Introduction: Contexts of Care
Abstract and Keywords
In this introduction to the Section II, the thrust of the component chapters is described. An important strand in the philosophy of psychiatry since its beginnings has been sociopolitical critiques: criticism which aims to improve and humanize psychiatric practice and mental health systems. From this standpoint, the introduction provides an overview of this tradition, including considerations of "postpsychiatry," value commitments in psychiatry, the recovery movement, racism and sexism in the field, and technology.
All works within the contemporary and past philosophy of psychiatry are critical in the sense of providing insightful analysis and description of psychiatric phenomena, uncovering metaphysical and other kinds of assumptions, and making meaningful distinctions about core concepts and procedures. Such is the work of philosophy broadly conceived. However, the philosophy of psychiatry has always had a strand of scholarship which was critical in the social–political sense as well. That is, this path in the philosophy of psychiatry explores the social, cultural, and political contexts of psychiatry, mental health care, and service systems. In this sense of philosophy-as-criticism, psychiatric concepts, procedures, and systems are analyzed not just to deepen intellectual understanding of the field, but also to embrace a kind of utilitarian interest that seeks sociopolitical revision, reform, or revolution. The philosophy of psychiatry as social criticism does not simply analyze psychiatry as it is; it points toward what psychiatry could, and should, be. This tradition extends historically from the late-medieval and Enlightenment eras, when elite intellectuals such as Johann Weyer, John Locke, Teresa of Avila, and Immanuel Kant questioned the traditional assumptions about madness as spiritual or occult phenomena. Instead, these thought leaders began the reformulation of madness as disease, as medical phenomena, which in turn demanded analysis of such concepts as rationality, affection, and conation. This emerging “modern” concept of madness/insanity/mental disorder has certainly prevailed into the present day, at least among most educated peoples around the world, but the Enlightenment victory was then, and now, only partial. Many cultures and subcultures still experience madness within, to use Edwin R. Wallace’s (1994) coinage, magico-religious frameworks and cosmologies. Mental disorder is still open to interpretation from many different sets of metaphysical assumptions, and such metaphysical assumptions can, as our authors in this section illustrate, be liberating or imprisoning, and, sometimes, both at once. Moreover, the philosophy of psychiatry has raised questions about the adequacy of Enlightenment accounts of madness. Our authors in this section challenge today’s, post-Enlightenment, assumptions about psychiatry and mental health, revisiting our metaphysical assumptions as well as our ethics. Not satisfied with psychiatry and the mental health system as they are, these authors point to what psychiatry and the mental health system can and should be.
The critique offered by Pat Bracken and Phil Thomas in Chapter 11 takes up the post-Enlightenment, “modernist” metaphysical assumptions directly, identifying three core (p. 120) assumptions of contemporary mental health care: (1) That mental illness is related to mechanistic failures, whether biological, psychological, or related to social systems. (2) These mechanisms or processes are “modeled in causal terms” which can and are abstracted away from the full context of the phenomena. (3) Mental illness should be addressed through technological tools and procedures, again abstracted away from everyday human concerns like “opinions, values, relationships, or priorities.” For Bracken and Thomas, these modes of thinking frame the terms of engagement with the mentally ill for all—clinician, policymaker, citizen. They argue that these modes of thinking set up and maintain power relationships for the mental health system that are self-interested and self-maintaining, disempowering the people whom the system is aiming to “help”—the mental health service user. They frame contemporary acknowledgments of the role of the patient as “partner” as little more than offering patients a handmaiden role to the larger mental health service system. Their vision for a “postpsychiatry” involves rediscovery of a different set of metaphysical assumptions about mental health and illness, a reinstatement of the ethical primacy of service users’ opinions, values, relationships, or priorities, and the reduction of the social power of psychiatrists in rendering assistance to those with mental distress.
In her essay about the legacy of racism and sexism in psychiatry and mental health (Chapter 12), Marilyn Nissim-Sabat considers four sets of theoretical accounts, each with their own metaphysical assumptions and methodological framework. Professor Nissim-Sabat is concerned that not only have racist/sexist trends in the field been inadequately addressed, but the intellectual tools in addressing the issues have been inadequately set. In her analysis of ontological naturalism and methodological naturalism, Nissim-Sabat notes that a tendency to “biologize” race and gender differences presupposes a universality to biodifference which is neither argued for nor established. Nissim-Sabat frames her discussion of social constructionism, her second theoretical account, as a tension between realism and anti-realist metaphysical accounts. She explores this tension from the standpoint of Ron Mallon’s A Field Guide to Social Construction, finding that Mallon smuggles in a form of realist naturalism in the form of cognitive predispositions towards categorizing objects and people.
