Association for the AA Advancement of and P&P Bulletin

From the Editor President’s Column

Getting Metaphysical In the last 15 months, there has been a resurgence of interest in a fairly obscure part of psychiatry’s code of medical called the Goldwater Rule. The Gold- This issue of the AAPP Bulletin is water Rule specifies that “…it is unethical for a to offer a professional opinion unless he or she has conducted an examination and has been granted prop- devoted entirely to Peter Zachar’s re- 1 cently published A of Psy- er authorization for such a statement.” While this proscription is unremarkable in chopathology (MIT, 2014). The range a clinical setting, it intends to prevent from speaking publicly about and depth of the commentaries speak to public figures who exhibit surprising or alarming behaviors. Named after the the multiple questions and issues pro- American Psychiatric Association’s [APA] response to the 1964 scandal in which voked by the book. magazine informally surveyed 12,356 psychiatrists on the psychological fit- The format of this Bulletin issue is as ness of presidential candidate Barry Goldwater to serve as president. At the time, follows. Peter begins with a summary only 2417 psychiatrists responded, and of those 1189 (just under half) of those of the book, providing those who have responses provided psychodynamic reasons for Goldwater’s unfitness. Goldwater successfully sued the magazine for punitive damages in Federal court shortly not read the book but want to follow 2 the discussions a starting point. Next thereafter, but in attempting to appeal to the refusal of compensatory damages was reminded that the first amendment “giv[es]each person in this country the come the commentaries. Finally, Peter 2 responds at length to all of them. As he unconditional right to print whatever he pleases about public affairs.” Nine years acknowledges, this exercise has al- later, the APA codified that psychiatrists must not make diagnostic pronounce- lowed him to rethink many of the is- ments about public figures. sues addressed in his book. Taken as a AAPP’s then-past-president Jerome Kroll, MD, and I started criticizing the whole, the commentaries and responses Goldwater Rule in 2008. We co-presented a paper called “APA’s Goldwater Rule: offer a very rich discussion of ques- Ethics of Speaking Publicly About Public Figures” at AAPP’s annual meeting in 2008, 3 and followed up with a related symposium at the APA meeting the same tions central to philosophy and psycho- 4 pathology. year with the same title. In 2008, the public figures of interest were terrorists, One other note regarding the format- school shooters, and celebrities with substance abuse problems. By the time Dr. Kroll and I fully developed our thoughts and published them ting. Inasmuch as Peter Zachar is now 6 President of AAPP, I asked Claire last June, the words and actions of Donald Trump were the hot topics of public Pouncey, our ex-President, to write the scrutiny. Our paper argues that the Goldwater Rule is intended to protect the President’s Column. APA’s reputation rather than the common good, public safety, or the well- of Before proceeding, I want to thank our patients. We detail limitations of the formal diagnostic interview, we illustrate both our commentators and Peter Zach- situations in which diagnoses or “professional opinions” are rendered remotely and ar for the work they have all put into unobjectionably as a matter of course, we note the logical inconsistencies between this extended discussion. the Goldwater Rule and other sections of the Code of Medical Ethics, and we chal- One of my strong impressions in lenge the APA to specify how and why psychiatrists can/should separate ourselves reading the commentaries and Peter’s as psychiatrists from ourselves as members of other social groups and roles. In responses is that in most cases a dia- sum, we endorse upholding the Goldwater Rule as a point of professional etiquette logue has been initiated that could have rather than ethics, but argue that if an individual psychiatrist has profound con- continued productively beyond the cerns about the of a public figure that are thoughtfully, responsibly, commentary and response. It is Peter’s accomplishment to have initiated so (Continued on page 55) many dialogues. This does, however, put me into a unique position as the gest that readers save this exchange for later and now proceed with the commen- editor who has read all the commen- taries. taries and responses. I take ad- About Rego Peter writes: vantage of that position to continue one of the dialogues. This one involves the One flaw of the correspondence theory relates to Rego’s notion of the dis- commentaries of Rego, Thornton, connect between our understanding of the natural world and the natural world Cooper, and myself, along with Peter’s as it exists. Given such a disconnect, how can you ever know that your con- responses. At the end of his responses cepts correspond to the world as it exists in itself? Is there only one way to to commentaries, Peter will respond to correspond? How would you check that the correspondence is there? this continued dialogue. I would sug- In addition, how do we know if what our statement corresponds to is indeed a fact? It would be circular to claim that a fact claim is true if it corresponds to the . One way to avoid circularity is to allow pragmatic tests and consid (Continued on page 55) Volume 24, Number 1 2017

A Metaphysics of Psycho- spired by a reading of Darwin that has recently been powerfully defended pathology (MIT Press, 2104) was ahead of its time because it did by proponents of the new scientific Summary not reject the primacy of natural se- essentialism. Hillary Putnam was an lection as did the most scientists of important early advocate for scientific Peter Zachar the day. Scientifically-inspired prag- essentialism but with increasing expe- matism represents the tough-minded rience came to abandon it. His prag- Chapter 1: Introduction: dimension of James’ thought, which matist-inspired rejection of essentialist Wars, Psychiatry, and the Problem he called radical . Radical metaphysics emphasizes the various Of Realism empiricism is the view that we do not ways that we actively elaborate upon need to look beyond or transcend in order to acquire factual In psychiatry, it is common to experience in order to legitimately that serves our interests and question whether a given psychiatric use “metaphysical” distinctions such goals. disorder is real. In psychology, schol- as subject versus object or appearance ars debate the of theoretical versus reality. Radical empiricism Chapter 5: Misplaced Literalism entities such as general intelligence, foreshadowed some of the ways that the empiricist tradition would evolve Literalism is the heir of the search superegos, and personality traits. These th concerns raise a further question: what in the 20 century. for an ancient Adamic language of is meant by the abstract philosophical “true names” in which names and of “real?" Indeed, some psy- Chapter 3: Instrumental Nominal- things were believed to be in unity. chiatric disorders have passed from ism The conceptual contrast that is of con- being considered real to imaginary (as cern in this chapter is “true versus liter- in the case of multiple personality dis- According to instrumental nomi- ally true.” To demonstrated how preva- order) and others from imaginary to nalism, it is important to conceptual- lent literalism can be in scientific dis- real (as in the case of post-traumatic ize what collections of particulars course, a list of examples where this stress disorder). have in common, but as the collec- distinction can be made but is not al- Concerns about the reality and tions grow larger and the ways made is followed by a critical unreality of psychiatric disorders are more abstract (e.g., ), they be- exploration the claim that genes are related to larger debates about scien- come increasingly obscure and ap- literally strands of DNA. In the field of tific realism. The passions that accom- plied to a contradictory list of in- psychiatry, diagnostic literalism is pany discussions of realism are exem- stances. There are three ways of mak- sometimes referred to as reification. plified by the Science Wars of the ing such abstractions less obscure. Three different “misplaced literalisms” 1990s. Optimistically considered, the One, they can be juxtaposed to con- that occur in psychiatric diagnosis and Science Wars resulted in a more nu- trast concepts. Two, they can be de- classification are one, literalism about anced use of metaphysical concepts composed into component concepts. taxa, two, literalism about diagnostic such as “real” on the part of those par- Three they can be stratified into more criteria, and three, literalism about ticipants who were both scientifically homogeneous sets of cases. Instru- explanatory constructs. All three of and philosophically inclined. Discus- mental is inspired by these literalisms are supported by our sions about the reality of psychiatric Charles Peirce’s claim that we are need to rely on authorities when decid- disorders are even more passionate. An never at the beginning or end of in- ing what truth claims to accept. important goal of this book is to en- quiry, but always in the middle. We courage an evolution of the use of met- cannot divest ourselves of metaphysi- Chapter 6: Literalism and the Dis- aphysical concepts in psychiatry and cal assumptions, but we can tempo- trust of Authority psychology that echoes what happed in rarily isolate and critically analyze the Science Wars. In this book, meta- any assumption in order to make con- A unique feature of modernity is physical concepts such as real, true, ceptual progress. the public expression of and objective are viewed in pragmatist about authority paired with the private fashion as conceptual tools that have Chapter 4: Psychological and Sci- realization that it is difficult to know an important role to play in psychiatry entific Essentialism what (and who) to believe. This mod- as long as they are not treated as trans- ern condition is shared by both con- cendent, absolute concepts. A common feature of essential- servatives and liberals. Different types ism is the that discovering the of authorities in both religious and Chapter 2: A Scientifically Inspired inherent natures of things will lead to academic communities are explored, a classification system that carves including self-styled prophets, self- at the joints. Some scientific taught experts, credentialed experts, Scientifically-inspired pragmatism psychologists claim that that essen- and innovators. The chapter ends with can be contrasted with the postmodern- tialist thinking constitutes a cognitive an accounting of the extent to which ist-inspired pragmatism of Richard bias. This bias emerges early in our everyone has to rely on communities Rorty. The founders of pragmatism development and continues into and recognized experts to know what represented the first generation of adulthood as psychological essential- to accept. This feature of our psycholo- scholars who could experience the the- ism. Whether we develop such a cog- gy raises the worry that we are all ory of evolution as part of their intel- nitive bias, however, is independent trapped, not so much behind a veil of lectual inheritance. The pragmatism of of the philosophical justification of ideas, but within the boundaries of our William James in particular was in- metaphysical essentialism – which chosen community’s beliefs.

