Neil Pickering’s closely argued and
sophisticated return to the very basic methodological underpinnings of claims
about whether "mental illness" constitutes a coherent category is a
welcome addition to the emerging scholarly field of conceptual and theoretical
studies in psychiatry. This nuanced and complex defense of the claim that
conditions such as schizophrenia and ADHD exist, and deserve recognition as
instances of "real" mental illnesses, is developed through, on the
one hand, a sustained and careful review of the literature (beginning with
anti-psychiatry thinkers), and on the other an analysis of the ways in which
ordinary science and medicine proceed. It depends on the development of two
arguments: the "likeness" argument, and the imagination’s role in
category making.

Readers of Philosophy,
Psychiatry & Psychology will already be familiar with Pickering’s
ideas about the first of these (Pickering 2003). The likeness argument is a
kind of methodological stance: the presumption that we can find a sufficiently
neutral, human-independent perspective from which to judge similarity and
difference between two kinds of things to determine whether they are
appropriately categorized together as things of the same kind. In his words,
that we can "prove or disprove the existence of mental illness or the
validity of some particular diagnostic category…by showing or discovering
whether such human conditions are or are not illnesses." (Introduction
page 6). We cannot, Pickering attempts to show. Any employment of the likeness
argument must inevitably be question-begging. Whether in the formation of other
scientific and medical categories, or in the formation of psychiatric diagnoses
and categories, there is no standpoint divorced from human agency, human goals
and purposes, and the effects of the human imagination. To think so is to
misunderstand science and medicine. 

Because mental disorders cannot be "discovered"
in the way the likeness argument implies, our decision to construe these
disorders in terms of (for instance) the brain functioning that allows us to
see them as analogous to other medical conditions, means that is what they will
become: medical conditions, theorized in the terms of medical science — genes,
cells, parts of brains, and relationships that are functional, and causal.

An evaluation of the success of
Pickering’s general critique of the likeness argument would require more detail
than can be provided here. But readers should be alerted to Richard Gipps’s and
others’ 2003 rejoinders to Pickering’s first published dismantling of the
likeness argument, to which Pickering in turn offers a response in the present
book (Gipps 2003, Loughlin 2003, Mullin 2003, Tyreman 2003). Like Gipps, I am
concerned about the adequacy of some of the putatively plausible, alternative
descriptions Pickering provides when, in illustration of his broader claim, he
explores what can be said of particular disorders, including alcoholism, ADHD,
and schizophrenia. At the very least it seems true that the first two of these
conditions better lend themselves than does schizophrenia to an application of
Pickering’s thesis that alternative explanatory accounts are available, because
whether alcoholism and ADHD are to be medically understood is widely contested
already. But making sense of schizophrenia, as Gipps points out, will be much
more difficult, and perhaps even impossible, without the language of illness,
disorder, dysfunction, health and deficit.  The proposal that a hallucinating
person with schizophrenia might be construed as willfully diverging from
consensual reality — he can but will not see the world as others do  — seems
extremely difficult to make sense of. Such difficulties suggest to me that
there must be some way the likeness argument can be resuscitated despite
Pickering’s attack. Additional questions around Pickering’s critique of the
likeness argument concern its shelf-life: if future brain science unlocks all
biological secrets about the causes of mental disorder, quieting the skepticism
over the category which the likeness argument was constructed to resolve, will
a likeness argument be entirely otiose? Or, as Pickering sometimes seems to
suggest — when he speaks of psychiatric concepts and categories as "intrinsically
tricky," for example — does the argument pick up on something more
fundamental here?

Pickering’s second broad focus is
on metaphors and the role of metaphorical language in category formation. When
Szasz spoke of "mental illness" as a metaphor, he did so
dismissively. However, rather than an enemy, the metaphorical reflects the
richness of the human imagination, Pickering insists, and the dynamism of human
concepts and categories. Using examples from the history of science and
medicine, such as Pasteur’s introduction and framing of vaccination (from vache,
the beast he recognized to mysteriously protect milkmaids from smallpox),
Pickering shows that new conditions and contingencies allow an imaginative
extension by way of metaphorical language. Just as Pasteur "made" the
category we now call vaccination — fixed on a metaphor, identified the causal
mechanism, and proposed a method — so "humans make mental illness and
make conditions such as ADHD and schizophrenia into illnesses."

