Download Mental Disorder Workshop Funded by the AHRC Lecture Room 1

MENTAL DISORDER WORKSHOP
FUNDED BY THE AHRC
Lecture Room 1 (room no. A.041)
Warwick Medical School
Gibbet Hill campus, University of Warwick
Friday 6 March 2009
Samuel Beckett and Mental Disorder: An Empirical Approach
Dr Elizabeth Barry (Warwick)
This paper will investigate Beckett’s interest in mental and neurological illness and its impact on his
creative work, arguing that his writing explores and dramatizes a continuity between states of socalled mental disorder and the most fundamental experiences of identity and social interaction. It
uses material from Beckett’s own unpublished ‘Psychology notes’, the fruits of reading in
psychology, neuroscience and psychoanalysis made between the two world wars, and traces the
impact of this research on his work. Beckett was intrigued by the developments in the fields of
psychology and psychoanalysis in the early twentieth century, and in particular by research done
into neuroscience and cognitive science as a result of studying soldiers with brain injury after the
First World War. The relationship between language and the brain was also a sustained interest of
his, as his work attests: he read widely on the topics of aphasia, echolalia and involuntary speech.
While Beckett was interested in emerging scientific and clinical theories and practices in the fields of
psychology, neuroscience and psychoanalysis, he was also concerned with the social aspect of
mental disorder, exploring in his fiction the uneasy encounters between his troubled and
unconventional protagonists and wider society. In a new direction in Beckett studies, this work
demonstrates links between Beckett’s writing and social theories of mental disorder, beginning with
his relationship with the Surrealists and their radical consideration of madness in a social framework,
but gaining authority and legitimacy through his research, acquaintances in relevant fields, and
personal experiences of mental disorder. His relationship with Lucia Joyce, Joyce’s daughter, whose
mental breakdown precipitated a lifetime of illness and institutionalization, was particularly
significant in this respect. This paper will make detailed investigation of Beckett’s knowledge of
mental disorder, and argue for an engagement that is political and social, as well as intellectual and
imaginative, in his life and his writing.
Defining Mental Disorder
Prof Derek Bolton (Institute of Psychiatry)
In this paper I will review definitions of mental disorder in the ICD and DSM, and naturalist
definitions, with particular attention to Wakefield’s currently dominant evolutionary theoretic
analysis. The definitions in the psychiatric manuals serve well various purposes but do not resolve
many contentious issues of the sort that the naturalist definitions address in greater detail and
depth. Wakefield’s analysis presupposes a distinction in the realm of the psychological between
what is natural and what is social that is crucial to the naturalist enterprise and specifically to
naturalism applied to mental disorder.
This distinction may have been plausible previously, but it has turned out to be unviable in the
context of current bio-behavioural science including genetics set within an evolutionary theoretic
framework. What is left after naturalism is something like a ‘social concept of health’, with
boundaries fluctuating under the influence of many and various pressures. Consistent with this, the
proper domain of healthcare is understood in terms of relationships and working assumptions,
rather than as a ‘natural class’ of medical disorders. Finally I will compare and contrast briefly ways
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in which this line of thought plays out in physical medicine on the one hand and psychological
medicine on the other.
Epistemic Definitions of Mental Disorders: Benefits and Pitfalls
Dr Lisa Bortolotti (Birmingham)
It is problematic to formulate a definition for the conditions of delusion and confabulation, for the
following reasons: (1) delusional or confabulatory behaviours occur in a number of pathological and
non-pathological conditions; (2) impairments giving rise to delusional or confabulatory behaviours
are likely to have different neural bases; and (3) there are no unique theories explaining the
aetiology of delusions or confabulations. An epistemic approach to defining delusion and
confabulation could solve these issues, by focusing on the surface features of the two conditions.
However, existing epistemic accounts emphasise only the epistemic disadvantages of delusion and
confabulation. In this paper, I argue that a satisfactory epistemic account of delusion and
confabulation should also acknowledge their neutral or beneficial epistemic features. Delusions are
often no more irrational than ordinary beliefs, and confabulation may allow subjects to exercise
some control over their own cognitive life when memory fails. Both conditions can be instrumental
to the construction or preservation of a threatened sense of self.
Mental Disorders as Mental
Dr Matthew Broome (Warwick & Institute of Psychiatry) & Lisa Bortolotti (Birmingham)
This paper argues for psychological realism in the conception of mental illness. We review
contemporary ways of understanding disorder when applied to the mental and discuss the dominant
view, namely that of a biological realism (or essentialism) of mental disorders. Drawing on the work
of John McDowell we criticize such an approach and offer a provisional conception of mental
disorder on the basis of the view that in psychiatry disorders are disorders of reason-giving and
hence their structure is revealed in terms of breaches in normativity. An example in the case of
delusions is elaborated, utilizing Moran’s account of authorship as a tool to examine the reasons
psychotic patients give for their abnormal beliefs. We conclude with some thoughts as to the scope
and limits of biological psychiatry and its dependence upon an account of mental illness that is
characterized in normative terms.