2 Volume 24, Number 1 2017

Chapter 7: The Objective Within, ral kind and social . Both of Not Beyond, Experience these concepts offer informative ways of thinking about psychiatric Gaining information about an ob- disorders, but they are more useful jective, mind-independent reality while when made less obscure by being needing to rely on a larger community decomposed into components. The to know what to accept as true and also decomposition of the natural kind remaining committed to is concept results in five overlapping 29th Annual Meeting challenging. According to radical em- features: naturalness, inductive po- of the Association for piricism, a workable notion of the ob- tential, existing in a causal frame- jective can be found within experience. work, carving nature at the joints, and the Advancement of The experiential basis of the objective being subject to the authority of sci- Philosophy and is found in the realization that things ence. The most obscure feature is Psychiatry are not always what we want or expect naturalness. The most useful features them to be. The normative claims about are supporting induction and causal our obligations that follow from this explanation. The concept of social Critical Psychiatry realization motivate an important inter- construct can be decomposed into est in the concept of objective historical concept, normative con- knowledge. The metaphysical concepts cept, and practical kind. A visual of “the objective” and “the factual” are figure in the form of a tetrahedron May 21 & 22, 2017 Hilton Bayfront Hotel associated with the experience of ra- may be used to place some of these San Diego, CA tionally compelled acceptance. Being concepts in dynamic relationships (in conjunction with the Ameri- compelled to accept some claims is an with each other to emphasize that can Psychiatric Association important feature of scientific they can all contribute to a better Annual Meeting Conference) knowledge, but the experience of being understanding of psychiatric disor- compelled is contingent upon the ac- ders. Edwin R. Wallace IV ceptance of epistemological norms. Lectureship in the Philosophy Chapter 10: Can Grief Really be a of Psychiatry Chapter 8: Classification and the Disorder? Concept of Psychiatric Disorder Moderator The debate about eliminating the Scott Waterman A caricature of nominalism, the bereavement exclusion in the DSM-5 assertion that “psychiatric disorder” is was contentious. The public side of Speaker only a name for conditions that psychi- the debate (should grief be classified Nev Jones, Ph.D. atrists decide to treat, is unacceptably as a ?) concerned the Director of Research, Client Centered relativistic. One of the most important proper place of scientific and psychi- Outcomes Research in Public Mental and persuasive attempts to regiment the Health, Felton Institute; atric authority in society. The aca- concept of disorder in response to such demic side of the debate (should de- is Jerome Wakefield’s harm- pressive symptoms that occur be- Title ful dysfunction model. Wakefield ad- tween two and eight weeks after the Toward an American critical vocates for a kind of essentialism. In death of a loved one be considered a psychiatry: Leveraging theory contrast, the imperfect community mod- psychiatric disorder?) concerned for real change el seeks to avoid both relativism and what is to be counted as a real disor- speculative metaphysical der. The de facto essentialism adopt- Program Chairs about essences. According to the im- ed in much of psychiatry is contrast- perfect community model, the various ed with the more empiricist imperfect Christian Perring, Ph.D. symptom configurations that are classi- community model. From the de facto [email protected] fied by psychiatrists resemble each essentialist perspective, the debate other in a number of ways, but there is was about how to distinguish the Douglas Porter, M.D. no property or group of properties that simulacrum of depression that occurs Algiers Behavioral Health Center, all of them share in common as a class. after bereavement from a true depres- New Orleans, LA Turning to scientific psychology, this sion. From the perspective of the [email protected] non-essentialist model is elucidated by imperfect community model, the de- describing causal networks as alterna- bate was about whether some depres- G. Scott Waterman, M.D. tives to the essentialism promulgated in sions should be normalized. University of Vermont latent variable models. [email protected] Chapter 11: Is Narcissistic Person- Chapter 9: Four Conceptual Ab- ality Disorder Real? stractions: Natural Kind, Historical Concept, Normative Concept, and After reviewing the history of Practical Kind the constructs of pathological narcis- sism and narcissistic personality dis- The pragmatist’s view of concepts order (NPD), the reasons why NPD as tools that we use for certain purposes was targeted for elimination in the is applied to the contrast between natu- DSM-5 are described. There is disa- 3 Volume 24, Number 1 2017 greement about the reasons for its deeper into pragmatism and pursues his eventual reinsertion: does it have some As a non-philosopher with a goal of situating it into experience only. clinical utility or was it reinserted only strong interest in the subject, my first Here is where I hope for more from for political purposes? The chapter impression of a philosophy book pragmatism and find it almost there but concludes by looking at why constructs depends not only on its perspective, not reaching its goals. In particular, I such as narcissistic personality disorder but on its ability to teach me some- do not find the conclusion of finding all are included in the domain of psychiat- thing. On this point I enjoyed reading we need within experience more than a ric disorder. It is argued that competing Zachar’s “The Metaphysics of Psy- diagnosis of exclusion. He promises versions of the essentialist bias inter- chopathology.(Zachar, 2014)”. In more, specifically in chapter 7, but I do fered with the implementation in the addition to the arguments made it not think he provides it. DSM-5 of a competition between cate- serves as an advanced primer on the Zachar leans on empiricism, here gories and dimensions that would have philosophy of psychiatric nosology. radical pragmatism (i.e. truth lies wi- set up conditions in which progress Articles have been written to accom- thin experience) to support his brand of would have had a better chance of oc- plish a similar goal but end up being pragmatism. For Zachar Truth (and curring. lists of terminology without context. thus the objective and the real) do not Zachar covers a lot of territory in lie “out there” to be discovered. Rather, Chapter 12: Psychiatry, Progress, pursuing his argument. In doing so they are things supported by the evi- and Metaphysics he takes some side roads into battles dence. The evidence can be very com- over the DSM 5 and other areas of plicated and highly specialized so we The claim that psychiatry has the psychological literature, all to understandably rely on an imperfect failed to make progress and gotten on edifying and interesting effect. My community of summaries to inform us. the wrong track by expanding the diag- small wish list for this book would Throughout the book Zachar uses nostic system to include conditions that have been to include a few other three types of pragmatism in his discus- are not really disorders has become terms for examination such as mate- sions; classical pragmatism (a high common place. According to this view, rialism, it’s cousin, , dependence on practical outcomes), much of the imperfect community is a and the matter of concept validity as radical empiricism (claims are justi- classificatory mistake as a result of a central tool of psychiatric classifi- fiable by experience alone) and instru- over medicalization. The history of cation. But you can’t have every- mental nominalism (groups of observa- what many consider to be the ultimate thing. tions or pieces of evidence will genera- mythical psychiatric disorder – hysteria For the purpose of this brief com- lize into some other useful informa- - is viewed through the lenses of the mentary I will take up two issues. tion). Each type of pragmatism accepts historical kind, normative kind, and First is the main subject of the book, some form of evidence as its form of practical kind perspectives. Hysteria is and of this review, pragmatism. confirmation. But the argument that the analyzed in nominalist fashion examin- Pragmatism, in my view, always various types of pragmatism accept ing its conceptual contrasts, seeing seems to fall short in fulfilling its evidence for different reasons comes up how it has been decomposed into com- expectations as a theory of short as it does not describe in each ponents, and describing its stratifica- knowledge. It does the same in this case why some evidence will be useful tion in recent DSMs. A more pragmat- book. I’ll explore why and hopefully and other evidence is not. Ultimately ic, less metaphysically encumbered draw some conclusions about where this leads to an infinite regress notion of scientific progress is also else to look for such a theory. (evidence is useful because it is offered. Progress is made when a new Secondly, I will briefly explore an useful…); things are accepted as evi- theory or model gains competitive su- overarching, tacit premise in Za- dence but with no end in sight because periority over another with respect to char’s explorations. This can better there is no absolute truth or truth “out some standard – and is most dramati- be described as an extension of Za- there.” cally seen when we can know or do char’s work rather than a critique. With regard to the acceptance of something that was previously Zachar’s begins with the goal of evidence, the first question is, evidence unachievable, even unimaginable. The situating pragmatism within empiri- of what? I imagine Zachar and I would book concludes by emphasizing the cism and therefore within expe- agree that the evidence needs to do importance of metaphysical concepts rience. By doing so he accomplishes something. Perhaps it would support a such as real and objective for thinking several things. One is to avoid the theory that already has other support. philosophically about psychiatric disor- poles of nominalism (in this form Or in more practical terms the evidence ders, urging also, that we think philo- just relativism in disguise) and essen- would make something work; and ex- sophically about these metaphysical tialism, which veers off into meta- periment or a device. We would seem concepts themselves. physical assumptions. Another is to to be agreeing on pragmatic terms. locate truth and its associates, objec- However, I think the rapprochement *** tivity and reality, within what we can would be short lived as I would say that as humans experience, measure and the evidence reflects an objective truth Limitations on What We Know use (as opposed to what we can ima- because it makes something actually Is Certainly “Out There” gine or logically conclude for work. That is, it corresponds to example). something “out there.” Again, Zachar Mark Rego On first blush this seems like an has no need for the “out there.” If there

Yale University attractive program. Certainly avoi- is evidence that gets something done, [email protected] ding extremes is a good policy. My we can call it true and have no need to concerns arise when Zachar digs go on from there.

4 Volume 24, Number 1 2017

All in all, I think it would be better these many assumptions true because to say that there are problems between form after dropping one grain at a they work does not explain the reverse our understanding of the natural world time onto a flat pile. These overlaps of this statement. Namely, why do they and the natural world as it actually take place in nature and most areas work? exists. One side does not easily map of knowledge and do not rule out the The second point I’d like to briefly onto the other. This is fundamentally a possibility of making a useful and take up here is an assumption that un- problem of human limitations and pers- accurate determination. derlies Zachar’s discussion as well as pectives. Pragmatism seems more like Later on he comments on levels most discussions within the philosophy a partial solution rather than a descrip- of explanation (a level which is of psychiatry. That assumption is that tion of the state of affairs. useful for teaching may not be useful good psychiatry should follow good I agree that absolute and for a scientist(Kendler, 2012)) and philosophy. I do not disagree with this. things nebulously “out there” are pro- suggests that they are also not exclu- Rather I think that the reverse should blematic but these are problems with sionary. I would add values as ano- be considered much more often than it the scope of what we can know and ther important perspective on this is. That is, philosophy should follow inherent limitations on how we find list. Values are incorporated into all the facts of empirical findings in both things out. of our thinking but do not exclude studies and common practice to com- Consequently, I do not see this as a the possibility of scientific pose its starting premises. The lack of metaphysical problem but an epistemo- knowledge(Sadler, 2002) this perspective gets to the thorniest of logical one that goes to the heart of To return to the “out there” pro- our problems. I will look at an example how we know things at all. I would blem I’d like to introduce the thought from Zachar’s book as an opportunity have found it helpful somewhere in this experiment of the NASA rocket. for philosophy to take a different turn part of the discussion if Zachar had NASA readies a rocket for lift off on when things don’t add up and to illus- included a description of what a meta- a Monday. Sadly, the entire human trate what I mean by this reversal. physical view of truth would look like. race unexpectedly dies on the Sun- The goal here is not a priority of I would probably agree that it would day before. Fortunately for NASA disciplines but a sequence involved in not be fruitful to try and fulfill the me- the lift off was the first of its kind in understanding phenomena. taphysical view and is not the direction which a computer program was set to comes first, theory follows. In this sce- I would go. handle the entire thing while engi- nario science provides the So rather than describe this as a neers stood by in case of a problem. as it is dealing with things like patholo- problem solved by pragmatism I would Now no one is there to watch. The gy and experimental results while phi- look at it as a limitation of how we scientific community whose approval losophy adds the layer of models and know things and attribute it to perspec- and agreement support the principles explanatory theory. tivism. The truth is “out there” but we which have gone into building the Let’s look at the case of psychopa- can never envelope the whole thing and rocket are all gone. thology. Everyone knows by now that are always biased in our perspective. We can guess the result. The does not divide up Furthermore, we have the problem of computer program takes over and the easily. Things exist on continuums and experimentation where our technology launch goes off as scheduled. What in dimensions, are heterogeneous in and goals affect the outcome of what knowledge went in to the successful their presentations and comorbidity is we discover. (N.B. I am aware that in launch? Not a social conversation (a the rule rather than the exception. Hun- quantum mechanics the nature of reali- la Rorty). Nor an agreement that de- dreds of genes underlie single diseases ty changes to one that is inherently creases cognitive dissonance. Mind and multiple causal pathways (prenatal unknowable and not limited only by dependency is no longer an option to later life experience) can bring a our own short-comings. This certainly (though one could claim it was when person to the same place. Medications extends the entire discussion but as we the system was designed). This is in lack specificity and have effects that do not know if this applies in other one sense the opposite of a tree fal- span different pathological states (also places in nature it makes sense to limit ling in a forest. The phenomenon in true for ). Given all this our discussion for now). question (making sound, having a lift why should we think that there are any Zachar is aware that our knowledge off) has already occurred. There is no joints at which we should carve psy- is biased and affected by aspects of question of that. The question is, chopathology? perspective. It is greatly to his credit without a mind-enabled participant Everything we know—which al- that he sees these things as parts of the how can the successful natural phe- though far from determinative is not experience of knowledge and not ex- nomenon, engineered by humans, be insubstantial—suggests highly com- clusionary of psychiatric knowledge as explained. Things worked because plex, interweaving networks and path- some critics of psychiatry would have something true was tapped into. ways. Nothing here suggests that psy- it. This is demonstrated in his model of Maybe a few theories were untrue chopathology exists in rigid, boxed-off the imperfect community. Another ex- and things worked anyway. We categories. Yet we criticize nosology cellent example is in Zachar’s descrip- know this happens. But in the case of when it does not fit such a model. Ra- tion of “heaps”. These are areas bet- a rocket thousands of assumptions go ther than criticizing nosology for not ween two poles of relative of, into place to make things work. Most cutting nature at the joints we should be a diagnosis for example, where overlap if not all had to be true or there exploring models which do not involve takes place (e.g. a description of the would be no lift off. We do not know joints at all. categorical vs. dimensional problem in it completely but can test what we By following the findings of psy- diagnosis). In this analogy the “heap” is think we know. The rocket itself is chopathology research and the expe- the point at which a heap of sand takes such a test. To say that we are calling rience in clinical care, philosophy is

