How has philosophy of psychiatry developed over the past few decades, and what questions and subjects currently captivate researchers in this interdisciplinary area?
On the occasion of the 30th anniversary of the journal Philosophy, Psychiatry, and Psychology, two of its senior editors, Awais Aftab (Case Western) and Nancy Nyquist Potter (Louisville) survey developments in philosophy of psychiatry over the past three decades.
Celebrating 30 Years of Philosophy of Psychiatry
by Awais Aftab and Nancy Nyquist Potter
The Association for the Advancement of Philosophy and Psychiatry (AAPP) was organized in 1989 to foster investigation and debate across philosophy, psychiatry, and other psy-disciplines. A few years later the journal Philosophy, Psychiatry, and Psychology (PPP) was founded by AAPP, in cooperation with the International Network of Philosophy and Psychiatry and the Philosophy Special Interest Group of the Royal College of Psychiatrists (UK). The journal is published by Johns Hopkins University Press and this year the journal is publishing its 30th volume. A series of editorials in the 30th anniversary issue of PPP offers a snapshot of many contemporary concerns that animate the academic philosophy of psychiatry community.
PPP has been a locus of seminal philosophical work in philosophy of psychiatry, psychology, and madness, and a great deal of its success is owed to the fact that it is embedded in a larger network of conferences, blogs, dialogues, and research that foster collaboration, dialogue, research, and critique. Reflective of the broader field itself, PPP has maintained a strong interdisciplinary spirit and is invested in facilitating a meaningful dialogue between philosophers, psychiatrists, psychologists, and scholars from related disciplines. In recent years, PPP has also committed to publishing the winning paper of the Karl Jaspers Award, which is an award given annually by AAPP to the best unpublished paper related to philosophy and psychiatry by a trainee in the disciplines of philosophy, psychiatry, or psychology. By doing so, PPP has highlighted and drawn attention to important, at times groundbreaking, work being done by trainees, in addition to academics in various stages of their careers.
In the remainder of this guest post, we identify some prominent developments in philosophy of psychiatry over the past 3 decades, noting issues that have sparked articles and conversations, and future directions for the field, with a nod to the role played by PPP in this disciplinary evolution.
Phenomenological Psychopathology is the application of phenomenological methods to psychopathological states to explore and describe the individual experience of those suffering from mental disorders. Many consider it to be the foundational science of psychiatry, which has been overshadowed in the clinical domain in recent years due to an emphasis on diagnosis and classification. The field itself has a rich history, going back to the seminal work by Karl Jaspers in the early 20th century. Scholars working in this area pay special attention to how psychopathology modifies experiences of time, space, embodiment, intersubjectivity, and selfhood. Philosophical work related to phenomenological psychopathology has had a stable presence at PPP over the 3 decades and continues to generate interest, with contributions in PPP by leading experts as Louis Sass, Josef Parnas, Giovanni Stanghellini, and Dan Zahavi. Aside from its core application to schizophrenia and states of psychosis, recent philosophical work in phenomenological psychopathology has also focused on areas such as anorexia, loneliness, anxiety, self-illness ambiguity, ontologically impossible experiences, pharmacological treatment, and psychiatric research.
While phenomenology has continued to interest and, indeed, challenge clinicians and researchers in psychiatry, a significant shift has developed regarding the importance of lived experiences of patients and those who care for them. Given that subjective experience does not comfortably fit with an ideal of objectivity in psychiatry and other sciences, it is difficult to understand the possibilities and limits of valuing experiences of people carrying diagnoses. How much weight should be given to patient experiences? Given their first-person perspectives in suffering, stigma, and treatment, should they be considered experts of their own illnesses? To what degree should their voices be taken into account in treatment, research, psychiatric ethics, and even the development of diagnostic manuals and conceptual models? In professional roles, academia, celebrity status, and political positions, some people who carry mental diagnoses speak publicly about their experiences. One aim may be to be more open about themselves; another hope is eventually to destigmatize mental disorders. Philosophers, psychiatrists, and psychologists engage in both theoretical and practical questions about the place and value of first-person narratives, to what extent they may be reliable and under what conditions, how to engage with those who (want to) share their experiences, and how to factor in their contributions to the clinician and psychiatric institutions themselves. Issues of lived experience in philosophy of psychiatry intersect with the role of service users and psychiatric survivors (see special issue of PPP on critical underpinnings of user/survivor research and co-production with Jayasree Kalathil and Nev Jones as guest editors), experiential authority, and lived experience and narratives. We are also witnessing innovative applications of traditional philosophy in this area, illustrated, for example, by an exploration of the experience of trauma through the lens of Kantian philosophy.
