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date: 12 November 2019

Introduction: Establishing Relationships

Abstract and Keywords

A cross-disciplinary discussion of the basis of interpersonal relating is of interest to philosophers and psychiatrists for several reasons. The development of successful clinical practice may depend, at least partly, on having an accurate understanding of the basic character of unimpaired interpersonal relating because such understanding can shed light on the nature and source of its disturbed forms. How we think about the basis of "mind-minding" competencies influences how we think about the prognosis and possible treatment of dysfunctional interpersonal relating. Another reason is that philosophical frameworks influence the way we think about and evaluate possible psychiatric disorders and philosophical discussions may be of direct practical importance to psychiatry given that different theories suggest different potential ways of devising therapies.

Keywords: discursive approach, empathy (varieties of), hermeneutics, intersubjectivity, interview, mind-minding, mind-reading, phenomenology, psychopathology, self-awareness, theory of mind

A cross-disciplinary discussion of the basis of interpersonal relating is of interest to philosophers and psychiatrists for several reasons. The first, and perhaps most important reason, is that psychiatry is chiefly about establishing therapeutic relationship and understanding other forms of life. The history of psychiatry is disseminated with errors, sometimes catastrophic ones, involving forgetting this elementary ethical as well as methodological principle. Diagnostic assessment and therapeutic prescription, the two columns of psychiatric practice, presuppose the clinician’s capacity to encounter the patient and to make sense of his experiences, emotions, cognitions and actions. Psychiatric practice without establishing relationship and without attempting to understand the other’s mind is not only ineffective—it is iatrogenic.A second reason for the importance of a philosophical discussion of interpersonal relating is that the development of successful clinical practice may depend, at least partly, on having an accurate understanding of the basic character of unimpaired interpersonal relating because such understanding can shed light on the nature and source of its disturbed forms. How we think about the basis of “mind minding” competencies influences how we think about the prognosis and possible treatment of dysfunctional interpersonal relating.A third reason is that philosophical frameworks influence the way we think about and evaluate possible psychiatric disorders. Philosophical discussions may be of direct practical importance to psychiatry given that different theories of other-awareness suggest different potential ways of devising therapies. The issue of other-awareness is closely related to self-awareness. This notion is notoriously ambiguous. Chapter 17 (“Varieties of Self-Awareness”) by Günbaum and Zahavi is about self-awareness.In everyday life, self-awareness is often thought to be a matter of a person thinking about herself. But even that apparently simple definition can cover a variety of very different accomplishments. Consider for instance, the difference between introspectively scrutinizing one’s occurrent experience, thinking about one’s past performance, anxiously appraising how others perceive one or taking pride in one’s ability to fulfil a chosen social role. Günbaum and Zahavi venture into this theoretical debate, and help us to make sense of the philosophical, psychological, psychiatric, and neuroscientific literature filled with (p. 218) competing, conflicting, and complementary definitions. In their chapter, they argue that explicit (reflective) self-conscious thinking is founded on an implicit (pre-reflective) form of self-awareness built into the very structure of phenomenal consciousness. Their argument is that a theory denying the existence of pre-reflective or minimal self-awareness has difficulties explaining a number of essential features of explicit first-person self-reference, and that this will impede a proper understanding of certain types of psychopathology.

How we think about the basis of “mind minding” competencies—as Dan Hutto argues in his chapter on “Interpersonal Relating” (Chapter 18)—influences how we think about the prognosis and possible treatment of dysfunctional interpersonal relating. Another reason is that philosophical frameworks influence the way we think about and evaluate possible psychiatric disorders and philosophical discussions may be of direct practical importance to psychiatry given that different theories suggest different potential ways of devising therapies. Hutto’s chapter is divided into five parts. The first one highlights some basic facts about the complexity and multifaceted character of interpersonal relating and some of its most prominent dysfunctions. The second introduces popular “mind minding” hypotheses which claim that the dysfunctions in question are rooted in impaired capacities for attending to and attributing mental states to others. Part three summarizes recent evidence from cognitive psychology and neuroscience with which these “mind minding” hypotheses must be made compatible. The fourth highlights the important differences between two main philosophical frameworks—frameworks that offer opposing ways of understanding the nature of mind minding capacities. Focusing on these differences, the final part highlights how adoption of these philosophical frameworks matters to thinking about the prognosis and strategies for the treatment of certain mental disorders.

Shaun Gallagher develops some of these issues in his chapter on “Intersubjectivity and Psychopathology” (Chapter 19). He first reviews and discusses mainstream theories of social cognition, namely theory of mind, which characterizes intersubjective relations in terms of the cognitive practice of mindreading. He then introduces so-called “interaction theory” (IT) which involves a shift away from defining the problem of social cognition in terms of mental states hidden away in the mind of the other. This phenomenology-based approach, which borrows from developmental studies of primary and secondary intersubjectivity, emphasizes perceived social affordances and the engaged interactions taking place in our shared, intersubjective world. In developing the basic tenets of IT he clearly explains the concept of “primary intersubjectivity,” which refers to perceptual and motor processes that allow newborns to engage with others from birth, and the processes of “secondary intersubjectivity,” starting around nine months of age, whereby infants begin to enter into contexts of shared attention and tie actions to pragmatic and social contexts in which they learn what things mean and what they are for. Following the pioneering work of Colwyn Trevarthen, Gallagher explains that in joint attention and joint actions the child looks to the body and the expressive movement of the other to discern the intention of the person or to find the meaning of some object. Children begin to see that another’s movements and expressions often depend on meaningful and pragmatic contexts and are mediated by the surrounding world. Others are not given primarily as minds that we encounter cognitively. We perceive them as agents whose actions are framed in pragmatic and socially defined contexts.