5 Volume 24, Number 1 2017 well positioned to generate new models Anti-realists provide a reinterpreta- which include these findings. My sus- broader approach to philosophical tion of the nature of such truth claims. picion is that such models will need to method. The method dovetails with This might be a social constructionist be cross disciplinary, but this is consis- substantial metaphysical claims account of scientific practice. Or it tent with much of the work in philoso- about the connection between reality might be the claim that the truth of a phy of mind. and experience. It is not antithetical belief consists in its coherence with As a bonus for this approach, philo- to advancing metaphysical claims but other beliefs. Such modifications re- sophers would be doing psychiatric takes such claims to be advanced interpret the common core. Fine’s char- research a significant service. Genera- within the boundaries of experience acterisation of what a realist adds to the ting data by itself will not, in my view, rather than attempting to gesture to a common core is simpler: ‘what the re- be adequate for generating explanations reality without them. alist adds on is a desk-thumping, foot- for mental function. In fact, recent [T]he pragmatism that I stamping shout of “Really!”’. The rea- work in complexity theory has shown explicate in this book is con- son for this is that: that increasing the output of data from cerned with nitty-gritty issues The realist, as it were, tries to empirical studies brings with it an ex- in the scientific disciplines. stand outside the arena watching ponential increase in the number of Based largely on the pragma- possible explanations for the data in tism of William James, scientif- the ongoing game [of science] and question.(Bar-Yam, 2016) What is ically inspired pragmatism has then tries to judge (from this exter- needed are overarching theories to or- no a priori commitments that nal point of view) what the point ganize information. Reformatting phi- oblige it to take a side in meta- is. It is, he says, about some area losophical premises to the data at hand physical debates such as those external to the game. The realist, I is the path to this end. between scientific realists and think, is fooling himself. For he

antirealists. Neither does it de- cannot (really!) stand outside the References ny the value of the substantive arena, nor can he survey some area philosophical distinctions (such Bar-Yam, Y. (2016). The limits of as appearance versus reality or off the playing field and mark it phenomenology: From behaviorism to subject versus object) that are out as what the game is drug testing and design. explored in such debates. (ibid: about.’ (Fine, 1986: 131) Complexity, 21(S1), 181–189. https:// 25) Zachar summarises the realist side doi.org/10.1002/cplx.21730 of this disagreement thus: Kendler, K. (2012.). Levels of ex- Radical empiricism is a planation in psychiatric and substance view proposed by William What then is the use disorders: implications for the de- James that asserts that experi- between scientific realists and anti- velopment of an etiologically based ence rests on nothing outside of realists? What is the contrast be- nosology. Mol Psychiatry, 17(1), 11– itself (i.e., neither behind nor tween these two philosophical po- 21. beyond all experience). The sitions if it is not about what scien- Sadler, J. Z. (Ed.). (2002). Descrip- metaphysical distinctions that tific statements are true? Accord- tions & Prescriptions: Values, Mental we make in order to see how ing to Fine, the key contrast be- Disorders and the DSMs. Baltimore: things hang together (such as tween the scientific realist and the The Johns Hopkins University Press. subjective versus objective) are antirealist is that along with the Zachar, P. (2014). A Metaphysics of made using the resources avail- various considerations that are Psychopathology. MIT Press. able to experience. (ibid: 239) relevant in accepting as true a Radical empiricism is a statement such as “bipolar disorder *** theory about the sufficiency of has a genetic component,” a scien- experience for making meta- tific realist wants, in addition, to Philosophical minimalism and ideal- physical claims. (ibid: 52) assert some special relationship ism in Peter Zachar’s ‘A Metaphys- called correspondence to reality. ics of Psychopathology’ As well as this general claim For example, in addition to accept-

about the experiential limits of meta- ing all the reasons for agreeing that Tim Thornton physical distinctions, two other ideas bipolar disorder has a genetic com- University of Central Lanca- play an important role in the machin- ponent, the scientific realist stomps [email protected] ery of the book. One is Arthur Fine’s his foot and shouts out—“Bipolar disorder really does run in fami- deflationary approach to debates Although Peter Zachar’s book is between scientific realists and anti- lies, really!” (Zachar, 2014:51) called a ‘metaphysics of psychopathol- realists in the philosophy of the phys- A third element of the framework ogy’ its focus is, in fact, broader in two ical . Fine argues that both is what Zachar calls ‘instrumental nom- respects. First, it outlines an approach realists and anti-realists accept a inalism’. to metaphysical concepts in general, common core. Both sides accept the outside psychopathology. Second, the truth claims made by scientists which If we were to specify what all approach to be taken to metaphysics – Fine calls the ‘natural ontological true statements have in common, which following William James, Zach- attitude’. But then both interpret the result—called the universal ar labels both ‘scientific pragmatism’ these in additional metaphysical essence of Truth—should be fully and ‘radical empiricism’ – reflects a terms. present in every possible true state-

6 Volume 24, Number 1 2017

ment. Nominalists reject such uni- may lead one versals and attend instead to the behind diagnostic categories, he sug- to ignore practical details because of a variability and plurality that exist gests that the actual pattern of over- prior belief that they cannot be rele- within concepts such as truth... lapping similarities and differences vant. But, the suggestion goes, the de- Instrumental nominalism is the exhausts the facts of the matter. And tails might contain just what was need- view that abstract metaphysical hence he commends an ‘imperfect ed to resolve one’s philosophical diffi- concepts (which are best defined in community’ model of kinds rather culty. terms of contrasts such as subjec- than an explanation of kind which tive versus objective) can be al- dig beneath the clinical surface. A Cora Diamond provides an extend- lowed as long as we are clear on similar approach guides the detailed ed discussion of Wittgenstein’s meta- the purpose for making the distinc- discussion of particular diagnostic philosophy which includes an interpre- tion. (ibid: 238) categories in the final chapters of the tation of this passage (Diamond, 1991). book. She suggests, following a gnomic com- Zachar uses instrumental nominal- ment from Wittgenstein, that the ten- ism as a means of avoiding hasty essen- I think that this is an admirable dency to be blinded to important details tialist thinking. It fits with the idea that approach to the philosophy of psy- by philosophical theory is a mark of metaphysical distinctions should be chiatry. Explanatory minimalism is a . This is a surpris- tied to experience. For example, alt- hygienic view of the insight philoso- ing remark because, in philosophical hough he commends Wakefield’s phy can provide into other disci- debates about the reality of the past, or harmful dysfunction analysis of psychi- plines. In the next section I will out- distant spatio-temporal points, or math- atric disorders as a ‘parsimonious, ele- line a different route to the same ematics, realism is usually thought of gant, and useful’ his key criticism is metaphilosophical approach: Witt- as the non-revisionary position, the that it goes beyond possible experience. gensteinian philosophy. It can seem, position which most fits everyday lan- however, that it falls prey to an accu- guage. Nevertheless, realism fails to be Horwitz and Wakefield use a sation of . I will argue that it realistic when it goes beyond the eve- conceptual analysis of what we need not but then return, in the final ryday phenomena and instead attempts should and should not be expected section, to ask whether the same is to explain them by postulating underly- to do to identify what lies within true of Zachar’s account. ing processes or mechanisms. Diamond our biologically designed, natural- suggests that the central ambition of ly selected range of behaviors. Wittgenstein’s philosophy is to be real- According to them, talking to fam- Wittgensteinian anti- istic whilst eschewing both, on the one ily members without intense anxie- explanatory minimalism hand realism and, on the other, empiri- ty lies in this range, but handling cism. snakes without intense anxiety does not. Only psychiatric symp- In an early passage in the Philo- Diamond uses two examples from toms that interfere with what we sophical Investigations Wittgenstein outside Wittgensteinian philosophy to should naturally be expected to do suggests that a failure to pay atten- clarify the distinction between realist are to be considered objective dys- tion to the details of language and and realistic philosophy. One is Berke- functions. In this analysis the dis- practice is not simply the result of ley’s discussion of matter in his Three tinction between disordered and carelessness: Dialogues. Hylas, the philosophical normal is being made not by dis- realist, argues that the distinction be- If I am inclined to sup- covering an objective dysfunction tween real things and chimeras - mere pose that a mouse has come but by intuition. The HD analysis hallucinations or imaginings - must into being by spontaneous cannot, therefore, be reliably used consist in a fact which goes beyond all generation out of grey rags to do what it was proposed to do— experience or perception. For this rea- and dust, I shall do well to factually demarcate valid psychiat- son, philosophy has to invoke the phil- examine those rags very ric disorders from the larger class osophical concept of matter to explain closely to see how a mouse of problems in living. (ibid: 120-1) the difference. The presence or absence may have hidden in them, of matter is beyond direct perception or how it may have got there The objection is not that the analy- experience, although perception can and so on. But if I am con- sis is false or incoherent. Rather, the provide evidence of its presence or vinchat a mouse cannot appeal to biological dysfunctions to absence. This however presents Phi- come into being from these underpin a notion disorder inverts actu- lonous, who speaks on behalf of a real- al explanatory priority. Intuitions about things, then this investiga- istic approach, with an opening for a what is and is not a disorder drive tion will perhaps be super- criticism. Because of its independence judgements about selective history ra- fluous. from perception, matter cannot explain ther than the other way round. So the But first we must learn to the distinctions that we actually draw objection is that the model is a gratui- understand what it is that between reality and chimeras. But nor, tous metaphysical explanation which opposes such an examina- given our actual practices of drawing a goes beyond clinical experience. tion of details in philoso- distinction, is such a further philosophi- Zachar adopts a similarly anti- phy. (Wittgenstein, 1953 cal explanation necessary. The practical essentialist view of psychiatric taxono- §52) or epistemological distinctions which my in general. Rather than assuming Hylas can rely on are also available to that there must be a common essence Philonous without commitment to the philosophical account of matter. The

