“Philosophy, Psychiatry, and Psychology” at 30
To commemorate the 30th anniversary issue of the journal Philosophy, Psychiatry, and Psychology (PPP), John Sadler (Editor in Chief) invited the senior editors and K.W.M. “Bill” Fulford (Founding Editor and Chair of the Advisory Board) to write brief essays on the past, present, and/or future of PPP. As one of the senior editors, I contributed as well. The resulting series of editorials provides a snapshot (limited, no doubt) of contemporary concerns that animate the academic philosophy of psychiatry community in its interface with clinical psychiatry, service users, and the society at large.
The themes of these essays include:
the role of editorship in cultivating deliberative and democratic discourse
moving beyond single message mythologies in psychiatry
the importance of clinician participation in philosophy
meaningful engagement with the sociopolitical dimensions of madness
narrative as a powerful clinical tool
clarifying conceptual and normative issues in public debates (such as around assisted dying for persons with mental disorders)
the challenge and importance of incorporating lived experience
the clinical and scientific relevance of hermeneutics
I have taken brief excerpts from the editorials to give readers a flavor of the discussions.
John Z. Sadler
“The current moment, in my view, represents a crisis in the history of editing and editorship. Digital communications have liberated communications worldwide. However, this liberty has come at the cost of colossal amounts of material not worth reading and an explosion of divisive, destructive discourse. Even worse, internet "trolls" on social media have moved bullying out of the schoolyard and into international cyberspace. Determining what is worth reading has moved away from a cluster of (hopefully) responsible editors to anyone who wants to go to the small effort of silencing others through online harassment and even violent threats. Such cyberbullying does not eliminate elitism, but instead substitutes a toxic online “elite” without principle other than self-promotion and the alienation of others. Our contemporary online culture has yet to figure out how to shape what is, and is not, worth reading. My wish and intent for the future of PPP is to maintain and grow our place of rational, deliberative, and open discourse, even in the face of such disruptive cultural change.”
My wish and intent for the future of PPP is to maintain and grow our place of rational, deliberative, and open discourse, even in the face of such disruptive cultural change.
K. W. M. Fulford
“Contemporary disenchantment with the repeated failures of translation of current narrowly empirical models of psychiatry, points to the truth of our German colleague, Paul Hoff's, characterization of the history of psychiatry as a history of serial collapses into single message mythologies. This disenchantment might seem to offer an opportunity for colonial expansion of philosophy into psychiatry (a re-assertion, perhaps, of phenomenology?). But PPP was born out of the “decade of the brain” and has remained throughout an ally of, not competitor to, the neurosciences. So, while it is true that… PPP is actively extending its reach (to new areas of philosophy, and to new voices, informed notably by experience as well as by training), this expansion remains a collegial not colonial enlargement of the field. I need hardly point to the challenges presented by the inclusive ambitions of such enlargement (not least to maintaining the highest standards of editorial and peer review). But PPP's collegiality provides the foundation for the work needed to deliver on these challenges. Even if imperfectly realized, this collegiality will help to take us beyond the single message mythologies by which our discipline has too long been hobbled.”
“… the challenge of ensuring continued participation of clinicians is not insubstantial. After all, the point is not token participation, but a robust and transformative interdisciplinary engagement. Clinicians have much to contribute to philosophical debates, however, such capacity for dialogue requires sustained cultivation (Aftab & Waterman, 2021), and forces in medical education have led to a situation where comparatively fewer psychiatrists have the interest or the ability to engage in such rigorous dialogue with philosophers… This means that PPP and its affiliate organizations have a responsibility to take a more active role in supporting educational initiatives to ensure that future generations of psychiatric clinicians are able to contribute to philosophical debates, and that philosophy of psychiatry does not become divorced from clinical and practical concerns…
It is also vital that philosophy of psychiatry engage with the sociopolitical dimensions of madness (Kalathil & Jones, 2016). The failure of philosophy to do so in a meaningful way has already been articulated powerfully by commentators such as Nev Jones (2022). An important aspect of acknowledging philosophy's failures in this regard comes from the notion of "elite capture," recently popularized by Olúfẹ́mi O. Táíwò (2022). It refers to how progressive philosophical ideas such as standpoint epistemology are co-opted by the “elite” to serve their own ends. Discussions on social media have already begun to point out that concepts in philosophy of psychiatry such as “epistemic injustice” show signs of elite capture by the psychiatric establishment, resulting in token participation but no systemic changes. Philosophy of psychiatry needs to tackle its own vulnerability to co-option. This will require creative forms of philosophizing and engagement with real-world activism in ways that have been lacking in philosophy of psychiatry so far. It is my hope that PPP can provide a venue for such philosophical developments to take place.”
Philosophy of psychiatry needs to tackle its own vulnerability to co-option. This will require creative forms of philosophizing and engagement with real-world activism in ways that have been lacking in philosophy of psychiatry so far.
“The use of narrative in mental health contexts models consciousness as something necessarily embodied, as already part of the world, in an inherently value-laden and perspectival way. As such narrative presents a powerful tool for critical reassessment and reevaluation of preconceived ideas in relating to difficult concepts in clinical interactions… The notion of empowering narratives to encourage positive change is a core concept behind the emphasis on the critical role of empathy in explaining human development and psychoanalytic change within the self-psychology tradition but is also key to recovery-based models of the significance of person-centered quality of life in medicine more generally…
What my (Bergqvist, 2018, 2020, 2022, forthcoming) account adds to this claim is that while such choices are revelatory or expressive of a distinctly first-personal stance, they do not constitute or determine selfhood and self-interpretation in a fixed way. Moreover, the reason is that one can also adopt a second-personal stance on one's own experience and address oneself, where the relationship between the first- and the second-personal narrative perspective on experience and self-understanding is itself a dynamic and open-ended evaluative process.”
