Philosophy of Psychiatry is a new
name for something that is, in a sense, very old. The topic of how best to care
for and heal a person’s mind or soul has received philosophical attention since
antiquity. The professional demarcation of a medical discipline called
psychiatry, however, is far more historically recent and the idea of a field of
philosophy called Philosophy of Psychiatry is so new that, to my knowledge,
this is the first anthology of papers ever to bear the name. The publication of
this book is a major event in the ongoing development of the field.

Jennifer Radden has assembled a
number of thought-provoking pieces from some of the major figures in the field:
the collection as a whole gives a sense of both the philosophical excitement
and the cultural and practical importance of this area of study. Radden has
divided the anthology into five major parts: Psychopathology and Normalcy;
Antinomies of Practice; Norms, Values and Ethics; Theoretical Models; and
Circumscribing Mental Disorder. Many of the questions and issues raised in the
different sections interconnect in a rich and fascinating way: this means that
the standard organizational challenges of assembling an anthology of this kind
must have been particularly acute (indeed, Radden alludes to them in the
acknowledgements) – how can any piece or part come first, for example, when in
order fully to understand any of the pieces or parts one needs to have read one
of the other pieces or parts? However, while I can see that any choice in this
regard has costs as well as benefits, I think that I would have placed a piece
on the topic of how to define mental disorder far closer to the start of the
book.

Part I of the book, as it stands,
provides a kind of tour of the theoretical issues involved regarding
psychopathology and normalcy in a variety of areas: cognition, affectivity,
desire, character, action, self-ascription, memory, body, identity, and child
and youth development. One has to wait until pp.70–71 before one gets (from
Louis C. Charland) the first clear explanation of the evaluative nature of
diagnostic categories and one has to wait until chapter 29 out of 30 before one
reaches the chapter by Charles M. Culver and Bernard Gert devoted to the issue
of defining mental disorder. Now, of course, nothing prevents one from jumping
straight to the end of the book: all the pieces work as self-contained
contributions. But the issues surrounding the concept of mental disorder – to
what extent it is evaluative, nonevaluative, natural, universal, culturally
constructed, political, and so on – are so pervasive that I would have opened
the book with a piece that simply set out all these issues. John Z. Sadler’s
helpful piece on mental diagnosis would, in particular, have benefited from a
stage-setting chapter on the concept of mental disorder. The same is true of
Daniel N. Robinson’s piece on the issue of how to respond to the issue of
dangerous (or possibly dangerous) patients.

The concern about the placing of
the chapter on mental disorder, in a way, raises another question: is this book
intended to serve as an introductory guide or to represent the current state of
advanced thinking in the field? On the whole, I would say, it both aims at and
best succeeds at the latter goal. But there is a definite (perhaps somewhat
unavoidable) tension regarding the aims of the anthology here: some of the
pieces are quite sophisticated, others speak to the novice; some pieces are
highly opinionated, others adopt the more neutral and impartial style of an
encyclopedia. To give one example of the contrast: Grant Gillett’s explanation
of "discursive naturalism" (25) is likely to be impenetrable to those
not already familiar with a distinct philosophical literature that aims to
synthesize certain elements of Kant and Wittgenstein where as Nancy Potter’s
piece on gender includes some very basic points of gender theory such as, for
example, an explanation of what the term "Gender role" means
(237). This tension within the anthology as a whole also shows up in a number
of the individual contributions – some of which swing from the rudimentary to
the advanced and back again very rapidly. The danger, of course, is that the
article is then too obscure for the newcomer but too superficial for the more
advanced reader. Tim Thornton’s discussion of the reductionism/antireductionism
debate is generally helpful but his sketch of John McDowell’s philosophy of
mind is likely to be too opaque for those not already initiated and unnecessary
for those who are. The same point applies to Marilyn Nissim-Sabat’s exposition
of Foucault (248-249) and to Simon Wilson and Gwen Adshead’s overview of the
insanity defense (298).

