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.

Human volition: towards a neuroscience of will

Nature Reviews Neuroscience 9, 934-946 (December 2008)
Human volition: towards a neuroscience of will
Patrick Haggard, Institute of Cognitive Neuroscience
http://www.nature.com/nrn/journal/v9/n12/abs/nrn2497.html?lang=en

Here's the abstract:
The capacity for voluntary action is seen as essential to human nature. Yet neuroscience and behaviourist psychology have traditionally dismissed the topic as unscientific, perhaps because the mechanisms that cause actions have long been unclear. However, new research has identified networks of brain areas, including the pre-supplementary motor area, the anterior prefrontal cortex and the parietal cortex, that underlie voluntary action. These areas generate information for forthcoming actions, and also cause the distinctive conscious experience of intending to act and then controlling one's own actions. Volition consists of a series of decisions regarding whether to act, what action to perform and when to perform it. Neuroscientific accounts of voluntary action may inform debates about the nature of individual responsibility.

I always get a bit nervous when scientists and especially neuroscientists start talking about the will and responsibility, because they so often start making big claims -- such as Libet denying free will. I also am skeptical that neuroscientists can tell us anything of moral or philosophical significance regarding free will. I've often liked the work of Stephen J. Morse at PennLaw who has cast doubt on the helpfulness of neuroscience in understanding criminal responsibility.

Nevertheless, I haven't yet found any a priori arguments that neuroscience must be useless in understanding free will and responsibility, and I can imagine that when used in conjunction with a sophisticated philosophical theory, the work of neuroscience would actually be very illuminating. The work of other psychologists, such as Roy Baumeister on ego depletion, has been used to great effect by Richard Holton and Neil Levy, has been used to illuminate our understanding of weakness of will, to give just one recent example. So I'm looking forward to reading Haggard's article.

Monday, November 17, 2008

Report on the NEH Summer Institute on Mind, Self, and Psychopathology

Patricia Ross (also a member of the Executive Council of AAPP) and I were both participants in the 1998 NEH Summer Institute on Mind, Self, and Psychopathology. After it, we were interested in reflecting on the experience, so we wrote a report, but didn't make any great efforts to publish it.

Patricia Ross is a Research Associate at the Minnesota Center for Philosophy of Science at the University of Minnesota.

Report on the NEH Summer Institute on Mind, Self, and Psychopathology, led by Jennifer Whiting and Louis Sass, Cornell University, Ithaca, NY 1998

Abstract

We relate out experience as participants at the 1998 NEH Summer Institute on Mind, Self, and Psychopathology, and our reflections on the lessons to be learned. This seminar was an important attempt to generate discussion of the connections between Anglo-American philosophy and psychiatry. It brought together participants from many different realms with experts in both philosophy and psychiatry. We discuss the strengths and weaknesses of the Institute. We focus especially on the difficulty in achieving productive dialog between researchers from widely disparate fields, because of a lack of mutual agreement about both methodology and also what has been shown empirically in psychiatry. We suggest that it would be helpful for future such seminars to narrow their focus of study or else for participants to discuss directly what methodological procedures would be best for the group as a whole.


I. The Purpose of the Institute
In the summer of 1998, a diverse group of individuals came together at Cornell University to learn about and discuss issues at the nexus of philosophy, psychiatry and psychology. We were among the approximately twenty-six participants in this NEH Summer Institute. Our intention here is to share with you our impressions of this interdisciplinary venture, our thoughts concerning the particular questions that were addressed and what reservations we have regarding this type of work.

