Introduction: Summoning Concepts
Abstract and Keywords
The editorial introduction sets the stage for the chapter by identifying the roles that concepts and categories play not just in the field of mental health medicine but in the human mind itself. Then, each chapter is summarized or highlighted.
Earthworms don’t need concepts. They spend most of their time burrowing in the ground. They possess neither separate sensory organs (unless one classifies their entire epidermis as a sensory organ) nor cognitive capacities. When they plug their holes with leaves, petioles, and twigs, they do not think, or presumably they do not think, of these things as classified into categories. Nor do they do what they do in order to intentionally keep their skins warm and moist. While they may profit from the result, they do not, or presumably they do not, conceive of the result as a result. They don’t think “This twig here fits into that hole there.” Or “Thank goodness, I am nice and warm now.”
Human beings need concepts. Our powers of discrimination, selection, purpose, and deliberative reasoning depend upon them. Our thoughts have concepts as their constituent parts or elements. Science, literature, and, indeed, all of human culture exhibit our astounding conceptual powers and the multitudinous theoretical and practical roles that concepts perform.
There are few more stunning examples of human conceptual proclivity than the concepts exhibited by psychiatrists and the mental health profession. The field of psychiatry has a prodigious capacity for constructing concepts and categories for understanding and treating mental illness or disorder.
Dozens of concepts in psychiatry could be cited as examples. Some specific to particular theories of disorder (like the concepts of “Id” and “Superego” for Freud), and others parts of general psychiatric parlance (like “delusion” and “dissociation”). Given the basic roles of concepts in the understanding and treatment of mental illness or disorder, it is not feasible to summon forth or design apposite concepts for the discipline without taking sides in a number of issues in the philosophy of psychiatry. In fact, discussions of appropriate concepts for the discipline have become focal points for debating different orientations to the topics of mental health and illness. For instance, the theory of concepts for psychiatry is essentially bound up with issues such as whether there are real, observer independent mental disorders or whether concepts for disorder are descriptive, evaluative, or some mixture of the two. Or again: perhaps the most disturbing worry about the Diagnostic and Statistical Manual of Mental Disorders (DSM) as well as the International Classification of Diseases is their super-abundance of taxonomic concepts or classificatory categories for mental disorder. In the case of DSM, by the end of the 1980s it had become obvious to the mental (p. 360) health profession that the spiral notebook that was DSM-II in 1968, 150 pages in length, and available in the United States for three dollars and change was in danger in later versions or editions of becoming an unmanageable and expensive brick. Conceptual subtraction and excision was needed, urgently. As successive versions have revealed, such activity has yet to occur.
It’s time to re-think and re-examine the concepts of the discipline, not just those used in diagnosis and classification, but in the whole theory and practice of the mental health profession. Chronic conceptual fatigue syndrome is settling in.
The aim of the fourth section of the book is to explore just which concepts and categories, which ways thinking about mental disorder, are worth summoning forth, and for which purposes. Naturalistic concepts? Normative or evaluative ones? Concepts derived from neurology and brain science, character assessment, or definitional considerations? Concepts apposite for assessments of rationality? Tackling the mind/brain problem?
Chapter 25 by Elselijn Kingma is the first in the section. It is aimed at clarifying just what makes a mental disorder a mental disorder. What is it in nature that makes for a mental disorder or illness? One possibility is that if this or that aspect of mind has its source of psychiatrically relevant functions in natural selection and contribution to genetic fitness, then appeal to failures in those adaptational functions should be used to describe the disorder of a mental disorder. According to such a failure-of-biological-adaptivity view, there is nothing in the distinctive elements of a mental disorder that concerns what we persons ourselves may value in mind and behavior. Human values and personal or social interests or preferences are irrelevant to the warranted attribution of a disorder. Kingma describes such an adaptationalist approach to characterizing mental disorder as resolutely naturalistic, and although she offers criticisms of the global utility or range of applicability of the approach, she believes that it may yet make a contribution to our understanding of a mental disorder.
Fulford and van Staden, in Chapter 26, share Kingma’s worry about the makings of a mental disorder, in some very general way, but approach or interpret the topic from a different angle. They ask about the purposes that the worry or debate over definition serves. Who or what benefits by focusing on the very idea of a mental disorder? Concern with what makes a mental disorder a mental disorder serves, they claim, at least four purposes. Two are mentioned here. One: it signals a concern about the nature of bodily disorders, first and foremost, and not primarily, except by segregation from the domain of bodily disorder, mental disorder. Two: it helps to identify the value-laden concepts of disorder as a whole. Whatever makes a person disordered, sick, ill, diseased, or defective can only be understood, they claim, against background appreciation for the diverse values of human beings and of our evaluative practices and activities. These lessons, and others that they discuss in their chapter, derive, they say, from an appreciation of the tradition of ordinary language philosophy. The tradition urges that the analysis of any concept stems from the necessary philosophical field work and from discovery of the scope and roles of a concept—its full logical geography.
A variety of scientific disciplines have set as their task understanding and explaining mental disorder or illness, recognizing that in some way or another mental disorder or illness depends upon the brain, for the brain is the bearer of mind and meaning. Mind is what brain does. Thinking of the brain as the bearer of mind and meaning often is taken to require thinking of it as a mechanism that processes information. What is crucial to understanding the information that is processed requires not just studying the hardware implementation of that information (its physical vehicles) or embodiment (e.g., changes in sodium and (p. 361) potassium concentrations), but how an organism appropriately or inappropriately relates to or interacts with the surrounding environment—how it plans actions, remembers events, perceives changes in its surroundings, and so on.