The Changing Boundaries of Mental Illness
Prof Joan Busfield (Essex), TBA
In this paper I begin by mapping the wide range of concepts – both lay and professional – used to
refer to mental ill-health and locate them in their social and historical context. I then examine the
expanding boundaries of mental illness, making reference to official psychiatric classifications, and
consider the factors that underpin the expansion as well as its consequences.
Mental vs. Physical Disorders? A Pluralistic Framework
Dr Leen De Vreese (Ghent)
In my talk, I will defend a pluralistic view on the concept of “disease” which relies on different kinds
of disease causes. According to this view, physical and mental diseases cannot be clearly separated
but should be situated on a same continuum of kinds of diseases, although both classes of disease
might tend towards the opposite extremities of this continuum. Such a continuum approach
opposes the mainstream in the current philosophical debate on the concept of “disease”. In this
debate, the search for a single, monolithic definition of “disease” still stands on the foreground.
Further, the concept of a “mental disease” is often interpreted as being categorically different from
the notion of a “physical disease”. And lastly, the social constructivist approach to the concept of
“disease” is in this debate often seen as one totally opposing the biological basis approach.
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This state of affairs is astonishing given the diversity of diseases and the different degrees of
influence of sociocultural beliefs on disease conceptualization. In as far as philosophers aim at a
descriptive view on what the notion of “disease” covers in practice, they would better consider an
account in the line of psychologist Nick Haslam’s account of mental disorders (Haslam 2002). He
recognizes different kinds of mental disease causes as defining different kinds of mental diseases
(“kinds of kinds”). Some kinds of mental diseases need a pragmatist account while others need a
realist or even essentialist account, according to Haslam’s framework. The continuum approach that
I will propose is based on this view of Haslam, but broadened to the concept “disease” in general in
order also to include physical diseases. I will argue that such an account stands much closer to
medical practice, including psychiatry. And, what is equally important, such an account might further
a more nuanced and more appropriate view on what it means to be “diseased”, both among
laypeople and practitioners.
In the second part of my talk, I will reconsider some of the central topics in the debate on the
concepts of health, illness and disease in the light of the proposed pluralistic framework. More in the
concrete, I will consider what the above framework entails for (1) the discussion about the
distinction between “healthy” and “diseased”, “normal” and “abnormal”; (2) the discussion about
the distinction between disease / disorder / illness / etc.; (3) the discussion about whether mental
diseases are ‘real’; and (4) the discussion about whether mental diseases are natural kinds. I will
weigh some of the views and arguments that can be found in the current literature against what
follows from the pluralistic approach proposed in the first part of my talk. I will argue that the
pluralistic approach provides a less rigid, and much more nuanced view on the four subjects of
discussion mentioned.
Tolerance and Illness: The Politics of Medical and Psychiatric Classification
Dr Shane Glackin (Leeds)
Thomas Szasz has long propounded the notorious claim that “mental illness” is a misnomer, a
category error, as minds are not literally the sort of (physical) objects to which medical terminology
may properly be applied. The “medicalization” of mental disorders, he argues, actually conceals in
objective, clinical clothing the repression of certain sorts of behaviour which society finds
intolerable. In other words, what purports to be a value-neutral scientific classification is in fact a
thoroughly evaluative instrument of social control, enforcing particular determinations as to which
beliefs, actions, and ways of life will be tolerated.
Szasz’ thesis is, understandably, extremely controversial. Christopher Boorse, most influentially, has
proposed a rival account of illness and disease – defined in terms of impaired proper function –
which is inclusive of so-called “mental disorder”. Boorse’s contention that physiological and
psychological illnesses are on all fours together is, I argue, largely correct; but adopting this view
serves not to place psychiatry beyond ideological criticism so much as to extend the scope of that
critique to medicine generally.
All determinations of “proper function” and dysfunction, I argue, are inherently evaluative. Whether
or not a genuinely evolutionary account of biological “function” is possible – as Phillip Kitcher,
following Boorse, has argued – there is no reason to take it as normative for the lives and bodies of
actual persons. Dyslexia, presumably, results from no defect in any adapted function, while female
depression may even reflect an adaptation functioning correctly; but both are serious and
debilitating conditions in modern life. Conversely, homosexuality may be strictly defective with
regard to “normal” reproductive function, but Boorse’s claim that it therefore constitutes a disease
is extremely controversial, and deeply offensive to many. Certainly, few mainstream figures would
argue that it requires treatment, or “correction”.