At the time of application, the institute was described to us as an attempt bring together Anglo-American psychiatry and psychology on the one hand and analytic philosophy on the other, in order to promote "the sort of dialogue recommended by [Karl] Jaspers but sadly lacking in our [Anglo-American] tradition". We were thereby selected to "engage with a variety of experts representing a wide range of views and approaches in addition to our own". Specifically, the hope was to enable productive interaction between Anglo-American psychiatry, often characterized by its anti-theoretical bent, and the dominant form of philosophy in the US, i.e. that in the Anglo-American tradition, often labeled “analytic.” The format of the institute was to have two different guests each week leading on the topic of their expertise. The schedule turned out to be as follows (roughly):

Week
Presenters/Affiliation
Topic
1
Richard Moran (Harvard)
Self-knowledge and Irrationality

Ulrich Neisser (Cornell)
Models of the Self
2
Jennifer Whiting (Cornell)
Personal Identity and Multiplicity
3
Judith Armstrong (U of Southern California)
Multiple Personality
4
Katherine Loveland (U Texas Med. School)
Autism

Peter Hobson (Tavistock Clinic and University College London)
Autism
5
Josef Parnas (University of Copenhagen)
Schizophrenia

John Campbell (Oxford):
Schizophrenia
6
Louis Sass (Rutgers)
Wittgenstein and Schizophrenia

James Conant (Pittsburgh)
Wittgenstein and Freud

The Institute met in the mornings, five days a week, for six weeks. Afternoons and evenings were free with optional small group meetings scheduled for this time. These optional groups focused on particular issues, including multiple personality, autism, schizophrenia, philosophical approaches to self-constitution, psychoanalysis, and the body. A small writing group met as well with the purpose of reading drafts of papers and providing constructive criticisms. Reading for the morning sessions was assigned beforehand; when possible the visiting speakers for that week would attend the small group relevant to their expertise. These smaller groups often enabled more sustained, wide-ranging discussion. For instance, the multiple personality group was able to devote time to careful discussion of some themes in Ian Hacking’s recent book Rewriting the Soul, and the autism group read Simon Baron-Cohen’s Mindblindness.

We Institute participants were a diverse group. The authors’ own training was in Anglo-American philosophy of psychology, science and ethics. A few other participants had somewhat similar backgrounds to us. Others had different philosophical backgrounds, with several rooted in the continental phenomenological tradition. Nearly half the group was non-philosophers. This half consisted of psychologists with various forms of expertise, historians and literary theorists.

2. The Six Weeks of the Institute
The first two weeks of the Institute were dedicated to an examination of some general topics that the organizers believed to be relevant to framing future discussions of psychopathology. In the first week, Richard Moran discussed the philosophical problem in trying to understand irrationality. The problem might best be captured by seeing that our understanding is commonly taken to be constrained by the demands of rationality. There are limits to how irrational a person can be before she ceases to be interpretable at all. This idea, especially important in the work of Donald Davidson, has been important in philosophers’ attempts to understand self-deception. Moran set out the issues carefully and methodically; too slowly for some. He ended with the background to his own work on self-knowledge. Still, we had not yet come close to any sustained discussion of psychopathology.

During this first week we also heard from Ulrich Neisser. Neisser has a reputation as one of the more thoughtful psychological theorists of our time. The notion of the ecological self is interesting as well as important to many areas of psychological research - from child development to music theory. The plan, apparently, was to present his theory for use in later discussions of psychopathology. While Neisser did present us with detailed accounts of each of his five types of selves, his presentation seemed to lack in just the sorts of details that might make it relevant to our future discussions. For example, we never got a clear idea of how these different selves relate to or are integrated with each other. Moreover, the rationale for positing any one particular category of self was never given. Whatever empirical grounds there might be for positing these five categories of self was not offered up either. As a result, it was very unclear why this division was meant to be helpful to our thinking. Rather, Neisser's account came off as being merely a way for him to catalog a number of different psychological theories and experiments.

The second week continued much like the first. We briefly moved closer to the discussion of psychopathology (multiple personality disorder in particular), but then returned to the more general philosophical questions intended to provide some framework for future discussions. In fact, the foray into discussions of psychopathology, while tantalizing, was due to a couple of last minute cancellations on the part of individuals scheduled as discussants. The net result was that week two was disorganized and fit less well with the plan of the Institute as a whole.