7 Volume 24, Number 1 2017 mouse, in this case, is the distinction might be aware of by our and the rags, which Hylas is convinced Berkeley’s own claims to the contra- senses, though indeed it is cannot explain the distinction, are the ry, his opposition to matter is not clear on Hylas’s view that we practical distinctions actually made. simply a rejection of one philosophi- must use the evidence of our cal explanatory theory which leaves senses in trying to tell what is The second example concerns a everything else, including our normal real. Still, it is not what we more recent case of philosophical real- views of the world, unchanged. In- actually see or hear or touch ism. The distinction here is that be- stead, he advocates a revisionary that we are ultimately con- tween laws of nature and merely acci- idealist metaphysics. Secondly, Dia- cerned with in such judg- dentally true generalisations. Peirce mond characterises Peirce’s account ments; and this because how- argues that this distinction must consist of active principles as a ‘belief in a ever things appear to us, it is in the presence or absence of active connection supposed to be real, in quite another matter how they general principles in nature. These can the sense of independent of our are. (ibid: 47) be used to explain the reliability of thought, and for which the supposed predictions based on laws. But: regularity is evidence’ (ibid: 50). This suggests that the object of Dia- This passage contains two charac- mond’s criticism is the mind- terisations of what it is for something to The reply of a realistic independence of Peirce’s conception be real rather than imaginary. One is spirit is that an active general of active principles. In both cases the the claim that reality has ‘an absolute principle is so much gas un- examples of a realistic opposition to independent of our own’. The less you say how you tell that philosophical realism appear to sup- other is that reality goes ‘beyond any- you have got one; and if you port a form of idealism. thing we might be aware of by our give any method, it will be a senses’. It is ‘not what we actually see method which anyone can use Whilst Diamond’s account may or hear or touch’ and ‘however things to distinguish laws from acci- encourage an idealist interpretation, appear to us, it is quite another matter dental uniformities without idealism is not a necessary ingredient how they are’. Ignoring for the moment having to decorate the method of Wittgenstein’s opposition to philo- the qualification ‘absolute’, denying with the phrase “active general sophical realism. What matters in that reality has an existence independ- principle”. Peirce of course both these cases, if they are to illus- ent of our own - the first characterisa- knows that there are such trate philosophical minimalism, is tion - would amount to idealism. By methods, but assumes that his the opposition to realist explanations. contrast, the second characterisation mouse - properly causal regu- But anti-realist or idealist explana- goes beyond an everyday affirmation of larity - cannot conceivably tions are just as much to be rejected the mind independence of the real. It come into being from the rags: (cf. Fine’s natural ontological atti- presupposes a philosophically charged patterns of observed regulari- tude). Wittgensteinian minimalism and revisionary account of perception ties. (Diamond, 1991: 48) opposes speculative metaphysical in which reality always lies beyond our explanation and only thus realism (or senses. Thus its rejection is merely the anti-realism). I will clarify this by In both these cases, realist explana- rejection of a philosophical explanatory examining one further passage from theory and not itself a piece of revision. tion is rejected. This rejection does not Diamond’s account. depend on nominalist scruple, however. Thus a minimalist or realistic criti- Diamond suggests that closer attention cism of philosophical realism need not shows that realist explanations are This is how Diamond character- succumb to the criticism that it confus- wheels that can be turned although ises the realist account of matter es and . The nothing else moves with them. They which should be rejected as unrealis- rejection of realist explanations of the cannot serve as explanations of what tic: distinction between real things and the pre-philosophical difference in ei- illusions or between causal laws and ther case really comprises since their accidentally true generalisations does presence or absence is not connected to For Hylas, real exist- not imply that these distinctions are the practices which they were supposed ence is existence distinct constituted by the discriminations we to explain. Their presence or absence from and without any rela- make, by their epistemology. On the could make no difference. tion to being perceived; and other hand, the distinctions are not mat- There is, however, an obvious ob- so if the horse we see (in ters which lie beyond our ways of de- jection to such philosophical minimal- contrast to the one we mere- tecting them. They are not independent ism which needs to be countered. The ly imagine) is real, it is be- of our practices in that complete and problem is that an opposition to philo- cause its sensible appear- absolute sense. (If this is what Dia- sophical realism might be thought to ance to us is caused by qual- mond means by denying absolute inde- comprise a form of idealism, anti- ities inhering in a material pendence, then neither rejection is realism or social constructivism. body, which has an absolute tainted with idealism or constructiv- existence independent of ism.) Diamond’s account of the realistic our own. The judgment that spirit has idealist connotations for two the horse is real and not reasons. Firstly, and most obviously, imaginary, not a hallucina- Does Zachar’s pragmatism slight she selects Berkeley to illustrate a real- tion, is thus a hypothesis the independence of reality? istic approach to philosophy. Despite going beyond anything we

8 Volume 24, Number 1 2017

In the previous section, I suggested Holmes said to Watson the morning dependent on, human judgement. that Cora Diamond’s account of Witt- after they dispatched Colonel Sebas- genstein’s advocacy of a realistic spirit tian Moran was never a fact, but what Facts, and the experien- by contrast with realism can seem to Conan Doyle ate and drank on the tial limits of pragmatic philosophy seem undermine the independence of reality day he finished The Adventure of the to be at the heart of the venture. But but should instead be construed as a Empty House was a fact once, alt- avoiding both metaphysical and excess rejection of explanations which go be- hough it is likely no longer even a and a shotgun wedding is tricky. Con- yond the distinctions made in practice. potential fact because it is not public- sider this passage on the notion of what My purpose in juxtaposing Diamond’s ly ascertainable. That information has is objective: account of Wittgenstein with Peter been lost. (ibid: 109) Zachar’s framework of ideas is to high- But the latter remark does seem The metaphysical concept of light two similarities. First the similari- to be revisionary: a form of anti- the objective, however, is a useful ty in minimalism with respect to philo- realism about the past rather than a tool for understanding sophical explanations. But second, the natural ontological attitude. (One way of resistance to preference. The danger that the resulting account may to test intuitions on this is to ask concept of the objective is partly seem, at least, to slight the independ- whether bivalence applies such that inspired by and reappears with the ence of reality. Does Zachar also es- despite no present evidence either recurrence of such experiences in cape that charge? way still Doyle did or did not eat one or more members of a commu- It is clear that one central aim of breakfast that day.) It is one thing to nity, but it is not constituted by the book is to avoid such a charge. The stress the experiential realm when them. Whenever people start talk- first chapter describes the so called examining philosophical distinctions. ing seriously about the objectivity ‘Science Wars’: sociological accounts It is quite another to limit reality to of such things as the Copernican which may or may not have a debunk- what is currently experientially – model, the Apollo moon walks, or ing relation to scientific claims. On one directly or via evidence - accessible. global warming, the notion that view, accounts of the resolution of nat- someone’s preferences are being ural scientific disputes offered in socio- I think it is unclear whether resisted is not far away. The re- logical terms imply that physical nature Zachar successfully treads the fine sistance to what we prefer is not itself is socially constructed. Zachar line between explanatory minimalism The Objective in an elaborate meta- suggests offers a less metaphysically and idealism. Take the following ex- physical sense. Metaphysical elab- charged rapprochement: “One im- ample of Zachar’s commendation of a orations go beyond their experien- portant realization on the part of some coherence theory of truth: tial bases, but nevertheless, taking account of those experiences is Science Wars participants was that an In philosophical terms, useful for bringing the lofty con- analysis of metaphysical terms such as radical empiricism advocates cepts down to earth. Something “reality” and “objectivity”—terms that for a version of the coherence important occurs when the world is are used to theorize about of truth. One of the ideas not the way we want it to be, but theories—can be critical without being behind a coherence theory is that is a very minimal, even deflat- motivated by an underlying hostility to that what we consider to be true ed, notion of the objective—one the truth claims of scientists. (ibid: 11) beliefs are important in evaluat- that does not require getting outside Hence later, when discussing ing new beliefs whose truth is of experience. (ibid: 109) whether his suggestion that distinctions not yet assured. New proposi- should be framed within experience tions that seem to readily cohere and hence forms of realism that go be- with what we already believe My worry about this passage is that yond such experiential limits trap sub- are going to be accepted more it starts with a notion which is connect- jects within experience, he connects his easily than propositions that ed to ‘the objective’ which is that one nuanced view back to his account of contradict currently accepted may wish certain beliefs not to be true the Science Wars. “Does radical empir- knowledge... Correspondence and yet nevertheless they are true. This icism of this sort imply that we are theories sometimes give the alone does not constitute what we mean trapped within our own experience impression that in knowing by objectivity. It is ‘a very minimal, along the lines of a philosophical ideal- what is really there we get be- even deflated, notion of the objective’ ism? If so, then we are back to the de- yond evidence and experience. although it is not ‘far away’ from it. But bates of the Science Wars and the claim Coherence, in contrast, works then the only hint at what would consti- that nature is constructed by us, not from within experience. (ibid: tute it is ‘The Objective in an elaborate discovered. According to the radical 36-7) metaphysical sense’ which isn’t some- empiricist, however, we are not The contrast case with corre- thing that Zachar is prepared to set out “trapped” in experience, and making spondence suggests that a theory of for the reader. So what is the sense of distinctions such as objective versus truth is in the business of saying what objective ‘that does not require getting subjective or real versus imaginary truth is: ontology rather than episte- outside of experience’? This passage helps us to understand why. (ibid: 34) mology. But the account of coherence seems to contrast what it admits to be On the other hand, some remarks concerns ‘what we consider to be true an inadequate account of objectivity do seem to slight reality. For example, beliefs’ or what is ‘going to be ac- with something that is merely beyond when discussing facts he draws a dis- cepted more easily’: epistemology the pale according to the metaphilo- tinction – within the experiential realm rather than ontology. Putting the two sophical framework of the book. – between fact and fiction. But he then together suggests a shotgun wedding goes on to say something more obvi- of what is independent of, and what The same sort of problem occurs in ously metaphysically charged. “What 9 Volume 24, Number 1 2017 trying to set out how a diachronic ap- proach can balance the aim of remain- The modern dilemma is not tive reality. This is not to say that dis- ing with the experiential with a satisfac- that we are trapped behind a veil junctivism is both without difficulties tory account of mind-intendent objec- of ideas and locked into our own or the only game in town. But it would tivity: subjectivity to such an extent that be one way in which to begin to think the objective world is in continu- What about the notion that through the issues raised by the very al doubt. (ibid: 97 italics added). use of words such as ‘trapped’ or ‘veil truths about the world are true in- dependent of what we believe of ideas’. The package of ideas of It is important to be cautious which they form a part is mortal poison about them, and therefore reality is about taking the veil of ideas more than what we experience it to to Zachar’s commendable philosophi- metaphor too literally. For a radi- cal minimalism. be? Is this something that the radi- cal empiricist experience is not a cal empiricist cannot account for? veil of distortion that needs get- References No—it cannot be that either. ting beyond. According to such Events from the an empiricist we can justify mak- Diamond, C. 1991. The Realistic work well here… Taking a histori- ing distinctions between subject cal perspective allows us to see that Spirit: Wittgenstein, philosophy and the versus object and appearance mind, Cambridge, Mass.: MIT Press. our past experience was limited. versus reality, but those distinc- We can reasonably infer that future Fine, A. 1986. ‘The natural onto- tions are made within experience. logical attitude’ in The Shaky Game, generations, with their advanced (ibid: 102 italics added) learning, will see the ways in Chicago: The University of Chicago Press: 112-135. which our current experience is Something important occurs limited. Reality is one of the names Haddock, A. and Macpherson, F. when the world is not the way we 2008. Disjunctivism: Perception, we give to what lies outside those want it to be, but that is a very limits, but that naming occurs with- Action, Knowledge. Oxford: Oxford minimal, even deflated, notion of University Press in experience as a result of experi- the objective—one that does not ence. (ibid: 36) McDowell, J. 1982. ‘Criteria, de- require getting outside of experi- feasibility and knowledge’ Proceedings The significant phrase is ‘Reality is ence. (ibid: 109) of the British Academy 68: 455-79 one of the names we give to what lies Wittgenstein, L. 1953. Philosophi- outside those limits’. Who are ‘we’? In each case, Zachar suggests cal Investigations, Oxford: Blackwell. Zachar may mean realist philosophers that it is misleading to think that we Zachar, P. 2014. A Metaphysics of who mistakenly - or perhaps pragmati- are so trapped. But it is not clear to Psychopathology, Cambridge, Mass.: cally unhelpfully - do not accept the me that he offers enough of a diagno- MIT Press metaphilosophical framework of the sis of why – despite the temptation to book. If so, assuming the truth or prag- think that we are – we are not. For *** matic success of the framework, then example, the injunction that it ‘is im- that attempt to name what belongs be- portant to be cautious about taking Doing without A Metaphysics of yond the limits of experience must fail. the veil of ideas metaphor too literal- Psychopathology If, on the other hand, ‘we’ refers to or- ly’ suggests that it should be afforded dinary non-philosophers, there must be some insight into human predica- Rachel Cooper some success in this naming. But what, ment, that there is some sort of veil Lancaster University, UK according to radical empiricism, can be blocking our view of reality. Moving [email protected] named beyond the limits of experience? the concern from a Cartesian solitary And if nothing can, how can the incho- veil of ideas to a communal set of I think that A Metaphysics of Psy- ate thought that experience can mislead beliefs does not seem enough of a chopathology stands out as one of the – which is surely what gives this pas- transformation to yield philosophical best books in the philosophy of psychi- its drama - be captured even given ease. Given that Zachar’s key idea is atry written in recent years. Zachar’s a diachronic perspective? Later he says to draw distinctions only within the book asks what it means to say that a “One can accept this historically in- experiential realm, the worry that the disorder is real. I agree with Zachar formed without imagining a experiential realm somehow entraps that this is an important question, and I getting beyond the veil of ideas. (ibid: human subjects blocking knowledge- think he gives us a good answer. But 103) This picks up a repeated theme able access to reality surely needs I’ll suggest that the pragmatist meta- that it is tempting to think that we are more philosophical diagnosis? physical framework within which he ‘trapped’ within a veil of ideas or expe- Furthermore, it is not that there develops his answer is unnecessary rience or beliefs. are not diagnostic accounts to ease and unhelpful. In short, I think that A The chapter ends with an account- this intellectual cramp. The most fa- Metaphysics of Psychopathology ing of the extent to which everyone has miliar is disjunctivism (Haddock and would be even better without the meta- to rely on communities and recognized Macpherson, 2008, McDowell, physics. I’ll split my commentary into experts to know what to accept and how 1982). It holds that there is more to three sections: (1) what Zachar’s got this psychological fact raises the worry experience than what is common right, (2) problems with the pragmatist that we are all trapped, not so much between veridical and illusory framework, (3) how to do without met- behind a veil of ideas but within the experience. When all goes well, what aphysics in the philosophy of psychia- boundaries of our chosen community’s one experiences is the layout of the try. beliefs. world. So when all goes well, there is no veil, simply direct access to objec-