There are a number of pieces in the
anthology that illustrate the potential usefulness of philosophy for
psychiatry: Alfred R. Mele’s discussion of volitional disorder and addiction is
an excellent example of how philosophical sophistication could lead to
practical as well as philosophical gains. And there are times here when the
philosopher is almost playing therapist to the therapist – ministering, for
example, to the potential anxieties of some mental health practitioners
regarding the role of values in psychiatry. K.W.M. Fulford’s exposition of
values-based medicine, among other things, nicely brings out the way in which
psychiatry is not the only value-laden area of medicine: the appearance that
this is the case is a result of the fact that there is more contestation over
values in psychiatry. The silent consensus over value in some other parts of
medicine should not lead one to conclude that such areas are value-free. Some
pieces raise interesting questions about where, if at all, the line can even be
drawn between philosophy of psychiatry and psychiatry proper: consider the
claim of Andrew Garnar and Valerie Gray Hardcastle that "Biological
psychiatry would do better to approach soma in a different way" (365). Are
they writing as philosophers or psychiatrists here? Does it matter? If so,
where and how can one draw the lines?

Fulford’s piece brings out ways
that the differences between psychiatry and other areas of medicine can be
exaggerated. Nonetheless, there is no denying that much of the philosophical
excitement of philosophy of psychiatry comes from the fact that psychiatry is a
field uniquely freighted with philosophical preoccupations. What other area of
medicine so profoundly raises questions concerning human identity, well-being,
and the relationship between mind and body? Indeed, one could argue that
psychiatry is a field in a state of chronic and ongoing philosophical crisis.
What is the object of care in psychiatry? Should mental health treatment be
aimed at the mind, the brain, behavior, the self, the soul, or the whole
person? This is a question which is at one and the same time both a practical
concern (what should psychiatrists, clinical psychologists and psychotherapists
be doing?) and one of the deepest of philosophical questions (what are we,
ultimately?). At times it looks as if the possibility of practicing psychiatry
depends in some sense on answering the perhaps unanswerable philosophical
question. Thus the working psychiatrist, perplexed by these questions, is left
like some character out of Beckett: I can’t go on. I go on.

Many of the pieces in the anthology
deal explicitly or implicitly with issues concerning the relationship between
the epistemology and ontology of mind. The majority of the contributors show
sympathy with the idea that there is a fundamental discontinuity between the
kind of understanding involved in gaining knowledge of material nature and the
form of understanding required to interpret human thought and action. James
Phillips quotes Dilthey’s pithy expression of this idea: "We explain
nature, but we understand psychic life" (180-181). Phillips’
marvelous piece explores some of the difficulties (in philosophical theory and
psychiatric practice) of sustaining these demarcations but I remain struck by
how many of the contributors tend to treat the epistemological dualism as
unproblematic. There is little acknowledgement of the major and longstanding
debate (or set of debates) in the philosophy of mind concerning whether
acceptance of this kind of dualism in epistemology turns out to be a package
deal (i.e. you have to buy ontological dualism too). Moreover, as Phillips’
piece makes beautifully clear, the epistemological dualism in any case fails to
acknowledge the ways in which any neat isolation of the realms of mechanical
causation and human intentionality cannot survive close attention to
experience. Philips’ piece explores these issues via the case history of a
patient, Mrs. D, suffering from depression. One passage on p.184 is worth
quoting at length:

"On the one hand, Mrs. D’s constitutional predisposition
to depression, her altered brain state, did nor simply "cause" an
altered mood; to some degree her altered brain and altered mood
"caused" her to think about the world in a different way, to give
depressed meanings to her experiences. Thus, the causal dimension of
explanation invades the dimension of meaning. On the other hand, the meanings
with which she framed her life experiences themselves had a causal effect on
her mood. This is the basis of the cognitive therapy of depression. Thus, while
it remains very useful to distinguish the understanding of meaning and the
explanation of causes, we must also recognize the deep interpenetration of
these two dimensions in our analysis of any human being."