In this week we had one day when Ulrich Neisser discussed false memory syndrome. He turned out to be strongly partisan in the dispute, basically favoring the skeptical views of Elizabeth Loftus, and having very little interest in the possibility that multiple personalities might exist. Jennifer Whiting brought the discussion back to philosophical concerns with her examination of theories of personal identity. There is a large literature addressing the question of what makes a person numerically the same individual over time, and whether the answer is dependent on factors such as cultural circumstances or personal preferences. Whiting raised numerous interesting questions concerning this subject, especially concerning whether we should be looking for a universal theory of personal identity, or whether it makes sense for different people to have different theories, depending on their values. Often our intuitions about whether a person remains numerically the same in unusual cases of personality change, personality disintegration or dissociation will change depending on whether we describe the change from a third-person, onlooker, point of view, or from the point of view of the subject of experience about to undergo, or having undergone the changes in question. In cases of multiple personality, we find difficulty in finding an adequate vocabulary to even describe the changes in a theory-neutral way. This was especially clear when it came to the question of whether two alters of a person with multiple personalities can literally be said to perceive each other’s experience. This raised general issues such as whether it is an a priori requirement that persons should be able to have first-person access to their own mental states.

While the motivation for raising such questions seems clear in retrospect, especially after the discussions in the ensuing weeks concerning multiple personality disorder (MPD) and schizophrenia, the connection was not made at the time. For this reason, some participants found it hard to see the motivation behind much of this discussion and it most likely lacked the overall impact on our discussion that it could have had.

It was only in the third week that the philosophy and the psychopathology started to come together. Judith Armstrong joined us at this time and shared with us not only her clinical experience but also her thoughts concerning the theoretical issues surrounding MPD. One of the main philosophical questions that arises in this context concerns how to understand the alleged multiplicity of personality while recognizing the existence of only one body. MPD challenges philosophical conceptions of how to individuate persons. Armstrong's insistence that MPD both exists and does not exist as a disorder, while seemingly contradictory, really helps to see the inherent problems with the philosophical questions that are being asked. While the experiences of the MPD patient are obviously organized in the form of one body suggesting that the multiplicity somehow lacks reality, Armstrong maintains that as a clinician charged with the job of reducing suffering and increasing the social functionality of the patient, the most promising approach is to start from the reality of the personalities. Her summary of the disorder - that there is nothing that it is like to be an MPD patient over and above what it is like to be one of the alters - nicely summarizes why, from a third-person point of view, the only point of entry to understanding the disorders is through an assignment of reality to such alters. However, on the question of whether the reality of the disorder is thereby determined, Armstrong remains agnostic.

Treatment cannot wait for the solution of difficult metaphysical problems. While the interaction of Armstrong and Whiting during this week worked well because it brought multiple perspectives together, it became clear that many of the standard assumptions about MPD in the philosophical literature surrounding personal identity turn out to rest on atypical cases or diagnostic criteria that have little descriptive value. Armstrong's presentations made it clear how to formulate the philosophical questions and, moreover, how practical concerns have a role to play in formulating the answers to such questions.

The fourth week on autism was valuable for similar reasons. There is a smaller philosophical literature on this topic, and it is less clear what the major philosophical questions are. It soon became apparent that maybe the primary question, both philosophical and clinical, is whether the extremely broad range of conditions that are now classified under the heading of autism really share something in common at their core. The diagnostic manuals may be able to reliably delineate a group of symptoms, but this does not guarantee that they correspond to a natural kind. The difficulty here seems to depend largely on finding which symptoms are the most telling ones about the condition, and this in turn depends on the etiology of the disorder, which is largely unknown. Kate Loveland and Peter Hobson each presented the results of experiments that they had performed, explaining the hypotheses they were testing and the speculations that the results prompted. Loveland’s presentation tended to be more evenhanded following closely the phenomenology of autism, while Hobson, who was more philosophically inclined, had more of a theoretical perspective to press. Both views differed from that of Simon Baron-Cohen, who has gained some philosophical attention with his view that autism is a form of “mindblindness,” and it became clear that this hypothesis, while potentially valuable in some cases, was unlikely to serve as a general explanation of autism.

