Nature and Narrative is a
collection of 17 articles taking a philosophical perspective on psychiatry. 
Some of the authors are well known philosophers such as Gordon Baker and Rom Harré
and others are in psychology and psychiatry, including Alfred Kraus and Daniel
Robinson. Most of the contributors are located in Europe: Natalie Depraz in
philosophy at the University of Sorbonne, Paris, Markus Heinimaa in psychiatry
at the University of Helsinki, Eric Matthews in philosophy at the University of
Aberdeen, Michael Musalek in psychiatry at the University of Vienna, Paolo
Rossi in philosophy at Florence University, Guy Widdershoven and Ineke Widdershoven-Heerding
based in philosophy in the Netherlands.  Some authors are from South Africa and
Australia.  They have a rich variety of perspectives, and employ diverse
methodologies. 

In their introductory chapter, the
editors make great claims for the recent renaissance of philosophy of
psychiatry, suggesting that it is likely to lead to a long-term partnership between
philosophy and psychiatry.  They go so far, at least in the section headings,
to claim that the project will give rise to "new kinds" of
philosophy, ethics, psychology, phenomenology, and scientific psychiatry.  The
articles in this book do not really live up to such an ambitious proposition,
and indeed, several of them amount to no more than a rehashing of long-familiar
themes in philosophy of psychology, or present questionable and even rather
bizarre ideas relating to the nature of psychopathology.  Nevertheless, despite
or possibly in virtue of its eclecticism, as a whole Nature and Narrative
is a valuable addition to the library of books in philosophy of psychiatry that
is especially likely to appeal to an interdisciplinary readership.

In this review, I will give brief
summaries and comments on each article. 

In "Towards a psyche for
psychiatry," Russell Meares argues that we need to go beyond the present
level of conceptualization and practice in psychiatry, we need to turn to the
modes of thinking of Hughlings Jackson, William James and Pierre Janet.  Meares
seems to think that the problem of current psychiatry is that it treats humans
as machines, and thus devalues or ignores the personal world of feelings and
imagination.  However, he does little to establish either that psychiatry
actually makes this error or that adopting the methods of Jackson, James or
Janet is the best way to correct the error.  His paper is more of a rallying
call than a philosophical argument.

Gordon Baker has a solid reputation
as an interpreter of Wittgenstein.  In "Wittgenstein’s method and
psychoanalysis," he continues this work to explore how dissolving the
puzzles that trouble philosophers can be seen as akin to psychotherapy. 
Wittgenstein uses Heidegger’s statement that "the nothing noths" to illusutrate
his approach.  He does not believe that we need to develop a philosophical
theory of the nature of reality to ascertain whether or not Heidegger’s
statement is true, but rather we need to diagnose what led Heidegger to make
this claim, searching for reasons that might even be termed
"unconscious."  By bringing back the philosopher to the ordinary
linguistic usage, we should be able to cure him or her of the urge to think
there was a deep conceptual problem to be solved.  The parallel between
Wittgenstein’s method and Freud’s is interesting, although it’s unclear how far
the connection between the two illuminates either.  What is clear is that this
tells us very little about psychiatry, since it is simply addresses the very
general issue of the nature of philosophy.  

Eric Matthews addresses a solidly
conceptual question in "How can a mind be sick?"  Matthews tries to
steer a course between biological reductionism and Szasz’s antipsychiatry: he
resists the view that mental disorders must necessarily be physical disorders,
but equally resists the view that mental disorders are simply cases of behavior
that differs from social norms.  He traces the problem to the difficulty in
conceptualizing the nature of mind and its relation to the body.  His solution
to the problem is pluralistic, that there are several ways in which a mind can
be sick.  But his main focus is on developing a notion of consciousness from Merleau-Ponty
as a way of illuminating the concept of mental disorder.  He emphasizes the
importance of embodied consciousness and the centrality of the concept of a
person rather than a reduction of the person to a mind or body.  Of course, to
what extent this approach really solves the mind-body problem is a matter for
extensive discussion, and Matthews does not go into much detail concerning the
implications of the approach for the nature of mental disorder.  Nevertheless,
he does make a strong case that a phenomenological approach could be a
productive one when addressing the conceptual puzzles that arise concerning
mental disorder. 

In "Psychiatry and the
law," Daniel Robinson steers the same course as Matthews between
biological reductionism and antipsychiatry, but his topic is the moral standing
of people with mental illness, and especially when they can be legitimately
coerced into treatment.  He throws in his lot with the conservative political
theory of Robert George as set out in his book Making Men Moral, as
opposed to the liberal theory of Robert Dworkin.  However, it is hard to find a
clear statement of a specific position that Robinson is arguing for.  He does
say that, "it should be a principal commitment of psychiatry to develop
and express as generous a disposition toward the dignity of the person as is found
in the law itself," but it is hard to imagine who would disagree with this
proposition.  It seems that Robinson’s general outlook is to be wary of the use
of state powers to deprive people of their liberty, but he gives very little
detail about exactly how he would draw the line. 