10 Volume 24, Number 1 2017

(1) What Zachar’s got right tions that act to group together indi- to obscure notions of ‘corresponding to viduals whose problems are more or facts’, and imply that truth might trans- Debates as to whether this or that less similar. Useful abstractions cend that which is humanly knowable. condition is a real disorder are com- (which can be called “real disorders” He worries that ‘Correspondence theo- mon, and commonly acrimonious as an honorific) group patients into ries sometimes give the impression that (consider, for example, arguments over classes that do a good job in enabling in knowing what is really there we get the ‘reality’ of ADHD, Multiple Per- reliable inferences to made, for exam- beyond evidence and experience. Co- sonality Disorder, mild depression). ple, about prognosis, or likely treat- herence, in contrast, works from within Zachar shows us how close attention to ment response. In Zachar’s view, experience.” (p.37) what is meant by terms such a “real”, more than one classificatory scheme Zachar is right to say that talk of “objective”, and “true” can help to might do a reasonably good job in ‘corresponding to facts’ is often ob- resolve, or more often dissolve, such enabling inferences, and the best clas- scure, but coherentist accounts of truth debates. sification will likely depend on our are also highly problematic. In particu- Zachar’s pragmatism is in part a interests. Using such an approach, lar, adopting a coherentist account forc- methodology, and, at this level, I find Zachar suggests that at least some es one to adopt a non-bivalent . his suggestions helpful. In considering grief-induced depressive episodes can For the correspondence theorist all an abstract concept, whether it be fairly be considered disorders, in that claims are either true or false (although “real” or “depression”, Zachar urges us it is reasonable to group them with often we will not know which). For the to think as concretely as possible. For other cases of depressive disorder and coherentist, this is not the case. Zachar example, we can elucidate concepts in see them as requiring treatment. Simi- tells us, for example, that ‘…what Co- terms of their contrasts. Abstract talk larly he holds that some cases of NPD nan Doyle ate and drank on the day he of “reality” is easier to keep a handle can be considered disorders on the finished The Adventure of the Empty on if we specify what contrast we have basis that they are similar to clearer House was a fact once, although it is in mind; “real” versus “fake”, or “real” cases of psychopathology such as likely no longer even a potential fact versus “artificial”, for example. psychopathy or low-functioning bor- because it is not publicly ascertaina- When it comes to asking whether derline personality disorder. Zachar’s ble’ (p.109). According to Zachar, some condition is a ‘real disorder’, approach seeks to take the heat out of claims about Doyle’s breakfast are nei- Zachar urges us to abandon the notion debates about the reality of disorder – ther true nor false. How problematic is that there is any underlying real dis- rather than arguing that this or that it to adopt a non-bivalent logic? I’m not tinction that can be drawn between condition really is or really isn’t a sure. At the moment logicians continue disorders and normality. Jerome Wake- disorder, we can switch to consider- to argue: Timothy Williamson has ar- field’s popular approach, according to ing whether the evidence suggests gued that rejecting bivalence is which disorders are harmful dysfunc- that putative cases can usefully be ‘absurd’ (1992), others contest this (for tions, is criticised as resting on essen- classified together, and whether treat- example, Pelletier & Stainton 2003, tialist assumptions and as being of lit- ment by mental health professionals Richard 2000). What is clear, however, tle use – our knowledge of the evolu- might prove helpful. is that debates as to the correct account tionary past is so limited, thinks Zach- So far, this is all good stuff. But of truth are difficult and ongoing. If at ar, that to claim that a condition was some of Zachar’s claims are more all possible, it would be best if philoso- either adaptive or maladaptive in evo- problematic. phers of psychiatry could avoid com- lutionary history is no more than hand- mitting themselves to particular ac- waving. More positively, Zachar sug- (2) Problems with Zachar’s counts of truth. gests we should accept that the domain pragmatist framework of psychiatry is an “imperfect commu- (3) Doing without metaphysics nity”. The psychiatric domain is cen- Zachar develops his account of tred on those disorders which were what it means to say a disorder is Zachar has developed his work first treated by psychiatrists – extreme ‘real’ within a pragmatist framework. within a pragmatist framework. I’ve psychotic states that were seen in asy- While I find the methodological sug- developed my own work within a real- lum patients. Over time, as psychiatry gestions that Zachar takes from prag- ist framework (eg in Classifying Mad- has expanded, more and more condi- matism useful, I balk at some of ness (2005)). While Zachar and I disa- tions have come to be considered psy- Zachar’s metaphysical commitments. gree at the metaphysical level (eg about chiatric disorders on pragmatic In particular, Zachar commits truth, the nature of reality etc), we grounds; other conditions can fairly be himself to a coherentist account of agree on many of our claims about the considered disorders if they seem more truth. The coherentist holds that for a nature and classification of mental dis- or less similar to more central cases of claim to be true means that it coheres orders. For example, we are agreed that disorder, and if treatment by mental with the rest of what we (the scien- health practitioners seems worthwhile. tific community) believe. More main- There will be a multiplicity of Chapters of the book flesh out stream alternatives to are pretty good classifications of psy- Zachar’s approach by exploring the either correspondence theories (‘snow chopathology DSM-5 debates about grief and narcis- is white’ is true iff it corresponds to sistic personality disorder. Zachar sees the facts) or deflationist accounts Which classification is best psychopathology as a messy domain in (‘snow is white’ is true iff snow is depends on context and interests which symptoms cluster in complex white). Zachar adopts a coherence ways. Disorder concepts are abstrac- account of truth because he worries that correspondence accounts appeal Good classifications support inductions 11 Volume 24, Number 1 2017