Schizophrenia was the topic of the fifth week. The speakers, Josef Parnas and John Campbell, presented us with two very different approaches to understanding schizophrenia. Parnas began the week with a brief history of the concept of schizophrenia as well as some neurophysiological and developmental facts about the disorder. He then turned to his own views about the developmental pattern of schizophrenic symptoms, which he is currently writing about with Louis Sass. Concentrating on the phenomenology of the disorder, he argued that schizophrenia typically involves a diminishing sense of agency, or self and a discontinuity of conscious experience. At the same time, the schizophrenic becomes hyper-reflexive whereby the structure of intentional acts is distorted. Since all conscious life is centered around intentional acts, which under normal conditions bring about unity of the senses, the schizophrenic loses this unity. Parnas describes this, using a term of Merleau-Ponty's, as having the intentional arc disturbed.
In dramatic contrast, John Campbell suggested that the phenomenology of schizophrenia is largely irrelevant to its explanation. Instead, taking an idea of Frith (1992), he argued that some of the symptoms of schizophrenia could be better explained at a more sub-personal level, as a defect in the monitoring of the thinking process. This disagreement is not the same as the long standing one between psycho-dynamic vs. brain disease models of schizophrenia, although there are striking similarities between the debates concerning the place of phenomenology in the explanation of the disorder.

The interactions between Parnas and Campbell during this time proved to be quite stimulating. One aspect of their discussions concerned the recognition of three levels of understanding schizophrenia - the phenomenological, the computational and the neurological. Each was concerned to express the limitations he felt existed for a particular level in providing an adequate explanation of schizophrenia. Parnas took the position that reduction of the phenomenal level to the neurological level is just to re-describe things at the lower level. However, such a re-description does not teach us anything about the phenomenal first-person perspective. Campbell, however, maintained that the phenomenal level cannot provide causal explanations of the disorder and that some appeal to cognitive processes is needed for such explanations.

The final week was devoted to a wider discussion of the interrelation of schizophrenia and philosophy. Louis Sass discussed Ludwig Wittgenstein, exploring the idea of understanding schizophrenia in terms of Wittgenstein's account of solipsism. Many of the ideas he explored had been previously examined in his book The Paradoxes of Delusion: Wittgenstein, Schreber and the Schizophrenic Mind. Sass was particularly interested in exploring his idea that schizophrenia can be understood in a non-pathological sense. James Conant then devoted some time to replying to and criticizing Sass’s proposal. In particular, he was interested in criticizing Sass's idea that since one can read Wittgenstein's Tractatus as exhibiting schizophrenic phenomena, we can take this as a reflection of the author's mental state. Conant ended the week with some discussion of psychoanalysis and philosophy of mind.

3. Lessons to be Learned from the Institute
There are many comments we could make regarding particular features of the Institute. However, we wish to focus our attention on some conclusions concerning such multi-disciplinary work in general that might be drawn from our experiences. One of the main ways in which this multi-disciplinary endeavor differed from other such endeavors lies in the lack of clarity about what exactly the issues are that need to be addressed. For example, inter-disciplinary work in other sciences such as physics or biology addresses well-defined theoretical or conceptual issues. All parties involved in these discussions are quite familiar with the subject matter under consideration. However, as became clear early on in our discussion, it is not yet entirely clear just exactly what the issues are when it comes to the intersection of philosophy and psychopathology. It may be the case that there are conceptual and theoretical concerns that require philosophical reflection, however it also may be the case that the questions to be answered are simply empirical questions which will be answered with more empirical research. The exact nature of the problems remains an open question.

One of the reasons for this may be that the study of psychopathology, itself, resembles a pre-paradigmatic science -- to borrow from Thomas Kuhn's now famous account of the stages of science. Pre-paradigmatic science is characterized by the lack of and search for an overall theory to guide research, a methodology that delineates the acceptable ways in which research will be done and well-defined puzzles, or problems, that remain to be solved. During this stage of a science, almost anything goes. Multiple theoretical frameworks exist for understanding the phenomena, all of which are given fairly equal credence. Vastly different methods are used in the study of the subject matter and no one method seems to obviously provide a more useful way of proceeding. Perhaps, because of this, the Institute also lacked any guiding methodology or clearly defined problems to address. This, alone, is not necessarily a bad thing. However, it does suggest that progress may require focusing on such foundational questions within psychopathology (such as an overall theory to guide the research) before pursuing any particular question about specific disorders.

