Judging from the number of books in the Psychology/Self-Help sections of bookstores, the general public has a strong interest in issues to do with mental health and clinical psychology. Academics in the fields of Philosophy and Biomedical Ethics have, however, largely neglected the metaphysical, conceptual, ethical and political issues to do with psychopathology that so fascinate others. Philosophers have had some well-publicized debates about the scientific status of psychoanalytic theory, but these have been of merely academic or theoretical interest, since in psychiatric practice psychoanalysis faded out decades ago. There has been a change of intellectual climate in the last five or so years that philosophers and ethicists have started to investigate clinical psychology as it is actually practiced. It is helpful to compare this book by Jennifer Radden with one by Carl Elliott; both are important landmarks in the development of the new field of philosophy of psychiatry.

Both books deal primarily with issues of the moral rights and moral responsibilities of people with mental illnesses. But they have quite different styles. Radden’s Divided Minds and Successive Selves is aimed at an audience with philosophical training. It is academic in its approach, and pays careful attention to detail. The actual writing style is quite typical of modern academic philosophy, i.e., dry and sometimes hard to read. Radden is prone to clunky prose style, and her book would have benefited from more careful attention from an editor. I even wonder whether the font (Bembo) in which the book is printed is hard on the eyes: something about the physical appearances of the pages makes the writing look unapproachable to me. Elliott is a better writer, and since The Rules of Insanity is a slim 124 pages of text, it is a comparatively quick read. His claims are easy to understand and his arguments are straightforward. The scope of the book is relatively narrow. In contrast, Radden’s book is ambitious, covering a wide variety of issues and fields of study. There is no overall simple thesis for which she argues, and her book defies quick summary.

Radden

While the subtitle of Radden’s book is Ethical Issues in Disorders of Identity and Personality, the book actually devotes more space to discussing metaphysical issues, which are then used in arriving at ethical conclusions. There are four parts to the book, the first of which is devoted to setting out the basic issues to do with understanding the differences between the unity of mind in normal people and the disunity of mind in the various forms of psychopathology. Radden is quite ready to agree that these differences are real: she is not sympathetic to some of the radical views of critics of psychiatry, who have claimed that there is no real difference between sanity and insanity, or madness is just a label that society uses to control deviancy. Although she does say some things which might go against some psychiatric practices, she is happy to stay within the mainstream.

Radden emphasizes that we need to be careful in our characterization of normal minds. They are not as unified as we might think. However, there are still striking differences between the normal and the pathological. The clearest case of multiplicity within a mind is in dissociative identity disorder (DID), popularly called “multiple personalities.” Here there are different “selves” coexisting within one body. Radden does not go so far as to say that the different selves are different people, but they collectively have significantly more diversity among them than a normal person does in him or herself. Each self is a separate agent, with a distinct personality, which persists over time (even though the self may not be present all the time), and the subject (i.e. the collection of selves) appears to experience unusual amnesia.

Armed with these criteria, she moves on to examine other clinical phenomena, such as mood disorders and schizophrenia, in order to determine the extent to which they also exhibit multiplicity. She points out that these illnesses do not, as a rule, lead to profound personality changes. The personality change associated with mania can last for weeks or months, and while there is no significant loss of memory, there is memory distortion and selectivity. But Radden’s discussion of these cases is disappointingly short. Despite the fantastic array of real clinical phenomena, she only considers in this part of the book one real life example of schizophrenia. She concludes that it can make sense to say that during a acute phase of the illness, we are dealing with a different self from the normal self that previously existed, and will return when the illness is controlled.

Contexts of Responsibility

Part II of the book is the longest of the four, at over 100 pages, divided into six chapters. The main point of this part is to investigate the responsibility of the successive selves we find in abnormal psychology for the actions of the person they constitute. Radden says that there is no simple rule with which we can judge the responsibility of a person with a mental illness. Instead, we need to specify the context in which we are concerned with responsibility. The approach used in psychotherapy, for instance, will be quite different from that used in a court of law. In therapy, the different selves of a person with DID will consider themselves quite separate from each other, and not responsible for each other’s actions. However, in a court of law, it is not practical to make such fine
distinctions, because there the bottom line is whether the defendant should be found innocent, or found guilty and punished. It is not feasible to find one self innocent and other guilty, even supposing that we could be sure that the defendant was not faking multiple personalities.