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Drawing comparisons with – especially – attitudes in the Deaf Community, I argue that all
judgements of medical “dysfunction”, then, reflect our collective willingness or reluctance to
tolerate and accommodate the conditions in question. In almost all cases, the determinations of
patient and society will coincide; but where they do not, the well-established principle against
“paternalism” in Medical Ethics is instructive. The relevant considerations, I argue, are precisely
those involved in accommodating divergent ways of life in a modern liberal society, and the same
response can be made to Szaszian complaints of “coercion”; societal tolerance for alternative ways
of life is desirable ceteris paribus, but cannot be absolute. The liberal state – and the medical
establishment – must be prepared to intervene where necessary both to protect vulnerable
individuals (occasionally from themselves), and to safeguard the very institutions that allow such
tolerance.
Are Relationship Problems Disorders? Harmful Dysfunction versus Pragmatism
Dr Christian Perring (Dowling)
I argue for a pragmatic view of the classification of mental disorders, in which classification decisions
should depend not just on scientific knowledge but also on social values, the social conditions, and
the state of psychiatry and clinical psychology. I will make this argument through focusing on the
category of relationship disorders. Wakefield (2006) has argued that his harmful dysfunction model
does include some relationship problems as disorders, because they involve dysfunctions of
evolutionarily evolved relationships between people who are in themselves normal. First, I argue
that there are problems with the scientific claims about the evolutionary theory of psychology and
especially with claims about the evolution of mother-infant relationships. I look at some of the work
in attachment theory on underinvolved mothers and show the difficulty in identifying dysfunctions
in relationships rather than locating the disorder in the infant or the mother.
I also point out some of the problems with the evolutionary theory of relationships due to cultural
variation: for example, data Germany shows very different expectations of what counts as normal
mother-infant relating from American or UK expectations. This casts significant doubt on the claims
about the natural functions of relationships between mothers and infants that Wakefield hopes that
evolutionary psychology can deliver. Furthermore, if we do take evolutionary psychology seriously,
it would suggest that the normal family is an extended one, and if departing from this norm has
been harmful, we would be forced to the conclusion that the "normal" nuclear family (2 parents and
children) of Western society is a medical disorder. This is a counterintuitive implication that may
cast doubt on Wakefield's approach to defining disorder.
I proceed to make the positive argument for a pragmatic account: rather than look to a scientific
theory for a distinction between natural and unnatural relationships, we will do better to take
distinguish between health and unhealthy relationships based on our values, norms and social
circumstances. However, we need to be careful in formulating a pragmatic account because it is
implausible that all social circumstances should be taken into consideration. Some clinical
psychologists have argued that couple problems and family problems should have their own
diagnostic labels because, in addition to being identifiable and validated by psychological theorizing
and observation, it would be clinically useful to have such labels. This is a consideration that it
makes sense to accommodate.
In contrast, there has been discussion in the USA about whether some conditions are disorders and
the tax implications for the reimbursement of treatment. It is far less intuitively plausible that these
considerations should be relevant to whether we include relationship disorders in our diagnostic
manual. So in order to make a pragmatic approach plausible, we need to identify a realm of
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pragmatic relevance, in which the consequences of our diagnostic decision is relevant to whether
make the classification, and out of which the consequences are irrelevant. We cannot identify this
realm a priori, but rather we will need to do this in a contextual manner. I tentatively conclude that
there is a strong pragmatic case for counting some relationship problems as disorders.
Defining the Key Features of Psychiatric Convalescence, 1830–1930
Stephen Soanes (Warwick)
Neither acutely sick, nor entirely well, the convalescent patient has continually occupied an
ambiguous position between dependence and self-volition, and consequently also between
institutionalisation and social rehabilitation. Medical dictionaries from the nineteenth century to the
present day have recurrently defined ‘convalescence’ as an intermediate phase of recovery between
acute illness, and final restitution to optimal health. Yet as this paper will explore, alienists and
psychiatrists from the same period also described differences in the therapeutic needs of psychiatric
convalescents, from those recovering after somatic ill-health.
The first part of my paper will consider the extent to which psychiatrists between 1830-1930
perceived psychiatric convalescence as essentially different from somatic recovery. Part two will
then briefly assess the medical, professional and social reasons for their conclusions.
From John Conolly and W.A.F. Browne in the 1830-40s, through J.C. Bucknill and Daniel Hack Tuke in
the 1850-90s, and afterwards on to Robert Jones, Thomas Beaton and J.R. Lord in the 1900-30s,
alienists’ publishing repeatedly positioned convalescence within the domain of institutional
psychiatry. Psychiatric convalescence offers historians an attractive focus for studying the
relationship between psychiatric and somatic medicine, because its characteristic features and
modes of treatment were frequently compared with those applied to patients with bodily ailments.