 Some conditions are likely will be rejected by those with a soft In his A Metaphysics of Psycho- vague, some dimensional. This spot for realism. In contrast, Zachar’s pathology our colleague Peter Zachar second argument, that insufficient is needn’t be a problem has offered us a rich discussion of core known about evolutionary history, concepts in psychopathology. He struc- makes fewer controversial metaphys-  Cases of a good category tures his argument within a framework ical assumptions and, for this reason, of William James’ radical empiricism, need to be similar in some way – is to be preferred. and he convincingly draws from this similarities need not be biological, To conclude, I suggest that framework a perspective on psychiatric but might be psychological (or at whenever possible it would be best disorders that is non-essentialist and some other ’level’) for philosophers of psychiatry to do nominalist. In this commentary I will without a metaphysics. Metaphysical begin with questions that challenge his That we can agree on so much, claims, for example about truth, or treatment of abstract concepts in the opens up the possibility that our meta- the basic structure of reality, are ob- early part of the book, and I will con- physical commitments are doing little scure, difficult, and contested, and clude with an argument that, whatever real work in supporting our claims philosophers of psychiatry should the merit of my challenges, they do not about the nature and classification of avoid getting into such disputes affect his illuminating treatment of mental disorders. As a matter of biog- whenever they can. Zachar’s claims psychopathology and psychiatric diag- raphy Zachar’s clearly developed his in A Metaphysics of Psychopathology nostic categories in the later part of the ideas through thinking through his about philosophical methodology, book. pragmatist commitments, and I’ve de- and about the nature and classifica- In his defense of radical empiri- veloped my arguments through think- tion of mental disorders, should be cism Zachar seems at times to be ing through versions of realism. But I accepted – but the metaphysics fighting a Platonic strawman. In his think we could both have made the should be rejected. central discussion of truth, the real, the claims about the nature and classifica- objective, and the within-experience, I tion of mental disorders that we want to References find it easy to agree with his argument make without depending on metaphysi- Cooper, R. 2005. Classifying but find myself puzzled about who ex- cal claims. For example, both Zachar Madness. Dordrecht: Springer. actly is the adversary. In the beginning and I agree that there will likely be a Dupré, J. 1981. Natural kinds and of the book he invokes creationism, multiplicity of acceptable classifica- biological taxa. The Philosophical whose ‘truth’ is based on a literalist tions of psychopathology. Zachar uses Review 90:66-90. belief in the bible account. He contrasts ideas from Nelson Goodman to support Pelletier, F.J. and Stainton, R.J. that notion of truth with the empiricist this claim; I draw on John Dupré’s 2003. On 'the denial of bivalence is notion that “the truth of any claim is an (1981) Promiscuous Realism. But in- absurd'. Australasian Journal of Phi- inference supported by evidence” (p, stead we could have argued without the losophy 81:369-382. 7). In this case it’s easy to spot the metaphysics. In this case an apt com- Richard, M. 2000. On an argu- strawman and agree with the empiricist parison with other sciences would have ment of Williamson's. Analysis 60: position. Only bible-thumping funda- sufficed, and we could have directly 213-217. mentalist argue for creationism. Zachar supported our claims via a considera- Williamson, T. and Simons, P. does provide more challenging exam- tion of classifications used in the bio- 1992. Vagueness and ignorance. Pro- ples such as Galileo’s discovery of dis- logical sciences (where a multiplicity ceedings of the Aristotelian Society, tant galaxies and carbon-14 dating’s of classifications are well-established). Supplementary Volumes 66:145-162. ability to estimate the age of organic Similarly, it would be possible to argue materials – examples in which develop- that dimensional kinds can ground in- Acknowledgements ing evidence forced scientific opinion ductions via pointing out that metal to follow the evidence. (For other dra- alloys are dimensional kinds that suc- A version of this commentary matic examples, see Elizabeth Kol- cessfully ground inductions. was presented at the conference bert’s The Sixth Extinction, in which Other key arguments of Zachar’s “Does philosophy of psychiatry need two major scientific discoveries – that could also have been made without metaphysics?” held at Lancaster, UK there are extinct animals and that there drawing on heavyweight metaphysical in June 2016. This conference was have been mass extinctions – faced claims. Zachar has two arguments made possible by generous funding massive resistance from the scientific against Wakefield’s account according from Lancaster University and the community until accumulating evi- to which disorders and non-disorders British Society for the Philosophy of dence broke the resistance.) are distinguished because disorders are Science. I am grateful for the helpful Readily and easily agreeing with harmful dysfunctions. First, Zachar comments of those present. the argument of , considers Wakefield an essentialist, and let’s now see where Zachar goes with he thinks that essentialism is committed *** this. First, he finds it more consistent to objectionable realist claims that, as a with a coherence than a correspondence pragmatist, he rejects. Second, Zachar Words and Concepts in theory of truth. Coherence is based on also notes that so little is known about Psychopathology accumulating evidence; correspond- evolutionary history that Wakefield’s ence points to a transcendent notion of account is of little use in practice. James Phillips truth. I think the difference is not as Zachar’s first argument depends on Yale University strong as it may seem to be. We agree many metaphysical assumptions and [email protected] that the earth is round rather than flat

12 Volume 24, Number 1 2017 because overwhelming evidence points The problem, now, is that Zachar has Some Thoughts on to that conclusion. There is a coherence actually already provided us with a A Metaphysics of Psychopathology of opinion based on massive evidence. definition of truth: that “the truth of But how different is that from saying any claim is an inference supported Jeffrey Bedrick, M.A., M.D. that evidence shows that the statement, by evidence” (p, 7). Presumably, Drexel University College of Medicine the earth is round, corresponds to the then, the imperfect community of true [email protected] fact, or reality, that the earth is round. statements, which purportedly don’t Or to simplify, a coherence of evidence necessarily have any feature in com- I found Zachar’s work, A Meta- demonstrates correspondence to fact – mon, do apparently have a feature in physics of Psychopathology, refresh- or reality. And nothing in this, includ- common: they will all be statements ingly undogmatic, a quality that is in ing the word ‘reality’, takes us out of supported by evidence. short supply these days both in and out experience. To say ‘it is true that the In this discussion, I may be mak- of the academiy. I found myself fre- world is round’ is not invoking an other ing much of nothing. I am as nomi- quently agreeing as I read the work. -worldly, Platonic notion of truth. It’s nalist and anti-essentialist as Zachar But as listing my areas of agreement is shorthand for saying that evidence is, but I am arguing that concepts unlikely to further discussion, let me leads us the conclusion that the world is such as truth and reality may be Pla- go to a few questions I had about the round. In this regard, Zachar quotes Ian tonic, essentialist, and transcendent to positions outlined, some of which, I Hacking as follows: experience, or they may not. I am think, point to how hard it actually is arguing in a Wittgensteinian manner to hew to the positions Zachar defends. For example, someone blieves that the meaning of words is in their My first comment is more of an the universe began with what for use, and that in their use these con- aside, however. Zachar makes central brevity we call a big bang. A host cepts cover a range from the essen- use of the notion of the imperfect com- of reasons now support this belief. tialist to the nominalist. munity, a concept that seems to share But after you have listed all the These little cavils all involve the many features, if I may put it that way, reasons, you should not add, as if first part of the book. When Zachar with Wittgentein’s notion of family it were an additional reason for moves on to psychiatry, the empiri- resemblances. This latter notion is believing in the big bang, ‘and it cist, nominalist, imperfect- briefly considered in Neil Pickering’s is true that the universe began community argument comes fully The Metaphor of Mental Illness, which with a big bang’. (1999, p. 81) alive. He begins with the concept of a has interesting similarities and differ- mental disorder and recognizes that ences to Zachar’s work. Thus Picker- Here I again glimpse the Platonic there is no one correct definition that ing concludes “Our concepts are not strawman. If I say, ‘all the evidence covers all that we identify mental fixed: we develop new ideas (such as points to the big bang, so I guess the disorder. Here the concept of an im- Pasyeur’s notion of vaccination) and big bang is true’, I may be invoking a perfect community fits perfectly. Re- new categorizations for things (such as transcendent standard, or I may just be garding the diagnostic categories the body or patterns of behavior). And underlying the first phrase. It all hangs themselves, we know that, despite the ideas that our new conceptualiza- on how language is being used. For DSM-5’s objections to the contrary in tions may lead to can be formulated in each of the out-of-experience terms the Introduction to the manual (and testable ways” (Pickering, p. 177). I such as ‘reality’, the term may refer to the same is true of the earlier DSMs), will leave it up to those whose are a transcendent Reality, or may refer to many clinicians and researchers treat more expert than I am in these areas of the in-experience reality that is there in DSM diagnoses in an essentialist philosophy to decide whether Zachar’s front of us. manner. Clinicians labor exhaustively link of pragmatism and nominalism In the discussion of truth, Zachar and unnecessarily to find just the works, and is a more fruitful way of backs himself into a bit of a corner. right category, and researchers carry approaching the broader questions. I Citing Nelson Goodman, he writes: out endless studies to prove the core will say that pragmatism has often biologic etiology of this or that psy- been thought to be friendly to a scien- In comparison to Socrates, chiatric condition. How refreshing it tific approach to the world, and I won- nominalists advocate for an anti- is to see diagnostic categories as im- der if Zachar sees this, as I think he Platonic attitude about abstract perfect communities – psychiatric does, as a way of preserving psycho- philosophical concepts such as conditions grouped together for rea- pathology, psychology, and psychiatry, virtuous, true, good, and free. Con- sons of similar presentation, treat- as scientific disciplines. sider the concept of true. From a ment, and research. The implication My second point, and one that nominalist perspective, the class of of the anti-essentialist, imperfect- touches on the difficulties of avoiding true statements forms what Nelson community approach is that we can essentialism, relates to the role that the Goodman (1966) called an imper- give up on the need to find a core idea of a decline in functioning plays fect community – meaning that presentation, a core etiology, and a in Zachar’s argument. Zachar states there is no property or set of prop- core treatment. This is vastly messier that declines in functioning “are devel- erties that all members share. To than the essentialist approach, but it is opmentally unexpected and not a part be a nominalist is to harbor skepti- certainly closer to the ‘reality’ of psy- of the typical course of life” (p.122). cism about claims such as ‘there is chopathology. The idea is a central one to Zachar as a single essence of truth that can be “its objectivity does not depend on inferred from a set of many true *** speculation about natural func- statements. (pp. 41-42) tions” (p.122). He goes on to say that declines are objective in two different