In her third theoretical exploration vis-à-vis sex and gender, Nissim-Sabat provides a transparent exposition of the self-refuting radical relativism (e.g., everything is relative, including this statement) over against her preferred brand of relativism, “relativity-to,” which she argues is neither self-refuting nor a true metaphysical relativism. This analysis is then applied to ordinary-language discourse on bigotry, then to Erik Gillett’s work on social construction of truth-claims in psychoanalysis. Nissim-Sabat finds Gillett’s approach wanting in that Gillett is never able to provide a non-relativistic account of culture and history to ground psychoanalytic truth-claims.
What is needed, for Nissim-Sabat, is an epistemic framework that does not posit essences as “material entities” but rather posits essences as “intentional objects of consciousness” that are subject to affirmation or rejection by philosophical evidence. Husserlian phenomenology provides such an epistemic framework. Phenomenological method avoids the metaphysical trap of failing to account for assumptions, a trap that the phenomenological method of epoche, suspending presuppositions, explicitly addresses. Such a method is not just relevant to exploration of race and gender, but conditions a methodological openness of mind that is incompatible with prejudice and discrimination.
(p. 121) In his essay on psychiatry and medicalization, Louis Charland (Chapter 13), turns the usual public decrying of medicalization upside down and instead concludes that medicalization is dangerous to psychiatry as a profession and field. Criticized by the anti-psychiatrists as problematic in defining too many human problems as medical problems, psychiatry appears to have partnered, historically to the present, with the pharmaceutical industry to find increasing kinds of human problems as psychopathological and demanding drug therapy. The gist of Charland’s argument centers on the “unbridled commercialization of psychopharmacology,” which threatens to trivialize psychiatry as a discipline, as understanding and demand for treatment moves out of the consulting room and into Internet social media and your home TV set’s direct-to-consumer advertising. Even diagnosis, a raison d’être of psychiatric training and expertise, has been dismantled and appropriated by Internet-based chat rooms, blogs, and interest groups who make their own decisions about what is, and is not, a legitimate disorder. Charland develops his perspective through a historical analysis of the development of psychopharmacological science and its appropriation by the pharmaceutical industry.
In discussing the relationship between psychiatry and technology, James Phillips (Chapter 14) frames technology in terms of three “faces”: The first involving technology as a practical tool in addressing the goals of medicine, most prominently, medication treatments. The second face of technology concerns technology as a means of apprehending or “seeing” things that otherwise psychiatrists wouldn’t. Technology supplies us instruments, from psychological tests to magnetic resonance imaging scanners, which allow us to see new things, as well as marginalize other facets of our experience in the process. The third face takes a more explicitly metaphysical turn: technology also transforms how we think and our life choices, through what Phillips calls “instrumental reason.” Phillips then systematically explores the meaning and significance of these three technological faces in relation to psychiatry as a profession and practice. What is crucial to his analysis is how technology, through its ubiquity and ultimately, banality in our lives, comes to change how we conduct ourselves and what we think is important. His examples are many and vivid; a paradigm example is the National Institute of Mental Health’s Research Domain Criteria, a new “diagnostic” system for psychiatry that is divorced from ordinary experience and built upon highly abstract theoretical entities, themselves only accessible through instruments, scales, and neuroscientific measurements. In the second half of his chapter, Phillips places these trends into the history of philosophy, finding the roots of instrumental reason in Aristotle and elaborated by Enlightenment rationalism. In the concluding pages of his essay he evaluates these technological changes in psychiatry, and explores what a “right balance” in our attitudes and use of technologies might mean.
If Phillips explored the meaning of rating scales, abstract neuroscientific concepts, and technogadgetry for psychiatry, Larry Davidson, in Chapter 15, returns us to the nitty-gritty of fundamental concepts of illness: cure and recovery. He uses a semantic analysis of these two words to reveal the second-person/objective character of “cure,” and the first-person/subjective character of “recovery.” A doctor may “cure” you, but she doesn’t “recover” you. Echoing the concerns of Bracken and Thomas in the beginning of this section, Davidson explores the historical roots of this unilateralism in psychiatric practice, where the patient is a passive recipient of physician ministrations. In the context of this historical review, Davidson challenges the prognostic and therapeutic nihilism of received views of schizophrenia, and (p. 122) suggests that Kraepelin and the Bleulers themselves may have not believed that the ultimate fate of people with dementia praecox was as uniformly grim as thought today. In his contrasting of Pinel’s and Pussin’s patient-empowering moral treatment approach, he explores the self-fulfilling prophesies of poor outcome through the provision of squalid hospital conditions and treatments that impoverish morale, rather than enhance it. From this historical context Davidson then presents a contemporary model of recovery from mental illness; one not based upon cure but rather aiming to enhance functioning and quality of life, showing that the gratifications of work and employment, demonstrated by supported-employment studies of chronically ill persons, is a key to improving functioning. In this regard, the progress in “treatment” of schizophrenia has primarily occurred through the enhancement of functioning rather than the refinements of psychopharmacology treatments discovered in the mid-twentieth century. Davidson’s message is that to cure schizophrenia is misguided—and to aid in recovery should be our new direction.