The seminal work of Miranda Fricker on testimonial and hermeneutical injustice has developed exponentially, sparking deep and rich research and dialogue in how (or whether) epistemic injustice might apply in health care and, specifically, in psychiatry. Many patients/service-users are grateful for help from psychiatry in addressing psychiatric issues yet may still report that, in clinics and hospitals, they don’t feel sufficiently listened to and believed. People diagnosed with mental disorders are frequently marginalized. Their position as vulnerable and perhaps irrational, and their social position as ‘sick patient’ can overdetermine experiences of being treated as epistemically unjust. Being treated as not-knowers in such a context may be experienced as dehumanizing or silencing. One way these problems may be taken up by this interdisciplinary field is to argue that, as a result of their social position with respect to psychiatrists and psychiatry, patients/service users hold epistemic privilege. What is the role of standpoint epistemology in holding that mentally ill patients have a unique perspective? Should the epistemic ‘experts’ accept criticisms of epistemic injustice in psychiatry? It is not clear who decides whether and when epistemic injustice has occurred. How damaging is it to treat a patient/service user in an epistemically unjust way? Should psychiatric treatment override aims toward epistemically just responsivity—and when and on what grounds? Vigorous and trenchant development and critiques of epistemic justice and injustice in the field are vibrant and productive. This can be seen, for instance, in philosophical work looking at self-injurious behaviors and epistemic humility. Epistemic justice has been complemented with Helen Longino’s notion of social objectivity in science, and this has been productively applied in philosophy of psychiatry literature to the DSM and psychiatric science.
Another exciting area in philosophy and psychiatry is theoretical work around the notion of neurodiversity. Recognition that brains develop individually and uniquely has given rise to awareness of positive strengths in some people with mental disorders instead of previous iterations of mental disorders as brain dysfunctions. In fact, some thinkers have proposed that neurodiversity engenders a survival advantage. The divergence of brain formation and structure creates a space for people to shape their self-understandings not as disordered or as dysfunctions that need to be treated but as variations on brain development that are within normal range. Acceptance of the existence of neurodiversity has the potential to change how we perceive and relate to ourselves and others. Research and theorizing about neurodiversity show up in how autism is conceptualized but has been expanded to other differences such as Tourettes syndrome, ADHD, and even anxiety. The question is how far the domain extends to what many still consider mental illnesses. Even the language used to flag the concept is challenged and debated. One benefit of appreciating neurodiversity is that it potentially brings more inclusionary practices in employment, education, and social interactions. Much is at stake both for self-identity, for justice, and for the ways we conceptualize and respond to differences.
4E Cognition and Enactivism
Scientific research has revealed a number of causes, risk factors, and mechanisms across multiple levels of explanation. Psychiatry as a profession manages to navigate through the “biopsychosocial model” which has long been criticized for its eclecticism and vagueness. A philosophical challenge has been to articulate a framework that could meaningfully address the “integration problem.” Over the past 2 decades, approaches under the umbrella of “4E cognition” have gained prominence in the cognitive sciences, which view the mind as embodied, embedded, enactive, and extended. In recent years this framework has also been applied to psychiatry with exciting results and is an area of active philosophical debate. Enactive approaches to psychiatric disorders received special attention in PPP in a special issue with Sanneke de Haan & Richard G. T. Gipps as guest editors.
Disorder Concepts in Psychiatry
Following Jerome Wakefield’s account of mental disorder as “harmful dysfunction,” which is a hybrid account that includes both naturalist and normative components, there has been a flurry of philosophical work that has engaged, refined, and challenged Wakefield’s notion. Wakefield’s account (and to a lesser extent in the philosophy of psychiatry literature, Christopher Boorse’s naturalist account of disease) has become the node around which philosophical debates between naturalist and normative camps have taken place in recent years. While many philosophers of psychiatry influenced by the literature on biological functions remain committed to understanding dysfunction in evolutionary terms, others engaging with the clinical aspects of medicine are more cognizant of the normative nature of clinical concepts, and others are moving away from the naturalist-normative debate entirely to theorize new perspectives, such as using “natural” notions of normativity to argue for an account of disorder based on self-adaptation and maintenance needs, shifting the debate to address the boundaries of social recognition rather than the boundaries of illness, and understanding the domain of psychiatric disorders as being determined by a historical relationship to the method and practices of psychiatry as an institution.
The philosophical debate around natural kinds has been very influential not only within philosophy of psychiatry but has had an impact on how psychiatric leadership at the American Psychiatric Association and the National Institute of Mental Health understand psychiatric diagnostic entities. One strand of the discussion has focused on the possibility or impossibility of natural kinds in psychopathology, but a much more productive strand has been the examination of psychiatric disorders through notions of mechanistic property clusters and the elaboration of the notion of practical kinds and pragmatic approaches to classification by Peter Zachar and others. In the context of such debates, Nick Haslam has offered an ordered taxonomy of the “kinds” themselves (non-kinds, practical kinds, fuzzy kinds, discrete kinds, and natural kinds), and others such as Şerife Tekin have argued that we can focus on scientific properties relevant to psychiatric intervention while remaining neutral on the question of natural kinds.
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Our discussion above is by necessity a partial and limited survey of a diverse and dynamic discipline. We encourage readers of Daily Nous to explore the philosophy of psychiatry literature in the volumes of PPP. We also want to acknowledge here the important role played by other journals such as Philosophical Psychology, Synthese, and Psychological Medicine, as well as book series such as International Perspectives in Philosophy and Psychiatry by Oxford University Press and Philosophical Psychopathology by MIT Press in making philosophy of psychiatry a rich, scholarly discipline.