Widdershoven and Widdershoven-Heerding
propose a hermeneutic alternative to the predominant neuroscientific causal
model of dementia.  One might expect this to be a replay of the long-standing
debate between psychodynamic and "brain disorder" interpretations of
bizarre beliefs, but they link their ideas to Gadamer rather than Freud.  In
their paper "Understanding dementia: a hermeneutic perspective," they
present a case of a woman on a psychogeriatric ward, who accuses her daughter
of taking her money.  They suggest that all odd behavior becomes meaningful and
even acceptable on their view.  They relate this to adopting a caring stance
towards people, and say that one should "abstain from judgements about the
adequacy of the person with dementia’s perceptions."  This suggests that
the primary aim of their project is not to find the correct explanation of the
person’s beliefs, but rather is about how to interact with her and her family
in order to provide the best standard of care, and indeed the authors make an
Aristotelian claim that ultimately understanding dementia is a practical matter
connected with looking after the patient.  Their practical suggestions about
how to help dementia patients make good sense, but it seems that their ideas
could be summed up by saying one should be sympathetic and non-judgmental, and
the heavy philosophical artillery used to justify their approach is
unnecessary. 

Derek Bolton provides a more
satisfactory discussion of the nature of explanation of mental disorder and
human behavior more generally, in his article "Meaning and causal
explanations in the behavioural sciences."  He summarizes the well-known
split between causes and meanings in the history of psychiatric theory, and
argues that this gap has been bridged with the new cognitive sciences.  Bolton
argues that these show that meaning is encoded in the brain, and that the
understanding of human behavior is firmly grounded in evolutionary theory,
developmental psychology and the cultural sciences.  We can explain the
symptoms of schizophrenia, for example, using multiple interacting levels of
explanation, including neurosciences and systems of meaning.  He suggests that
the "deconstruction" of the old dichotomies between physicalism and
hermeneutics is an essential step for the progress of an integrated
biopsychosocial science.  Bolton’s chapter is programmatic, but those
interested in a deeper exploration of these issues can look forward to the
forthcoming second edition of the book he wrote with Hill, Mind, Meaning,
and Mental Disorder.

In "Subjectivity and the
possibility of psychiatry," Rom Harré synthesizes a number of
philosophical perspectives into what he calls a discursive, constructionist
approach heavily influenced by Wittgenstein and Goffman.  He emphasizes that
the social is prior to the individual, and thus is unsympathetic to
explanations of people’s behavior that suppose they can have private
languages.  With this approach, he briefly proposes that one of the problems of
people diagnosed with multiple personality is that they incorrectly use
pronouns, and they should use pronouns in way that acknowledges their own
actions.  He makes the rather bizarre claim that "repairing grammar is
repairing the mind."  He moves onto note that in the case of Alzheimer’s
patients, their use of personal pronouns is robust, and makes the even more
surprising claim that, "According to Wittgenstein’s ‘expressive’ account
of the uses of language, the personal pronouns express one’s sense of self in
relation to others."  While paying attention to language is certainly
important in interpreting other people, Wittgenstein is not often interpreted
as providing a psychological theory.  If there are any studies that show that
one cure mental illness or even relieve suffering through correcting people’s
grammatical mistakes, one would expect them to be better known.  Harré does not
cite any.  Nevertheless, his claims are provocative, and he allies his project
with other work in psychology so it might be counted as part of a productive
research program. 

Grant Gillett and Harré jointly
wrote a book entitled The Discursive Mind, so Gillett’s article
"Form and content: the role of discourse in mental disorder" can be
seen as continuation of the discursive approach.  He emphasizes that
conceptualizing the world is an interactive process.  Our conceptualizing of
ourselves at least partly constitutes our own natures.  Gillett engages in the
familiar debate between psychological and biological science, but he disagrees
with Bolton and Hill’s claim that mental explanation is a form of causal
explanation, and suggests that the discursive view provides a better
alternative account of mental explanation.  As he puts it, "Discursive
explanations, in a way that differs from causal explanations, put the
self-forming relational subject at the center of all mental
explanations."  Gillett expresses sympathy towards Ian Hacking’s
well-known account of "the looping effect of human kinds," although
he does not note that Hacking has used this account to express some skepticism
about categories such as multiple personality and abused children.  While
Hacking surely agrees that he need to use human kinds in the human sciences, he
is less enthusiastic about their inevitability than Gillett seems to be. 
Gillett proceeds to apply his account to the case of anorexia, which is exactly
the kind of phenomenon Hacking’s approach applies well to.  Gillett focuses on
rather more biological details than conceptual, and he argues that a young woman’s
feelings about her gender and her development into womanhood can cause her to
reduce her eating, which stops her menstruation and causes other physical
changes in her body. 

