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Transcript
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 It uses material from Beckett’s own unpublished ‘Psychology notes’, the fruits of reading in psychology, neuroscience and psychoanalysis made between the two world wars, and traces the impact of this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 1 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. 2 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”. 3 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 4 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 5 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. 6