13 Volume 24, Number 1 2017 senses “They are often intersubjective- conceptualizing personality and its pear after a decline in functioning that ly confirmable, and denying that they disorders in the DSM-IV and DSM-5. look like the autism spectrum disor- have occurred, although common, is a In the course of this discussion he ders. A bigger issue, it seems to me, is distortion’ and “Second, this minimalist notes “Because personality disorders that behavioral abnormalities that occur notion is also normative….The affected are not declines in functioning, think- after a brain injury due to accident, or person experiences declines that should ers such as Kurt Schneider as sequeIae of infection, are often not have happened. They are unwanted (1923/1950) and thought of as being neurological disor- declines. They represent something (1923/1963) did not believe they ders rather than psychiatric ones. Per- being broken. They are capacity fail- should be conceptualized as diseas- haps it is enough that they share the ures” p. 122. All italics are in the orig- es” (p.188.) Is decline in functioning space of symptoms so they can be con- inal.) He goes on to argue “a decline in sneaking back in as an essential ele- sidered disorders, and we can then di- functioning is not an essence. It is nei- ment of a disorder or disease? Poten- vide the disorders as we will. ther necessary for the attribution of tially in line with this, Zachar goes on I would think that it might have psychiatric disorder (e.g., many cases to discuss personality disorders, and been preferable to say that they were of mental retardation evidence no de- hypertension, as perhaps being worth disorders in their own right, but per- cline) nor sufficient (e.g., a gradual loss clinical attention because they are haps it is hard to find a non-essentialist of strength after age thirty is not a dis- associated with the risk for other reason for saying so. As it is, they ap- order)” (p.123). (real?) disorders such as mood disor- pear to be parasitic on the paradigmatic The advantages of focusing on de- ders, anxiety disorders, or cardiac cases of illness or disorder, which all clines in functioning for Zachar are disease and stroke (p.189). involve a decline in functioning. This clear, but his attempt to keep it from He goes on to offer “two reasons looks as if it comes very close to mak- being thought of as an essential feature why personality disorders in general ing a decline in functioning essential – of psychiatric disorders seems less are in the domain” of psychiatric even if we are at times willing to accept clearly successful to me. He correctly symptoms (p.198). The first reason is something that is “a close simulacra” of notes that mental retardation often just that “they tend to be symptoms a disorder with a decline in function- shows no evidence of a decline in func- that are commonly seen in psychiatric ing. It might have been better, I think, tioning. But on what basis then can we populations” (p. 198), which may if Zachar had been willing to say that consider it a psychiatric disorder? seem a little circular or tautological. any condition that is clinically relevant Zachar addresses this issue in Chap- He goes on to say “second, in some in the sense of being something that ter 11 “Is Narcissistic Personality Dis- cases, the symptoms that characterize required treatment, qualified as being a order Real? “ He begins the discussion personality disorders represent ob- disorder. Hypertension, for example, with a subsection entitled “Two Prob- servable declines in functioning” (p. which as noted above he discusses as a lems with Personality Disorders” with 199)! He adds “Because the symp- clinically relevant condition, might that section beginning with a further toms space of personality disorders thus be considered a disorder in its own sub-heading “There is no Decline in and the personality deficits associated right, even if a very heterogeneous one, Functioning” (p. 181). He initially with these injuries overlap, the per- rather than as simply a condition that is states “a personality disorder is not an sonality disorders are close simulacra of concern because of its link to other intrusive decline in functioning. The of unambiguous personality patholo- pathologies – even if that link is why it category of personality disorder is, gy” (p.199). I would say that most is of concern. For what it is worth, therefore, one of those additions to he clinicians, and a sizeable body of essential hypertension is assigned an domain of psychiatric disorders that researchers, would say that personali- ICD-10 diagnostic code. Certainly per- make the domain an imperfect commu- ty disorders are clear examples of sonality disorders, and other disorders nity” (.181) – and that keep decline in personality pathology not just close that are not marked by a decline in functioning from seeming to be an es- simulacra of it. function, seem to be marked by symp- sential part of the conception of a psy- It seems that Zachar ends up say- tom networks of the sorts Zachar talks chiatric disorder. The problem is that ing that because the personality disor- about in his discussions of depression Zachar does not say at this point what it ders share some similarities with the and anxiety disorders, as long as one is that he thinks allows us to justifiably “real” disorders we can include them does not insist on symptoms represent- include the personality disorders in the in the imperfect community of psy- ing a decline in functioning. Impair- imperfect community of psychiatric chiatric disorders. I imagine a similar ments in functioning seem clearly evi- disorders. argument could be made for intellec- dent in personality disorders, autism This problem is made more acute tual disabilities – because they look spectrum disorders, and in the intellec- when Zachar heads his next sub-section like the sort of cognitive disabilities tual disabilities, and I am not sure that “’Personality Disorder” May be a Label people can have after suffering cer- we need to reference evolution or some for Unlikable” (p.181). He states that tain injuries, whether from accident essential character of human function- there is at least a suggestion “that the or illness, we can consider them to ing to be able to say this. Zachar is attribution of a personality disorder to a fall within the imperfect community willing to countenance norms, as we patient is a way of saying ‘Your per- of disorders. I think it might be a have seen, in the establishment of psy- sonality—Yuck!’” (p.182). little harder to make this argument for chiatric diagnoses, and I would think it Zachar then goes through a long autism spectrum disorders, though I would be possible in his model to point excursion on the history of personality don’t think it works that well for the to better or worse ways of functioning disorders, focusing on narcissistic per- personality disorders, though I imag- in the world without by that commit- sonality disorder, and the complex ma- ine if we try hard enough we might ting oneself to a hypothetical view of neuvering that went on around ways of find neurological disorders that ap-

14 Volume 24, Number 1 2017 the course of human evolution and its to loss, then it strains credulity to quite an endeavor, even for just a six- teleological goals. regard the consequent depression as a week period of time. The goal is also disorder. Nevertheless, if depression elusive because it is to draw a line in References as a mental disorder implies that a the sand that demarcates those states or person is experiencing particular conditions that warrant interventions Pickering, N. 2006. The Metaphor symptoms over a certain time frame, from those states or conditions that are of Mental Illness. Oxford: Oxford then it seems as though how a person difficult but, nevertheless, part of a University Press. comes to be in that state is an irrele- healthy mental life. For the sake of sim- Zachar, P. 2014. A Metaphysics of vant detail that might prevent some- plicity in this commentary, I will as- Psychopathology. Cambridge: The one from receiving appropriate inter- sume that what hinges upon the diagno- MIT Press. vention. Second, and more specifical- sis of a mental disorder is primarily ly, the debate was informed by the access to treatment. The idea that re- *** classification parameters for depres- forming the access to (and delivery of) sive disorders already in place. Prior Appreciating Perspectives: mental health care might weaken the to the publication of the fifth edition significance of this debate is an inter- Another Step Towards Treating of the Diagnostic and Statistical Disordered Concepts esting one, but it will not be addressed Manual of Mental Disorders, or the here. DSM-V, in 2013, bereavement was Robyn R. Gaier, Ph.D. Zachar helps his audience to un- regarded as a special circumstance in derstand the complexity involved in Viterbo University which the symptoms of a depressive [email protected] thinking about mental disorders as his- disorder may appear in otherwise torical concepts and normative con- mentally healthy individuals. A de- Peter Zachar’s book, A Metaphys- cepts, as well as through the lens of the bate about whether the bereavement ongoing tug-of-war between natural ics of Psychopathology, is both fasci- exclusion should be kept surfaced nating and insightfu. Zachar is able to kinds and practical kinds. I suggest, during the composition of the DSM- however, that there is a further layer of draw upon resources in both philoso- V. Zachar explains that “… in the phy and psychiatry to help his audi- complexity that needs to be unpacked DSM a depressive episode must be in order to get a fuller picture of mental ence to gain clarity about particular present for two weeks before it can be concepts, such as what constitutes a disorders and, ultimately, to gain in- called a disorder, and that the be- sight into the bereavement exclusion mental disorder. In focusing upon par- reavement exclusion did not apply ticular questions in the philosophy of debate. Because psychiatrists diagnose once the symptoms persist for more mental disorders, it is understandable psychiatry, Zachar’s work calls atten- than two months ….” (2014, p. 162). tion to the many assumptions inherent that their perspective became privileged Hence, Zachar further explains that in the related issue about what should in what are thought to be facts about “the dispute was about what to name psychopathology. Gaining clarity, (and what should not) count as a mental cases in a narrow six-week period – disorder. But these are separate, albeit then, about the concept of say, after two weeks but before two “mental disorder,” is not merely an interdependent, tasks. To diagnose an months” (2014, p. 162). individual with a mental disorder seems exercise in semantics. It is also an Prima facie how to classify a ontological exercise. Zachar’s book to require a different set of skills and potential six-week period in knowledge than what is required to goes a step further than simply ac- someone’s life seems to be a minor knowledging that much is at stake in determine whether a state or condition dispute. But this dispute is an in- is a disorder in the first place. the ways that particular concepts are stance of a more complex problem of employed in service to psychopatholo- To be sure, it might be helpful here discerning both the power and the to think about the characterization of a gy, however. Zachar aims to take steps authority of the psychiatric communi- – indeed, strides – towards resolving a mental disorder as a harmful dysfunc- ty, as well as discerning the appropri- tion, and to return to thinking about a few of the perplexing ontological ate limitations to their power and questions that are at the heart of psy- stress-triggered depressive episode, authority. As Zachar notes, “the emo- such as a depressive episode following chopathology. In this commentary, I tional core of the bereavement dis- will focus upon one such question that the loss of a loved one. Being able to pute concerned both the proper role recognize depression as depression Zachar addresses in his book, namely, of science in psychiatry and the au- the question ‘can grief really be a dis- seems to be a clear advantage to taking thority that society gives psychiatry up a third-person perspective. A psy- order?’ After presenting the merits of to declare what is disordered” (2014, Zachar’s analysis of the question it- chiatrist who is experienced, well- p. 162). Indeed, the bereavement ex- educated, and trained to recognize par- self, I suggest that there is a further clusion dispute is about reaching a dimension – namely, that of perspec- ticular actions and behaviors in a client consensus regarding the scope of that are at root in that person’s inability tive-taking – which is missing in the what is considered to be disordered. conversation and which, I believe, to complete everyday tasks has a type Throughout his book, Zachar careful- of knowledge that often escapes even might help to explain a problem that ly articulates the idea that mental Zachar’s analysis leaves unresolved. the client. Furthermore, a psychiatrist is disorders have multi-dimensions in- able to give suggestions and to validate The question ‘can grief really be sofar as they are informed by science, a disorder?’ needs a context. First of the emotions that a client may be expe- social constructions, politics, and riencing precisely because a psychia- all, a debate had ensued about how to history, in addition to being rooted in classify grief as a stress-triggered de- trist is taking-up a third-person perspec- value systems. Defining and designat- tive regarding each client’s situation pression. If grief is a healthy reaction ing what is to count as a disorder is and experiences. I do not aim to sug- 15 Volume 24, Number 1 2017 gest that a third-person perspective way in which attention to the debate affords people like Mary access to provides the foundation for an objec- about the bereavement exclusion is treatment. Zachar concludes that the tive point-of-view, because even third- informative. For instance, even if DSM-V’s middle-of-the-road stance in person perspectives are value-laden Mary may be helped medically, her regard to the bereavement exclusion is and, hence, inevitably biased. But, nev- existential crisis needs to be ad- “an imperfect solution to the debate, ertheless, a third-person perspective has dressed as an existential crisis. She but that does not make it a bad clear advantages in both the diagnosis needs the time and ability to address one” (2014, p. 179). While I agree that of, and in the treatment of, mental dis- her shattered worldview and to pro- it is an imperfect solution, I believe that orders as harmful dysfunctions. cess the meaning of her loss as it re- it could be regarded as an attempt – But shifting to the determination lates to her self-concept. Perhaps albeit unwittingly – to include first- about whether such a dysfunction exists Mary can do this on her own, or per- personal perspectives into the criteria in a person’s life is a different matter. haps she will need help in doing so. for determining mental disorders. In Just as a third-person perspective can In any case, it is interesting that a that respect, I would make the stronger yield insight into the mental life of a concern about over- assertion that the middle-of-the-road person that even escapes that person’s was not a factor in the bereavement stance was a good solution in a culture knowledge, so too can a first-person exclusion debate. Including first- that equates treatment with medicaliza- perspective aid in the determination of person perspectives in the determina- tion, and which privileges a third- what ought to qualify as a disorder. The tion of mental disorders also does not person perspective in determining what bereavement exclusion debate provides take away from the authority of psy- counts as a mental disorder. In sum, an illustration as to why this is so. For chiatrists in both diagnosing and Zachar’s book makes a genuine and instance, from a third-person perspec- treating mental disorders. If part of much-needed contribution in the do- tive, I can discover that a particular the aim of psychotherapy is for the mains of both philosophy and psychia- person, Mary, has recently lost a loved client to gain self-knowledge, then try, but I hope that it also starts further one; and I can observe Mary’s actions psychiatry needs to play an essential discussions about these important is- and behaviors. But the sources of infor- role in educating the public about sues. mation about Mary that are available to mental health. There’s no hope for me from a third-person perspective the possibility of Mary seeking out Reference inform my understanding of Mary’s help if either she does not know that mental life only indirectly, at best. One help is available, or she does not Zachar, P. (2014). A Metaphysics of potentially crucial piece of information know that her mental health depends Psychopathology. Cambridge, MA: that is valuable in this situation is upon her worldview and self-concept. MIT Press. Mary’s worldview and how she is pro- Ultimately, the DSM-V took a cessing her loss. Suppose that Mary’s middle-of-the-road stance on the be- loss triggers either an existential crisis, reavement exclusion. As Zachar ex- Zachar on Classification and the or a faith crisis, for Mary such that she plains, “the bereavement exclusion Concept of Mental Disorder begins to have serious thoughts about has been eliminated, but the manual killing herself. Ironically, I would not notes that depressive symptoms may Neil Pickering know about Mary’s internal, psycho- be considered appropriate responses University of Otago, NZ logical (and possibly spiritual) crisis to bereavement, financial ruin, a seri- [email protected] unless she discloses that information to ous medical illness, and so on” (2014, me – that is, unless she makes the deci- p. 179). Interestingly, the consensus Peter Zachar is a consistently inter- sion to talk with me about what she is reached in the DSM-V concluded that esting, original and admirably clear experiencing. Therefore, allowing a depression as a mental illness is writer in a complex subject area. I first-person perspective to have a voice thought to be “different from these offer a few comments on an aspect of in determinations about what counts as other experiences because the dys- his recent book A Metaphysics of Psy- a disorder, or what qualifies as a harm- phoria and negative preoccupations chopathology. The aspect I’m interest- ful dysfunction, is neither being whim- are pervasive and not anchored to the ed in is his account of mental disorder sical nor irresponsible. Indeed, if men- loss itself” (2014, p. 179). Certainly and its boundary with normality. tal disorders are to be informative of a understanding whether a person’s In his chapter on classification and person’s mental life, then such disor- depressive symptoms are anchored in the concept of mental disorder, Zachar ders ought to be determined, in part, by a particular experience does not ex- brings together two fields of thought. a first-person account, which can give a clude the possibility that they can One is psychological research into fuller picture of one’s mental life. I become unanchored, and so the elimi- human concepts, and the other is psy- propose that a combination of a first- nation of the bereavement exclusion chological and neuro-psychological person perspective and a third-person makes sense in that respect. Mary’s research into causal networks. The perspective is more informative in de- circumstances might be illustrative of question I want to ask in this commen- termining what ought to qualify as a such a possibility, for instance. If it is tary is whether bringing these two mental disorder than a third-person supposed that what hinges upon a fields together helps answer the ques- perspective alone. labeling a depressive episode as a tion ‘what is mental disorder’. Zachar Including first-personal accounts disorder is access to treatment, and if suggests that it does. And I shall ar- in the determination of mental disor- it is further supposed that depressive gue in agreement with him that an ders might be especially worrisome to disorders are focused upon the symp- interesting connection between the two those who are concerned about over- toms ‘without an anchor,’ then elimi- can be demonstrated which does help medicalization. But here is yet another nating the bereavement exclusion