Often distinguished as a particularly fraught final phase requiring careful supervision, seclusion and
rehabilitation, it was described in ways that legitimised ongoing psychiatric intervention, rejected
familial care, and presented its management as an integral and explicitly specialised medical phase
of treatment.
Examining psychiatric discourse through psychiatric textbooks and journal articles, this paper
considers the ways in which psychiatrists before the 1930 Mental Treatment Act presented recovery
from mental illness as a distinct and problematic stage of treatment. The century between 1830–
1930 witnessed a proliferation in psychiatric writing, and the professionalization of the discipline.
This can be seen in the advent and expansion of a professional psychiatric association and journal,
and the number of textbooks designed for an increasing number of asylum superintendents (A.
Scull). Confronted with legal and social impediments against treating incipient or voluntary cases of
insanity (R. Porter; K. Jones; L. Clarke), psychiatrists arguably turned instead to the borderland of
convalescence to help legitimise their status alongside general medicine. Comparing psychiatric and
somatic convalescence, alienists could present their discipline within the contexts of broader
medical practice. At the same time, psychiatrists also (arguably) pursued professional interests by
pointing to its specificities and the particular psychiatric expertise required to bring recovery to a
successful conclusion.
How Should We Understand Mental Illness?
Serife Tekin (York)
Ian Hacking (1994, 1995) argues that some mental illnesses can be classified as human kinds. Human
kind, a term he coins by taking natural kind as a point of departure, is a classification that includes a
variety of people, their behaviour, their condition and modes of action. The most important
characteristic of human kinds that distinguishes them from natural kinds is that classification
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generates a looping effect, i.e., the classification results in a self-awareness in the subjects so
classified, which in turn, has an impact on the classification rubric itself. According to Hacking,
looping effects only occur in human kinds; there is no such looping effect in natural kinds.
Rachel Cooper (2004) opposes this and asserts that the feedback effect in human kinds is
comparable to the one found in natural kinds; suspecting that some types of mental disorder are
natural kinds. From Cooper’s argument it follows that psychiatrists should pursue empirical research
programs that seek to understand these ‘natural’ mental illness. However, remaining skeptical,
Cooper acknowledges that even if types of mental disorder are natural kinds, there are
epistemological and practical reasons to doubt that the Diagnostic Statistical Manual (DSM), the
widely accepted criteria for mental illness diagnosis, will ever reflect their natural structure.
Hacking (2007), abandons the notions of natural and human kind and proposes a ‘framework for
analysis’ for the kinds of people studied by human sciences, in which, the looping effect occurs
between five axes. There are not only the names of the classifications, and the people classified, but
also the experts who classify, study and help them, and the institutions within which the experts and
their subjects interact, and through which authorities control. Additionally, there is an evolving body
of knowledge about the people in question as well as experts who generate the knowledge and
apply it to their practice.
This paper analyzes Cooper’s criticisms of Hacking’s earlier claims, in light of his more recent
arguments. I agree with Cooper that the DSM schema cannot fully account for mental illness, but I
disagree with the assertion that some mental illnesses are natural kinds. Instead of classifying
mental illness as a natural kind, I suggest we use Hacking’s new framework to illuminate the
phenomenon. By doing this, we would not only focus on the subject who experiences mental illness
and the neurochemical structures underlying her experience but also the inter-subjective and interinstitutional context that her experience is situated.
By itself, focusing on the person’s symptoms to pick out the ‘nature’ of her illness with the help of
empirical research is not sufficient. For instance, institutional practice of psychiatric diagnosis acts as
the agent of identity constitution, and a variety of experiences such as clinical trials, education
programs for psychiatrists and cutting edge research all contribute to the culture of diagnostic
classification. They impact person’s identity, their interpretation of their experience and other
persons’ account of their illness. In this sense, the phenomenon of mental illness is multiplex and
cannot sufficiently be captured in purely scientific terms.
Values and the Pathological Status of Psychiatric Symptoms
Prof Tim Thornton (UCLan)
At a recent meeting organised by the World Psychiatric Association on their Institutional Program for
Psychiatry for the Person, my colleague Pat Bracken suggested that there was one particular thorny
question to be addressed in any rethinking of the relation of diagnosis and taxonomy. How should
psychiatry respond to those who argue that their experiences, such as hearing internal voices, whilst
fitting a psychiatric diagnostic category, are not really pathological?
I will consider what makes that a particularly difficult problem in the light of two dimensions of Peter
Zachar and Kenneth Kendler’s suggested conceptual framework to assess psychiatric taxonomy. My
aim is simultaneously to use their framework to shed light on what I will call ‘Bracken’s question’ and
use that question to further clarify aspects of their framework.
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