One of the strengths of this book
is Pickering’s use of extended historical examples such as the one about
Pasteur. Particularly noteworthy is his narrative of the way the enlightenment
metaphor of human body as machine reached the ranks of everyday
conceptualization through a human process that in his words, changed the
features of the world (page 93). Once, he argues, body as machine was a jarring
piece of fancy. Today our notion of the body is deeply imbued with the
functionalist and causal aspects of that initially unlikely idea. Pickering may
overstate here: arguably, these functionalist and causal features emerged much
earlier, with Greek and Greco-Arabic medicine. Nonetheless, this is a
captivating example of how innovation (here, mechanistic thinking) could have
shaped conceptions of, and so changed, the world.

Several groups of people will have
difficulty accepting Pickering’s conclusions. Skeptics about mental disorder
may find his work too respectful of the claims of medical psychiatry, and be
impatient with the closeness of what shakes out from the critique of the
likeness argument, to the kind of "if it walks like a duck" reasoning
that critique should have exploded; on the other hand, supporters of a more
robust sense in which mental disorders can be said to exist may find his
efforts timid.

A different sort of concern may be
raised by the benign portrayal of scientific progress in Pickering’s book,
which seems to ignore much of the alarming reality of today’s science. It is
one thing for scientific "discovery" to proceed as if it were the
effort of detached and neutral observers and catalogers of categories
pre-existing in nature even when, in fact, its efforts are the products of
human fashioning. Somehow here, we want to say, different human perspectives
will be represented; a balance of human interests will influence how things
turn out, and which metaphors come to prevail. But it is another thing
altogether to recognize that certain interests are strongly over-represented in
this process. If we are to accept recent exposés of the underpinnings of
psychiatric research, for example, such as those of David Healy (Healy 2004) we
seem unable to avoid the conclusion that at least in this country, diagnostic
concepts such as schizophrenia, or ADHD reflect less categories fashioned from,
and for, a range of human purposes, than categories created by giant
corporations for a very narrow and circumscribed set of interests and purposes,
corporations that direct what will be studied and how; they way findings will
be interpreted and represented; even how they are marketed and communicated to
practitioners and consumers.

The Metaphor of Mental Illness
is a complex and extended series of arguments marshaled towards a set of subtle
distinctions and nuanced conclusions. Pickering meticulously distinguishes his
own position from several variants that are more radically skeptical, including
that of Szasz; as well as from the closely related "strong programme in
the sociology of knowledge," and from social constructionism; he separates
medical metaphors from medical models of mental illness, and "human
constructs" from "social constructs" — to name but a few of the
distinctions delineated in these pages. Although each such distinction and
separation is warranted within its argumentative context, the overall effect of
the extremely fine-grained approach Pickering employs is not easy on the
reader, it must be admitted. Moreover, the way the author anticipates and deals
with apparent weaknesses in his own positions as he proceeds and qualifies his
conclusions, admirable as it is from the perspective of intellectual rigor and
candor, at times threatens to bury the main argumentative threads. A less
discursive style, and greater use of footnotes for prima facie
objections, might have made this an easier set of theses to absorb and
evaluate. Yet its rigorous and comprehensive style is also a strength, and the
reader prepared to put in the effort will be rewarded with a deeply integrated
and original vision of the intricacies we face in trying to understand the "intrinsically
tricky" concepts and categories of psychiatry.

 

Gipps, R. 2003. Illnesses and Likenesses. Philosophy,
Psychiatry&Psychology. 10, No.3: 255-259

Healy, D. 2004. Let Them Eat Prozac.New York: New
York University Press.

Loughlin. M. 2003. Contingency, Arbitrariness, and Failure. Philosophy,
Psychiatry&Psychology. 10, No.3: 261-264.

Mullen, R. 2003. Definition Is Limited and Values
Inescapable. Philosophy, Psychiatry&Psychology. 10, No.3: 265-266.

Pickering, N. 2003. The Likeness Argument and the Reality of
Mental Illness. Philosophy, Psychiatry&Psychology. 10, No.3:
243-254.

Tyreman, S. 2003. Lkening Strikes Twice: Psychiatry, Osteopathy,
and the Likeness Argument. Philosophy, Psychiatry&Psychology. 10,
No.3: 267-271.

 

© 2006 Jennifer Radden

 Jennifer Radden, Ph.D.,
Department of Philosophy, University of Massachusetts, Boston.  Radden is
editor of The
Philosophy of Psychiatry: A Companion, and The Nature
of Melancholy: From Aristotle to Kristeva and author of Divided Minds
and Successive Selves: Ethical Issues in Disorders of Identity and Personality

Categories: Philosophical