“Over the last 5 years, I have been involved in the academic and policy debates about assisted dying for persons with mental disorders. Policymakers and clinicians alike demand that public policy be based on 'evidence' by which they tend to mean empirical, usually quantitative, data. There is little acknowledgement that some questions are not empirical and that facts require interpretation.
The debate about whether a request for assistance in dying by a person with a mental disorder is a form of suicidality illustrates this problem… The approach to resolving this debate is to frame the problem as an empirical one. Because it is generally agreed that we should prevent suicide, we should not allow assistance in dying if it is the same thing as suicide…
Looking at the concepts at play can clarify the matter. People engage in a variety of different actions that they know may bring about their deaths. These include refusal or non-adherence to life-sustaining treatment, engaging in highrisk behaviors, or consuming potentially lethal substances to name but a few. Society's responses to these decisions vary. Sometimes society intervenes to prevent these deaths, sometimes it permits death, and sometimes society is neutral. If we think carefully about these different responses and the circumstances to which they apply, we see that suicidality is the term we use precisely to describe those deaths society wishes to prevent. Debating whether suicide differs from MAID is simply restating the issue at stake: is assisted dying for persons with mental disorders something we should accept or prevent?”
“There are many compelling reasons to have an interest in the philosophy of/and psychiatry… But mine was a purely disinterested academic interest. This is perhaps the usual approach to what is in part a professionalized academic subject with its formal rules for publication and dissemination of research.
It has only been in the last decade that I have experienced things in a more personal way, following what I would term, though psychiatry would not, a nervous breakdown…
I thought I would be able to maintain some sort of inquiring mind and write experientially grounded philosophy of psychiatry as a catharsis. I could study my own illness. This immediately proved a ridiculous hope… What I would, previously and disinterestedly, have described as a dysregulation of emotional reactions turned out to transform my entire experience of the world and my ability to think rationally about it. I lost the ability to put my experiences into words. In truth, I lost all interest in that project. Only when not distressed could I take a view on my loss of world. Distressed, I did not understand myself.
What I would, previously and disinterestedly, have described as a dysregulation of emotional reactions turned out to transform my entire experience of the world and my ability to think rationally about it. I lost the ability to put my experiences into words. In truth, I lost all interest in that project. Only when not distressed could I take a view on my loss of world. Distressed, I did not understand myself.
This is a neat illustration of epistemic disjunctivism. But it also highlights a challenge for, and some of the brilliance in those who have contributed to, the philosophy of mental health care, through their expertise by experience. While experience may be a necessary condition for particular forms of expertise, my own case reveals that it is not sufficient. Further, even an everyday and familiar mental illness (like my own) can render the articulation of experience, in a way that makes sense to others, very much harder. Hence the fact that there is a thriving mental health service and patient movement, making their own experiences available to others combining first-person narratives with conceptual and phenomenological insight is both admirable and helps to set a part of PPP’s future agenda: bringing first-person experience within a philosophically and clinically informed discipline.”
Michael T. H. Wong
“The major challenge for psychiatry is how to organize clinical information of different nature (categories, dimensions, narratives; i.e., objective vs. subjective, personal vs. interpersonal) into a coherent and comprehensible account for us all. Mental illnesses are not only neuropsychiatric spectrum disorders but also dysfunctions of social relationship and environmental/ecological adaptation. Psychiatry as a clinical neuroscience per se lacks the semantics to address the rich interactions between the physical, psychological, social, cultural, and spiritual in the illness experience of our patients. Explanation in the diagnostic formulation (objective scientific discourse on cause and effect) and understanding in the patient narrative (subjective ordinary everyday discourse on significance and meaning) are irreducible to each other (Wong, 2018). They instead interact with one another to achieve an integrative formulation, not through merging different discourses into a single assertion/monologue but via the dialectic/dialogue of “explaining more in order to understand better,” as Ricoeur puts it, and between “the whole and the parts,” as Schleiermacher highlights.
This “therapeutic hermeneutic circle” of “explanation vs understanding” and “the whole vs the parts” includes symptoms behavior function and life events. It correlates between bio-psychosociocultural-spiritual dimensions/perspectives and does not reduce them to any particular/single stance. The whole integrates the parts and the parts enrich the whole. It explains but does not explain away. It understands through an articulation of meaning and significance. This discourse is a multilayered (bio-psycho-social-cultural-spiritual) personal narrative that formulates diagnosis and care in a correlative (linking different voices/discourses) and non-reductive (no particular voice/discourse is prejudiced against) manner that is comprehensible to us all (Wong, 2021).
This discourse is a multilayered (bio-psycho-social-cultural-spiritual) personal narrative that formulates diagnosis and care in a correlative (linking different voices/discourses) and non-reductive (no particular voice/discourse is prejudiced against) manner that is comprehensible to us all.
PPP will be an excellent forum for discussing clinical hermeneutics in the future. In this digital era of social media and virtual reality, hermeneutics has the never-ending task to tackle the unprecedented challenges to meaning illness and health posed by polarizing discourses.”
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