This multiplicity in approaches was all the more evident among the participants at the Institute. The problem may have been that our different approaches were incommensurable and that we had difficulty finding a common language. However, it seems to the authors that we as a group did for the most part understand each other: what we were unable to do was agree with each other’s starting assumptions and methodologies. This was a major stumbling block, and meant that exchanges of productive dialog were rare during the six weeks.

Attending the Institute was highly educational in providing us with a wealth of information about psychopathology that is not easily available from psychiatry textbooks. It gave us the highly welcome opportunity to interact with peers and experts with interests similar to our own. The connections we made will be important in helping to form a community in the growing world of philosophy of psychiatry. In these respects, the Institute was invaluable. To an extent, the stated aim of the Institute was achieved: there was some productive dialog between philosophy and psychiatry. But we, the authors, felt that the dialog was often far from ideal. We were left wondering how it could have been improved.

One possible suggestion for how to proceed from here is to have people from different background working together on some of the issues we addressed. The institute presented a wide array of approaches, but each was similar in that it came from one perspective. The clinicians and psychologists presented us with their clinical and scientific findings and their speculations about the best interpretations of their research, together with ideas on directions for future research. The philosophers stuck to their respective philosophical terrain. The Institute could have benefited greatly from some interaction among our presenters prior to the institute such that diverse ideas and approaches were integrated when presented.
More generally, we recognize that when thinkers from many different domains come together for dialog, there is bound to be some struggle in achieving mutual respect and helpful conversation. One approach to this is to simply hope that high standards across the disciplines and professional courtesy can be relied on to create the right conditions. However, our experience suggests that this is too optimistic. It may be that in interdisciplinary contexts such as that of the NEH Institute, it would be useful to address the differences in styles of thought more directly, and lay down some meta-level directives for methodology at the start, or narrow down the goals of the group. For if both the methods and the goals of the group are highly diverse, it will be hard to achieve any rapprochement between the participants. The frustrations experienced at the Institute are often shared by the wider group of people working on philosophical issues in psychiatry, for example at interdisciplinary conferences. One of the major challenges to be faced by philosophy of psychiatry is how to make these interactions more intellectually profitable. We hope that our experience at the Institute will enable us to recognize and negotiate this challenge more successfully in the future.

References
Baron-Cohen, S. 1995. Mindblindness: An Essay on Autism and Theory of Mind. Cambridge: MIT Press.
Frith, C. 1992. The Cognitive Neuropsychology of Schizophrenia. Cambridge: MIT Press.
Hacking, I. 1995. Rewriting the Soul: Multiple Personality and the Sciences of Memory. Princeton: Princeton University Press.
Sass, L. 1993. The Paradoxes of Delusion: Wittgenstein, Schreber and the Schizophrenic Mind. Ithaca: Cornell University Press.
Wittgenstein, L. 1922. Tractatus Logico-Philosophicus. London: Routledge and Kegan Paul Ltd.

Sunday, November 16, 2008

Review of Self-Transformations: Foucault, Ethics, and Normalized Bodies by Cressida J. Heyes

This review appeared in Philosophy in Review, Volume 28, Volume 4 (2008), pages 267-269.


Cressida J. Heyes Self-Transformations: Foucault, Ethics, and Normalized Bodies.
New York: Oxford University Press 2007. Pp. 175. CDN$110.95/US$99.00 (cloth ISBN-13: 978-0-19-531053-5); CDN$33.95/US$29.95 (paper ISBN-13: 978-0-19-531054-2).

This is a work in feminist ethics about our relations to our bodies. In five main chapters, Heyes sets out a theoretical framework, and then examines three central cases of bodies that are considered in need of changing: transgender people, overweight people, and people who want cosmetic surgery. She finishes with a proposal of a Foucauldian way for us to care for our bodies.
Heyes takes her theoretical resources primarily from feminist theory and the philosophy of Foucault. She places herself in her text, not just setting out her own views, but also giving some details of her own life and her own experiences in joining Weight Watchers, as well as discussing some of the problems she faces theorizing about other people of whose experience she has limited understanding. Thus it may be reasonable for me as reviewer to disclose more in this review than I would do in other cases, especially since my review will make some criticisms of the book. I am sympathetic to much of the feminist project but I don’t ally myself strongly with the theoretical standpoint of Foucault. Furthermore, I’m a male who has no direct experience of being transgender, being overweight or having or wanting cosmetic surgery.