Radden considers whether people with DID who have committed crimes should be found not guilty on grounds on insanity, diminished capacity, or other possible defenses linked to the disorder. She concludes that no such defense is justifiable, although there might be good reason to reduce the punishment. Currently this is an issue of mainly theoretical interest, since there have been very few cases of defendants trying to avoid punishment on the grounds of having multiple personalities. It might become an issue of greater public concern if such a defense becomes more common, but this seems unlikely given the current public hostility to any insanity defenses, and the particular worry that it is easy to fake the dissociation of identity.

Forced Treatment

A topic of more public concern is when it is morally permissible to force a mentally ill person to undergo psychiatric treatment. The law generally permits us to hospitalize a person if she has a major mental illness and is a serious danger to herself or to others. But there are many more times when a person does not meet such stringent criteria, and yet her family or friends are concerned enough to try to convince her to seek treatment. When rational or emotional persuasion fails, there is not much that people can do, since, at least in America, so much emphasis is put on the right of citizens to be free from interference. Can a moral case be made for overriding this right in the case of people who are not dangerous but whose lives are going severely awry because of their untreated mental illness?

Radden argues against various philosophers who have tried to make such a case. It is hard to say that the mentally ill are incompetent to run their own lives, because we have no clear criteria of competence. If we force treatment on one person on the grounds of incompetence, for making a disastrous life decision, where can we draw the line? Clearly there is a danger that government or the medical establishment would start to have too much power over people’s lives.

Other proposals for justifying forced treatment are that it is in the patient’s best interest, or that it is what the patient would have wanted. Radden does an impressive job in showing the problems that arise for these approaches. Neither does it work to argue that, by making the patient take drugs or involuntarily hospitalizing her, we are actually returning her to her ‘true self,’ and so, despite appearances, increasing her freedom. There are enough difficulties with this idea that it fails to pass the crucial test of being a solid argument. Radden insists that if there are lingering questions about the soundness of the arguments, we should stay on the side of liberty.

Ulysses Contracts

Sometimes it is not just the family and friends of an ill person who wish she could get treatment. Sometimes she herself, before and after the illness, wishes that she would get treatment when ill. In such cases, she might write instructions ahead of time, while healthy, saying that she permits, or even demands, to be forced to accept treatment. These have been called Ulysses contracts. Presumably they are a legal minefield, but Radden is not interested in the legal aspects. She is concerned about the moral legitimacy of these directives, and argues that unless the ill person is actually self-destructive, we should not honor her previous request to force treatment.

Her argument is subtle. We can view the situation in one of two ways. Either the contract-writing healthy self counts as a different individual as the later irrational ill-self, or they are the same. If they are different, then what we have is one individual forcing another to get treatment, and this is unfair. If, on the other hand, they are the same individual, then that individual has the right to change her mind about whether she wants treatment, and she should be able to refuse it. We think people have the right to make bad choices, and the mentally ill should be no exception to this, no matter what they previously instructed.

Self-Destructive Wishes

It is a standard liberal view that we can override a person’s wishes just when those wishes are likely to harm another. In a person with recurrent major mental illness, understood on a successive-self analysis, when the ill-self threatens suicide, this also threatens the healthy-self, who would re-emerge if the illness was treated. We can interfere with suicidal wishes when a person is mentally incompetent, but incompetence is difficult to establish even in the suicidal. On Radden’s view, however, we don’t need to resort to declaring the ill-self incompetent, since her self-destruction can be prevented on other grounds, i.e., the protection of the healthy-self. Here she is assuming that the healthy-self and the ill-self are different individuals. The ill-self might have the right to destroy itself, but it does not have the right to destroy the healthy-self.