Kelso Cratsley and Richard Samuels (Chapter 27) offer their chapter as a description and assessment of the roles of cognitive neuropsychology and cognitive neuroscience in the study of mental disorder. These two disciplines, primary members of the larger field of cognitive science, devote themselves to thinking of the brain as an information processing mechanism, and to thinking of a mental disorder as grounded in damaged, injured, defective, dysfunctional, or flawed information processing in the brain. Their chapter examines the most important explanatory strategies of cognitive science for understanding a mental disorder or illness, aiming in applied particulars at the examples of autism spectrum disorder and major depressive disorder. Various concepts associated with the cognitive science of mental disorder are introduced and discussed (subpersonal mechanisms and double dissociations, among them) as well as misgivings that some theorists have expressed about the purport and utility of mechanistic subpersonal information processing models of disorder.
Keith Bolton, in Chapter 28, takes us back to the question asked by Kingma. What makes a mental disorder or illness a mental disorder or illness? He asks his readers to imagine a patient awaiting diagnosis in a clinic, and wonders how a diagnosis of mental illness may be warranted as over and against thinking that the person is suffering from normal or ordinary troubles or heartaches. Sadness or loneliness is one thing; major depressive disorder another. Anxiety about meeting strangers is one condition; agoraphobia another. Bolton argues that DSM puts its diagnostic finger on two features of a disorder: serious distress and pronounced impairment. While these two features help to characterize disorders, they do not, Bolton claims, cleanly or clearly divide the domain of mental disorder from that of ordinary problems of living. So can (or even should?) science help to distinguish between the two domains more precisely or determinately? The chapter considers how far a science of disorder may assist in drawing boundaries about mental illness.
Next, in Chapter 29, John Sadler examines several of the philosophical issues that surround mental illness concepts and the various roles that those concepts play, not just in the mental health professions but in the criminal justice system and in intellectual disability services and systems. He argues that there is a tight connection, both historically and in contemporary terms, between attributions of wrongful conduct, socially and morally speaking, and of mental disorder or illness. This is not to say that being “bad” is being “mad,” but the boundaries between the two are both vague and porous and cannot be distinguished without addressing a welter of metaphysical commitments and philosophical issues about the nature of moral and criminal responsibility, the character of forensic psychiatry, and much else besides.
In Chapter 30 Lisa Bartolotti examines a topic introduced at the start of the book. Sanity. Or more exactly, irrationality. While forms of irrationality are often cited as criteria for mental illness or disorder, Bartolotti argues that many psychiatric disorders are not best understand as violations of reason’s norms. In part, she says, this is because many non-ill people are just as irrational in their attitudes or behavior as individuals properly classified as mentally ill. So, irrationality is not generally sufficient for disorder. In part, it is also because serious deficits or malfunctions in one or more cognitive and emotional capacities may also be constitutive of a mental disorder—rather than persistent irrationality. So, irrationality often fails to be necessary. Much for Bartolotti depends on just what it means to be irrational as (p. 362) opposed to rational, and how far the rationality (or irrationality) of a state of mind or behavior can be differentiated from non-rational components.
Jennifer Church, in Chapter 31, refrains from general claims about the nature or identity of mental disorder. She focuses quite specifically on disturbances and disorders that reflect various and heart-breaking failures to negotiate and establish effective personal boundaries between one person and another, boundaries, in particular, of personal responsibility and of gain and loss. One person’s identity or sense of self, she says, should not always compete with another person’s. Just because you are responsible should not mean that I am not responsible. Just because you have gained (or lost) should not mean that I have lost (or gained). But human suffering, she says, often results from unhealthy misjudgments about gains or losses to one’s person or threats to one’s personal responsibility posed by the actions or inactions of other people. Such misjudgments occur in cases of depression as well as in instances of borderline personality disorder and threaten the integrity and sense of self of persons who are characterized by such disorders. Mistakes about personal boundaries deflect emotional energy away from more productive goals or ends.
Suppose mind is brain based. Does this mean that mental disorders are a subtype of brain disorder? George Graham, in Chapter 32, is skeptical of the temptation to conceive of mental disorders as a subtype of brain disorder. For him, disorders of mind, although based in the brain, are not disorders of the brain. Brain science, he says, is useful for understanding certain aspects of a mental disorder, to be sure, but not for various other aspects for which psychological understanding is needed. The need for psychology is not a matter of idle metaphysics, but is directly relevant to appreciating the significance of therapies and treatments for one sort of condition (a brain disorder) as opposed to another (a mental disorder). Grouping or ordering disorders into mental and brain disorders may depend, in part, he says, on which therapies or treatments succeed or fail. If a successful therapy works through reason or appeal to a person’s reason responsive psychology, the corresponding disorder may be a mental disorder. If sound and sensible treatment may occur only when a person’s rational capacities as such are bypassed, as happens under the knife of neurosurgery, the corresponding disorder may be best classified as a brain disorder. Truth of a diagnosis is a matter of fit—fit with a body of background theory and fit of theory with (among other things) past facts about successful and failed interventions.
In the last chapter in the section, Chapter 33, Eric Matthews offers an approach to the topic of mental disorder inspired by the French phenomenologist, Maurice Merleau-Ponty (1908–1961). In the spirit of Merleau-Ponty, Matthews claims that psychiatry should conceive of a mental illness or disorder as above all meaningful to the subject of the disorder and as rooted in the conceptual world of the individual. Mental health medicine requires, he says, both a humanistic understanding of a mental disorder and one that appeals to the neurosciences. Some aspects of a disorder may be explicable in brain science terms, but others require an understanding of the concepts that a subject of mental disorder uses or fails to use. To neglect or bypass the conceptual world of a patient with a mental disorder is to neglect what makes a mental disorder a disorder of mind and mentality.