Anita Avramides and Nancy Potter further develop the theme of intersubjectivity in their chapters (Chapters 20 and 21). In Chapter 20, “Other Minds, Autism, and Depth in Human Interaction,” Avramides suggests that, when considering the problem of other minds, we (p. 219) need to distinguish between “thick” and “thin” versions of it. The “thick” version corresponds to the question, “How do I know that I am not the only mind?” The “thin” one raises the question, “How do I know what another is thinking or feeling?” She discusses Dretske’s position, which while acknowledging the thick problem, proposes a perceptual model of our knowledge of other minds that addresses only the thin version. She then considers the “quality” of our interactions with others and, following Wittgenstein, suggests that where individuals share a nature their interactions exhibit a quality that she calls “depth.” She concludes that where that nature is not, or is only partially, shared, one might expect to find the quality of the interaction between persons disturbed—as it is the case with child autism.

Nancy Potter explores the “Empathic Foundations of Clinical Knowledge” in Chapter 21. Assuming that clinicians need a rich understanding of empathy, she treats empathy not just as an understanding attitude toward others, but as a moral and epistemic virtue. The reasoning necessary for empathy as a virtue is not abstract and detached; instead, it requires that we think about context, feelings, and social relations in a psychologically rich way––a way that attends to the full subjectivity of others––so as to determine the rightness or wrongness of particular actions. She argues that without empathy the moral agent is unable fully to grasp the moral features of certain situations. Treating empathy as a moral and epistemic virtue commits us to the view that empathetic responses are, at least to some degree, under our control. Following Hodges and Wegner she also distinguishes two kinds of empathies, “automatic” and “controlled” empathy. This clinical characterization of automatic empathy—through which we can take another’s viewpoint and experience that person’s world with no effort at all—is probably the equivalent to “natural virtue” in Aristotle’s sense. But people can also consciously and intentionally produce empathy. This may be called “controlled empathy,” matching up with the full virtue in the Aristotelian sense.

Grant Gillett and Rom Haré, in their “Discourse and Diseases of the Psyche” (Chapter 22), discuss (next to empathy) the second column of intersubjectivity. Seeing the human being as a situated individual in relation to others they argue that first and foremost it is “discourse” that creates meaning. They explain that in psychiatry, as elsewhere, meaning depends on the way we pick out events and what is part of them, on how we differentiate the networks in which they make sense, and reconstitute connections between events that show how they engender one another. How we paint the picture of a phenomenon (say, a disorder) shapes our understanding of it. They suggest that a discursive analysis of the subjective body as it is framed in discourse is likely to help us make sense of a wide range of human phenomena as they cause distress and present to a clinic. As examples of this, they take anorexia and hysteria: both can be seen as quasi-moral and interpersonal responses to life events creating insecurity about identity and the possibility of a life lived on your own terms. We can and do address them in terms of developing life skills that equip a person to face challenges that they currently find overwhelming and unable to be met. Following Kristeva and Levinas, they argue that each malady of the soul is unique or particular to a situated person such that the suffering patient, like every other human being, is an enigma. As enigma, every psychiatric patient is the product of a unique history in which are embodied the many and diverse traces of our dealings with him or her and a flesh and blood answer to the question, “Who am I?”

Finally, Giovanni Stanghellini develops these issues, and particularly empathy and the discursive approaches in the clinical context, in Chapter 23, “Philosophical Resources for the Psychiatric Interview.” Stanghellini first reviews the basic tenets of mainstream psychiatric (p. 220) interviewing techniques—the so-called technical approach—highlighting their main drawbacks and limitations. Since the psychiatric interview is, first and foremost, a search for symptoms, he then spends considerable time analyzing the different ways of conceptualizing symptoms in the bio-medical, psychodynamic, and phenomenological–hermeneutical paradigms. Then, he describes the family of dispositives in use during the interview, that is the first- (subjective), second- (dialogical), and third-person (objective) mode of interviewing. A short history of the discipline of psychopathology, the basic science for psychiatric assessment, introduces three levels of the psychopathological inquiry: descriptive psychopathology, whose main purpose is to systematically study conscious experiences, order and classify them, and create valid and reliable terminology; clinical psychopathology, which is a pragmatic tool for bridging relevant symptoms to diagnostic categories; and structural psychopathology, which assumes that the manifold of phenomena of a given mental disorder are a meaningful whole and searches for meaningful units. The chapter concludes with a phenomenologically- and hermeneutically-informed flowchart for the psychiatric interview.