philosophy of psychiatry as a distinct subfield. Or, to re-establish it would be more accurate historically. During most of this century, philosophy has neglected psychiatry, and psychiatry has neglected philosophy. In a sense, what is happening now, at the end of the century, that we are getting back to the starting point of Jaspers and others, for whom philosophy and psychiatry were intimately interwoven. So, this really is a millennial (or at any rate centennial) phenomenon.”

As editors of PPP, Fulford and Sadler have had the job of deciding what is relevant to their journal. Published since 1994, papers have been included discussion of the nature of self-consciousness, conceptions of personhood, moral responsibility and personality disorders, the classification of grief as a disease, the values implicit in disease concepts, children’s informed consent, the nature of the unconscious, the historical relation between the ideas of Edmund Husserl and Karl Jaspers, and the distinction between meaning and causality. Is there any thematic unity here apart from the fact that all of these papers involve discussion of clinical psychology in some form or other? Bill Fulford suggests that it is “the way in which normative (or evaluative) and descriptive elements of meaning are woven together in abnormal psychology and psychiatry.” Jennifer Radden, at the University of Massachusetts in Boston, expands on a similar idea, saying, “although there is increasing acknowledgment of the importance of psychopathological case material for philosophy of psychology, philosophy of mind, and even metaphysics (as in discussions of dissociative states in personal identity and theories of the self), there is nonetheless a concern with psychiatric concepts and categories to be found in philosophy of psychiatry which those other areas don't bother with.”

If the central theme of philosophy of psychiatry is the interrelation of normative and descriptive elements in our understanding of ourselves and our behavior, then how does the field relate to medical ethics? Bioethics has tended to marginalize mental health issues, and has instead focused on issues like physician assisted suicide and the right to refuse life-saving treatment, reproductive rights, and the allocation of scarce medical resources. Although medical ethics is a rapidly growing part of philosophy, it is by no means unusual to hear grumbling from non-bioethicists about its philosophical interest. Those interested in psychiatry tend to think that mental health ethics has a richer set of philosophical problems. Radden, says, “psychiatry has its own set of ethical issues - I believe - stemming from the nature of the subject matter, i.e. subjectivity, minds, human lives, rather than parts of bodies; and also from the nature of the practice (interpersonal exchange and the use of relationship as a kind of tool of the trade).” Fulford is more direct on this issue. “The basic point is that the tools of bioethics which work well enough for the conceptually simple areas of technological medicine (e.g. organ transplants, etc.) are simply not sharp enough for the much deeper issues presented by psychiatry.”

For the future, the boundary between bioethics, philosophy of biology and philosophy of psychiatry may vanish with the rise of interest of genetic technology. Edward Manier of the University of Notre Dame has a research project to integrate molecular neurobiological and discursive psychological approaches to mental disorder. He suggests that “Philosophers of psychiatry should engage in active dialogue with philosophers of biology concerning the methodological strengths and weaknesses of human behavioral genetics, particularly as that field is amplified by the results of the human genome project.”

So there has been an enormous growth and consolidation of philosophical interest in psychiatry in the last decade or so. There have already been two international conferences and another is planned for the year 2000. The Royal College Group and the Societa Italiena per la Psicopatologia will be hosting a meeting in Florence, in a conference entitled, “Madness, Science and Society: Florence, Renaissance 2000.” Will the subject become so well-established that its philosophical significance will be taken for granted in philosophy departments across the world? The leading researchers are optimistic, and tend to wax lyrical. John Sadler says, “The field is growing far beyond my dreams from a decade ago. Response from both fields has been growing steadily, grant support availability is growing as well, at least in the U.S., and our international outreach is showing growing bastions of interest all over the world. I hope the coming decades to be a second coming of philosophy of psychiatry on a par with that of the earlier part of this century in Europe.” Bill Fulford urges a little caution. “There really is a renaissance. But my view is that successful as the subject has been, it will stall if we fail (on both sides of the Atlantic) to establish proper research and teaching programmes on a collaborative basis.” Michael Schwartz in more succinct when asked what the future holds for philosophy of psychiatry, and replies simply, “What we make of it.”

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