The writing in this book does not rely excessively on jargon, and style is relatively straightforward. Chapters are divided into titled sections and Heyes summarizes her main points at the end of each chapter. She surveys a great deal of literature in the process of discussing each subject, and gives a sympathetic summary of each view relevant to the discussion, even when she disagrees with it. Furthermore, Heyes’ approach brings a set of theoretical approaches to issues such as weight loss and cosmetic surgery that are more sophisticated than in most other discussions in much feminist theory and certainly than in standard medical ethics. For that, she deserves a great deal of credit. On top of this, she advances existing debates in constructive ways. So there’s much to admire about this work.

One of the most important themes running through the book is the need to go beyond the dichotomy of either seeing people who engage in bodily changes such as sex change operations, dieting, or cosmetic surgery as either simply acting autonomously and therefore beyond criticism, or else acting out of false consciousness and therefore oppressed by gender stereotypes. Heyes acknowledges the importance of prior feminist critiques of idealized women’s bodies, and the problems with the pressures experienced by women to emulate those ideals. However, she also wants to acknowledge the importance of the care of the self, and the way that such focus on one’s own body can contribute to such self-care. In this, she draws especially on the last work of Foucault in the final two volumes of The History of Sexuality and some interviews.

In the chapter on Weight Watchers, probably the most accessible in the book, Heyes discusses in some detail the work of Susan Bordo and Sandra Bartky on the construction of femininity and the ways that focus on conforming to norms of beauty can oppress women. Heyes acknowledges their analyses of disciplinary practices relating to dieting, but she counterbalances these with a discussion of ‘the active, creative sense of self-development, mastery, expertise, and skill that dieting can offer’ (78). In her chapter on cosmetic surgery, she analyzes the issue through a discussion of the TV show Extreme Makeover. Again, she acknowledges the insight of influential feminist discussions of the representation of work on the body, in this case by Susan Bordo and Kathy Davis. Heyes finds no positive element of cosmetic surgery to counterbalance its problematic nature, but she does argue that current feminist critiques are not sufficient as forms of resistance or as solutions for women considering changing their bodies using medical technology.

The most provocative chapter in the book is the final main one where Heyes explores the possibility of caring for the self in a socially conscious, non-narcissistic way that would not contribute to oppressive practices. She defends Foucault from critics who accuse him of betraying his former political and ethical commitments in his final work, and she finds his discussion inspiring but elusive. She turns to the recent work of Richard Shusterman on somaesthetics for a more fully elaborated idea of what such caring for the self might look like, but still she does not find sufficiently concrete discussion. She finishes the chapter by considering three cases that might be considered as forms of caring for the self that might be ethically and politically admirable: bodily modification, British shipyard workers who practiced ballet, and yoga. She describes and evaluates each of these somewhat briefly, and she indicates that this topic is where her future work will be.

The theoretical position set out by Heyes is promising in its overall form, but her argument lacks enough detail to be convincing. In her short book, she covers philosophical methodology, sociology, cultural studies, feminist theory, medical ethics, and ethical theory. Her first main chapter uses Wittgenstein and Foucault to set out a way of thinking about the body in contemporary society, but really Heyes does no more than gesture at a theoretical position rather than develop a sustained argument.

While the earlier theoretical sections give some indication of how one might ground her approach, they don’t help much in explaining her later suggestions. Heyes is stronger in her discussion of mutual relevance of theory and personal experience or popular culture. Her positive suggestions about how we might understand an ethical approach to the care of the self are tentative and vague. I wish she had been bolder in her claims and had spent more time developing the ideas hinted at in her final chapter, especially those concerning yoga. Just when this book starts to get interesting, it finishes, and the reader is left wondering whether Heyes’ project for conceptualizing a progressive way to care for the self is indeed viable.

Christian Perring
Dowling College