There are several problems with this argument, but I will just mention one here. It proves too much. For it would follow from this analysis that the healthy-self does not have the right to destroy the ill-self. Of course, the healthy-self is not suicidal, but in a sense, it wants to destroy the ill-self. The healthy-self has a right to exist, but the ill-self has equal moral status, and so cannot be intentionally destroyed. A person who was successfully treated by medication, for instance, would seem to have a responsibility to go off it periodically in order to allow the ill-self some more time to exist. This conclusion is so absurd that it casts
doubt on Radden’s successive-self analysis.

Unitary Identity

For the third part of the book, Radden obliquely opposes postmodernists who advocate a multiplicity of self. She argues that being unified is generally better than being disunified. This is also relevant to therapists treating patients with DID: should they aim to bring all the personalities together into one, or is it reasonable to allow them to continue to coexist? Radden favors the merger of the different personalities into one.

In making her argument over four chapters, Radden goes into interesting details and thoughtful discussion. She tends not to take strong stands in this part. But she does argue that it makes sense to say a person is responsible for her past actions, at least in some ways, even when she has gone through such severe personality change that she is not the same self as she was previously. She concedes that in cases of extreme flux and discontinuity, as found in DID, it hardly makes sense to use our normal language to describe people’s lives. But she thinks that in more moderate cases, it is at least possible to apply the concepts to some degree. For example, we find no problem in saying a person was trustworthy for some period of her life, but not during another period. Radden points out that one can have integrity through dramatic changes in oneself, if there is a continuity of self-monitoring. Indeed, this is what
often goes on in therapy.

Metaphysics of Possession

In the fourth and final part of the book, Radden delves into philosophy of mind and turns to the ways that minds can be divided at one time. She starts off considering whether there can be more than one center of awareness within a body at one instant. Much of the supposed behavioral evidence for this phenomenon is not conclusive, both in people with DID and in hypnotic states, and in people who have had operations to sever most of the neural connections joining their two brain hemispheres. She says it is possible to explain these phenomena without recourse to hypothesizing a divided consciousness. She also examines a variety of other psychological phenomena, such as thought insertion, depersonalization,
derealization, possession states, and out-of-body experiences as other possible sources of evidence for divided consciousness. Radden argues that they are cases of division, but this does not mean that there are two separate independent centers of awareness. Rather, they involve a duality of experience happening to one center of consciousness.

Finally, Radden considers the ways in which we can see some parts of our minds as not really part of us at all. This is to do with the distinction between I and not-I. For instance, schizophrenics sometimes experience auditory hallucinations, where they hear voices as if they are coming from someone next to them. The voice sounds as if it is not their own, but belongs to someone else. In these cases, the hallucinators think that it does really belong to someone else. Radden says this strange phenomenon is not a matter of people failing to realize who is having the experience, but rather a failure to realize that they are the actual originators of the experience. In this kind of work, Radden is doing a form of conceptual tidying of our metaphysical understanding of the mind. It is worthy work, although it is hard to make it exciting to those who
are not predisposed to be interested in such fine detail.

Falling Between Several Stools

Divided Minds and Successive Selves is impressive for its relevance to current philosophical debates and shows how much the philosophers writing about subjectivity and consciousness are missing when they neglect issues arising from the study of psychopathology. But philosophers will criticize the book for not doing into enough detail, and its overly brief discussions of the ideas of other philosophers. The book may be interesting to philosophically-minded psychologists and psychiatrists who are interested in gaining a clearer conceptual understanding of the phenomena they deal with in their everyday practices. But unfortunately it is unlikely to appeal to a general audience. Apart from the stylistic problems and the use of philosophical jargon, the issues it deals with tend to be abstruse, and
Radden shies away from dealing the implications of her ideas for current social issues. This is a pity, because the work she has done is actually original and important, and deserves to gain wide attention. I hope that she will in the next few years write a sequel to Divided Minds and Successive Selves, which would be aimed at a wider audience, and would engage more in the debates that rage over social and legal policy.

Categories: Philosophical, Ethics

Keywords: metaphysics, self, ethics, morality, dissociative disorders
Tags: Mental Health Policy and Advocacy