There are some obvious difficulties
in the discursive view defended by Harré and Gillett.  One immediately raised
by Gillett’s discussion of anorexia is how the view differs from standard
psychosocial explanations of people’s behavior.  Although they put more
emphasis on the role of language, when it comes to particular examples, the
kinds of theories they use when explaining human behavior come very close to
those provided in standard psychological accounts.  More generally, it is not
clear to what extent the discursive view is a collection of empirical claims
and to what extent it makes conceptual, metaphysical, epistemological and
methodological claims.  The fact that it is hard to be clear about these issues
is a sign of vagueness in the discursive view.   We should welcome competition
between approaches to mental disorder which steer the path between biological
reductionism and antipsychiatry, and the debates between proponents of the
phenomenological, discursive and integrated biopsychosocial approaches should
lead to productive dialog, but the points of disagreement between the theories
need to be more sharply defined and there needs to be more discussion of
particular examples to see how the different approaches compare.  The articles
in Nature and Narrative do contribute to this dialog but one wishes that
there were more sharply defined interaction between them. 

Michael Musalek provides a thorough
discussion of "Meaning and causes of delusions," but while he does
refer to a number of philosophers in his article, it is far from clear what
philosophical debate he is participating in.  He mentions the debate over the
definition of delusion, this is not his primary topic.  His conclusion sets out
the various kinds of meanings that can be investigated when presented with
delusions, and his earlier discussion elaborates them at greater length.  His
final sentence says that more research is needed to "clarify the
significance of the various meanings of delusions in the pathogenesis of
delusional states and their effects as disorder-maintaining factors."

There is more of a philosophical argument
in Katherine Morris’ "The phenomenology of body dysmorphic disorder: a Sartrean
analysis."  She explains that she uses phenomenology as a method to find
the essence of what is experienced by people with the disorder, and makes great
use of Katharine Phillips’ book about BDD, The Broken Mirror.  Morris
distinguishes between the body-as-physical-thing, the
body-as-physiological/biological-object, the body-of-the-other, the
lived-body-for-itself, and the lived-body-for-others.  She identifies various elements
in BDD: longing for invisibility, nausea or self-revulsion, alienation, inapprehensibility
meaning that the BDD sufferer wants to know with certainty how others view him,
and responsibility without control.  Her conclusion is that BDD is "a specific
disorder of the ‘lived-body-for-others,’" and she recommends that this
result should be inform the DSM categorization.  Controversially, she suggests
that it is phenomenologically misguided to provide a sociological explanation
of the occurrence of BDD.  She agrees that the content of the disorder is
influenced by culture, gender and the media, but says the occurrence is
essential to humans living among others.  Her argument against the sociological
approach is brief, and many will be puzzled how there could be an a priori
argument to demonstrate such a conclusion. 

Continuing the phenomenological
side of the book, Natalie Depraz contributes a chapter on, "Putting the époché
into practice: schizophrenic experience as illustrating the phenomenological
exploration of consciousness."  She uses the case of schizophrenic
experience to call into question the common distinction used by those in the
philosophical phenomenological tradition between ordinary experiences shared by
most people and limit-experiences that are difficult to communicate.  She
argues that the schizophrenic époché combines a transcendental
disturbance of familiarity with a radical existential disturbance.  Depraz’s
discussion is admirably sophisticated, and does a wonderful job at showing the
richness of a phenomenological approach to the understanding of experience. 
However, it is somewhat surprising that in a paper that highlights the
importance of understanding of experience, there is so little discussion of
actual cases of schizophrenia.  For example, Louis Sass in his groundbreaking Madness
and Modernism and many of his articles makes far clearer exactly what
aspects of schizophrenic experience he is talking about.  Depraz briefly refers
to four cases in a long footnote, and her bibliography does list a number of
other works about schizophrenic experience.  One might hope that her recent
book, co-authored with Varela and Vermersch, On Becoming Aware: The
Pragmatics of Experience, take the opportunity to discuss actual
experiences in far greater detail. 

Alfred Kraus provides another
sophisticated discussion of phenomenology with "How can the
phenomenological-anthropological approach contribute to diagnosis and
classification in psychiatry?"  He explains that P-A
(phenomenological-anthropological) psychiatry makes holistic diagnosis oriented
to the person.  He thinks that this approach can complement the S-C
(symptomatological-criteriological) approach to diagnosis of the ICD and DSM,
using the examples of melancholia, hypomania and hysterical personality
disorder.   Controversially, Kraus supposes that one’s lived experience can be
disclosed without any theoretical presuppositions, and he distinguishes between
different approaches to phenomenology: eidetic phenomenology, the phenomenology
of constitution, and existential-hermeneutic.  His discussion of these is
brief, but fortunately it is possible to follow the main points of his
subsequent discussion without worrying too much about these distinctions.  The
central idea in his approach, that one needs to understand the person as a
whole rather than as a collection of symptoms, is illustrated in his discussion
of particular mental disorders, and Kraus also explains how his approach can
improve the relationship between the clinician and patient, especially in
psychotherapy and rehabilitation.  Given the limits of space, it is doubtful
that Kraus has said enough to win over true-believers in the DSM, and he says
nothing to compare the P-A approach to other alternatives to S-C diagnosis, but
he does at least provide a guide to further reading on the topic.