Phillips’ piece is a model of how careful attention to
actual cases can enrich both philosophy and psychiatry. He lingers over the
significance of the fact that a person is "both meaning and natural
process" (183) and his rewarding openness to experience suggests that it
is better to do justice to our sense of ontological puzzlement than rush to
theoretical closure at any cost.

Andrew Garnar and Valerie Gray Hardcastle
suggest in their piece on neurobiology that the philosophical divide between reductionists
and antireductionists about the mind is mirrored in the practical realm of
psychiatry by the "division of labor between psychopharmacology and
psychotherapy" (372). This claim certainly has an initial plausibility to
it and it would have been nice to have seen more exploration of some of the
questions this raises: for example, must a practitioner of talk therapy take an
antireductionist view? After all, as Phillips notes, "neuroscience and its
findings of neuroplasticity have also lent support to the notion that
psychotherapy and its work with the patient’s meaning structures have an effect
on the brain" (186). One can imagine a kind of pragmatic justification of
psychotherapy that is compatible with a strong form of reductionism regarding
the relationship between mind and brain. On the other hand, one can imagine
someone supporting the claim that psychopharmacological interventions are the
best way to treat psychiatric problems while rejecting the idea that this
implies any straightforward identification of mind and brain.

The anthology, for the most part,
does a nice job in examining the socio-political dimension of many of these
questions. The rise of psychopharmacology in psychiatric treatment, for
instance, obviously stems from more than philosophical argument or therapeutic
success. Carl Elliott’s characteristically trenchant piece, in particular,
stresses the role that money and marketing have played in making
antidepressants "the best-selling category of drugs in the United
States" (432). And Jennifer Radden’s introduction notes that part of what
has put philosophical and ethical issues surrounding psychiatry on the radar is
the growing recognition of "the profound social and political importance
of mental health care" (3). I thought the weakest piece in the area of
social-political philosophy was the discussion of criminal responsibility by
Simon Wilson and Gwen Adshead. They state at the outset of their discussion of
criminal responsibility that they will not be discussing "the broader
notion of moral responsibility" (296) and yet, not only is it not clear
that discussion of criminal responsibility can legitimately avoid dealing with
the broader notion, they themselves move on to discuss issues which are clearly
in the territory of moral responsibility. Their discussion of "mental
responsibility" (301) is a discussion of moral responsibility by another
name and it suffers from the tendency to contrast a metaphysically superstrong
notion of "real" responsibility with the idea of responsibility as an
"artificial social construction" (308). The piece is sorely lacking
the kind of philosophical sophistication that underpins, for example, Jennifer
Church’s elegant overview of social constructionist models of mental illness in
chapter 27.

There are many fine pieces in the
anthology I haven’t mentioned. To single out just three more: George Graham’s
piece on the phenomenon of thought insertion provides an excellent presentation
of the issue and subtle discussion of the relationship between the phenomenological
and the neurophysiological; Shaun Gallagher and Mette Vaever provide a valuable
presentation of the relationship between mental illness, embodiment and bodily
experience; and Dominic Murphy’s piece on Darwinian models of psychopathology
is an extremely useful and elegantly presented introduction to the issues. The
text isn’t perfect: there are a few typos ("V.W.O. Quine" is cited on
p.193), some erratic prose (see the pronoun roulette at the bottom of p.30) and
some references that don’t match up (the Boghossian article cited in the
footnotes on p.404 has a different title in the references on p. 405). However,
I would be amiss if, in closing, I did not reaffirm what a significant
accomplishment this is: it simultaneously represents, announces and consolidates
the arrival of an exciting new field.

© 2005 Daniel Callcut

Daniel Callcut,
Ph.D., is Assistant Professor of Philosophy at the University of North
Florida.

Categories: Philosophical, Ethics