One of the rising topics in
philosophy of psychiatry is that of nonsense, addressed in the paper by Markus Heinimaa,
"Incomprehensibility."  Some researchers have suggested that it is
part of the essence of some mental illnesses that the words or actions of those
with the illnesses are incomprehensible, and this immediately raises the
question of what counts as incomprehensible.  Some other approaches to mental
illness, especially hermeneutic or psychodynamic, take an opposite stance,
showing the underlying meanings of the words or actions of the mentally ill. 
Both approaches raise the issue of to what extent it is possible for a
clinician to understand a patient.  Heinimaa surveys some of the psychiatric
and philosophical literature on the topic, paying particular attention to the
work of Wittgenstein.  He argues that "saying that something is
incomprehensible is not an explanation at all, but just an expression of
despair when our ordinary ways of comprehending people and situations elude
us."  He concludes that this insight can be helpful to clinicians when
frustrated in their efforts to communicate with patients.  This area of
research seems particularly interesting, and Heinimaa’s paper should help to
spur further discussion.

Gerrit Glas tries to combine
biological and existential approaches to psychiatry in "Anxiety — animal
reactions and the embodiment of meaning."  He surveys some common
biological theories and the set out different kinds of psychodynamic causes of
anxiety, as related to loss of structure, existence as such, lack of safety, unconnectedness,
doubt and inability to choose, meaninglessness, and death.  He then brings in
the work developed during the 1950s of the Dutch philosopher Herman Dooyeweerd
as a way to integrate different perspectives.  Glas concludes that Dooyeweerd’s
work is very promising in this enterprise.  Given the limited length of the
paper, it is inevitable that all he can to is provide a sketch of his project but
he does make a case that it is worthwhile.  Since Dooyeweerd is an unfamiliar
name for most philosophers and clinicians, others may be reluctant to invest
much time in exploring his work until there is more decisive evidence that his
approach will help to advance our understanding the relation between the
biological and the psychodynamic, but one may at least look forward to Glas’
other work in this area to see the strength of the research program.

In one of the more technical pieces
in the collection, Werdie van Staden and Christa Kruger discuss
"Linguistic markers of recovery: semantic and syntactic changes in the use
of first person pronouns in the course of psychotherapy."  They briefly
present the results of their empirical study, which shows a change in semantic
use of first pronouns after psychotherapy, but no significant change in
syntactic use.  They then explore the theoretical implications of this result,
emphasizing the way that their study combines the study of meaning with
scientific method.  They conclude with some practical consequences of their
work. 

The book ends with a paper on
"Magic, science, and the equality of human wits" by Paolo Rossi. 
Rossi surveys the role of magic in pre-modern thought and the importance of the
rise of science in the modern era.  It is hard to see why the editors saw fit
to include the paper in the collection, since it includes no discussion of
concepts of madness or mental disorder. 

As a whole, this collection is
especially valuable for its presentation of more unusual perspectives in
philosophy of psychiatry. Many of the papers make a strong case for the value
of hermeneutic and phenomenological approaches to psychiatry, and address the
issue of how to integrate those approaches with more mainstream psychiatric
models.  The book should appeal to those with a background in philosophy and
with at least some knowledge of clinical psychology.  The book’s subtitle is
somewhat misleading, since it is hardly an introduction to the new philosophy
of psychiatry.  Despite the admirable attempts of the editors to tie the papers
together in their introductory chapter, the most striking feature of the
collection is its disunity.  The book would not be appropriate for use as a
textbook in an introductory undergraduate course to this field, and it would
have to be supplemented by a great deal of more central material if it were
used in a course for graduate students or professionals.  Nevertheless,
philosophers and mental health professionals who want to get a sense of some of
the work being done to understand the debates at the foundations of the study
of mental illness should find a provocative assortment of ideas in Nature
and Narrative.

 

© 2004 Christian Perring. All
rights reserved.

 

Christian
Perring, Ph.D., is Academic Chair of the Arts & Humanities
Division and Chair of the Philosophy Department at Dowling College, Long Island. He is also
editor of Metapsychology Online Review.  His main research is on
philosophical issues in medicine, psychiatry and psychology.

Categories: Philosophical, Psychology