16 Volume 24, Number 1 2017 answer this question. This connection, 2. Markedly diminished p.125) to be found in both the psycho- briefly, is that the features which arise interest or pleasure in all, or ses and in the neuroses. in some causal networks are features almost all, activities most of the It is this shared but diverse sympto- upon which a judgement about mem- day, nearly every day (as indi- matology that supports the idea that all bership in the class of disorders may be cated by either subjective ac- these conditions are mental disorders, based. I start with some exegesis of count or observation). rather than a ‘property or group of Zachar’s chapter, before proceeding to 3. Significant weight loss properties that all of them share in com- my elucidation of the connection be- when not dieting or weight gain mon as a class’ (as the summary of the tween the two fields of thought. (e.g., a change of more than 5% chapter has it). The result is a commu- Zachar starts the chapter by plotting of body weight in a month), or nity, but an imperfect community, pre- a course between the claim that mental decrease or increase 4. in appe- sumably in the sense that it is not made disorders are what psychiatrists treat (a tite nearly every day. up of exactly similar members. This is a form of nominalism, he suggests), and 5. Insomnia or hypersomnia non-essentialist approach, but it is not a the claim that there is an essence which nearly every day. nominalistic approach, because a pat- all mental disorders have which makes 6. Psychomotor agitation or tern of likenesses determines member- them mental disorders. Zachar opts for retardation nearly every day ship in the class, and not purely the fact something which lies between these, (observable by others, not mere- that these are the conditions psychia- which he calls the ‘imperfect communi- ly subjective feelings of rest- trists treat. Zachar suggests that his ty’ account of mental disorder. As he lessness or being slowed 7. approach is not dissimilar to the exem- says in the summary of his chapter: down). plar approach developed by psycholo- 8. Fatigue or loss of energy gists (Medin, 1989) or Lilienfeld and According to the imperfect commu- nearly every day.9. feelings of Marino’s Roschian account (Lilienfeld nity model, the various symptom worthlessness or excessive or and Marino, 1995). One of the things configurations that are classified by inappropriate guilt (which may such approaches allow for is that some psychiatrists resemble each other in be delusional) nearly every day disorders – the psychoses – will seem to a number of ways, but there is no (not merely self-reproach or be better or central examples of the property or group of properties that guilt about being sick). class, compared with others – the neu- all of them share in common as a 10. Diminished ability to roses – which will seem to be more class. think or concentrate, or indeci- marginal examples of the class. The siveness, nearly every day latter will be in what Zachar calls the This bears some unpacking. By symp- (either by subjective account or penumbra of the class. tom configurations, Zachar means the as observed by others). Having set out Zachar’s approach to sorts of patterns of behaviours and ex- 11. Recurrent thoughts of mental disorder as a class, I now turn to periences which characterise specific death (not just fear of dying), Zachar’s second focus in the chapter on diagnoses. An example of these clus- recurrent suicidal ideation with- classification and the concept of mental ters of symptoms are those to be found out a specific plan, or a suicide disorder, viz. the focus on causal net- in the diagnostic categories of the Di- attempt or a specific plan for works. What makes his approach new agnostic and Statistical Manual of the committing suicide. for this writer is Zachar’s link from the American Psychiatric Association When Zachar says that configura- imperfect community of mental disor- (DSM). Generally speaking, these are tions such as this resemble each other ders to the idea of causal networks in lists of symptoms a person might have, in a number of ways, he illustrates his specific disorders. and if the person has them in sufficient claim with a historical account. In Causal networks have been pro- number and degree, a diagnosis is pos- this historical account, he explains posed as an alternative to the latent sible. For example, here are the char- how the modern domain of psychiatry variable view of psychological condi- acteristics by which Major Depressive came about as various developments tions (see Borsboom et al. 2003; Bors- Disorder (MDD) may be diagnosed in the field took place through the boom and Cramer, 2013; Schmittmann using the DSM 5. (I’ve removed some C19th. For example, at the end of the et al. 2013). As Zachar puts it: references to variations relating to chil- C19th ‘the functional disorders of dren and adolescents and some other neurology—especially hysteria and … [I]n psychiatry and psychology material not relevant here.) neurasthenia—were combined with latent variables are interpreted real- A. Five (or more) of the following the functional psychoses and related istically—meaning the cluster of symptoms have been present dur- disorders of the alienists to form a symptoms that constitute depression ing the same 2-week period and new discipline called psychia- are considered to be correlated be- represent a change from previous try’ (p.124). This combination took cause they are manifestations of a functioning; at least one of the place despite the fact that many of the shared underlying psychopathologi- symptoms is either (1) depressed conditions that neurologists treated cal process. (p.131) mood or (2) loss of interest or ‘lacked one or both of the highly pleasure. weighted features of , The causal network approach contrasts 1. Depressed mood most of namely, decline in functioning and with this. Zachar illustrates with the the day, nearly every day, as reality distortion’ (125). The unifica- example of MDD (I’ve added the DSM indicated by either subjective tion of the field was based rather up- 5 diagnostic symptoms in square brack- report (e.g., feels sad, empty, on various other overlapping features, ets): hopeless) or observation made for example excessive anxiety and by others (e.g., appears tearful). fear (to cite one of Zachar’s list on

17 Volume 24, Number 1 2017

… for causal networks the symp- distinction between disorder and nor- ranted. It is also important not to toms hold together because they are mality. limit assessment to a single slice of in direct, possibly causal, relation- time because (e) a past history of ships with each other. For example, The network model also provides symptoms and a family history of rather than both sleep problems some resources for making the symptoms alter the base rates and [A4] and fatigue [A6] being mani- practically important distinction make the disorder attribution more festations of a single underlying between disorders and normality plausible. (p.136) cause [latent variable] called in order to avoid the problem of “depression,” sleep problems … defining psychiatric disorder arbi- Now, I must admit that I find a de- likely directly influence level of trarily as “what psychiatrists de- gree of ambiguity in this passage. For fatigue. In addition, such factors as cide to treat.” With respect to the there are three judgements it seems to depressed mood [A1] and loss of penumbra of the imperfect [p.136] me which various of these criteria interest [A2] are central symptoms, community, the contrast between might be used to make: (1) The judge- meaning they enter into a high num- disordered and normal is a con- ment that a person has MDD (2) the ber of mutual relationships with ceptual elaboration. Rather than judgement that a casual network is pre- other symptoms in the network. As making this distinction using a sent and (3) the judgement that MDD is a result of these connections, when single essentialist criterion such as a disorder. None of these is equivalent central symptoms are activated, it is objective dysfunction, it is more to either of the others. A brief look at more likely that other symptoms commonly made using a polythet- some of the criteria brings out the am- will follow. A pathological state of ic criterion set (i.e. a collection of biguity. depression would represent the conceptual elaborations). … As Consider the first sentence of crite- emergence of feedback loops be- more of these criteria are met, the rion (a). It seems to me that the extent tween symptoms that become self- more it makes sense to start think- to which a person has entered a psychi- sustaining. (p.131) ing of a symptom cluster as disor- atric symptom network is a basis for dered. (pp.135-136) making the judgement that the person What we call depression, then, is not has that particular diagnosis, in this something other than the network of What Zachar appears to be offering in case MDD. That is, that part of criteri- symptoms, underlying it, and causally this passage are resources for decid- on (a) helps with judgement (1). But, related to each part of it independently ing whether a particular causal net- this is by no means a way to decide (a latent variable), but rather depression work is a disorder, that is, a way of whether the person’s behaviour reveals is the network – or at least the network distinguishing causal networks which a causal network (judgement 2) or activated to a sufficiently self- are disorders from causal networks whether MDD is a disorder or a normal sustaining degree. which are not. pattern of behaviour (judgement 3). So, Zachar presents two ideas in the I believe Zachar is calling atten- Likewise, there seems to be an ambiva- chapter: one is the imperfect commu- tion to something important here, as I lence in what we can infer from the fact nity approach to defining mental disor- shall shortly try to explain. However, that symptom networks such as MDD der, the other is the network approach to see what it is requires a little bit are ‘locked in’ (as in criterion (b)). If, to explaining specific disorders, e.g. more digging. Zachar spells out how by locked in, Zachar means locked in conditions such as MDD. There are the polythetic criterion set for mental to a person’s behaviour pattern, that is some striking similarities between the disorder, would help us make the to say characteristic of the person’s two. For example, psychologists often judgement that MDD is a member of behaviour over time, then that seems to treat latent variables as a common the class of mental disorders. be a reason for thinking someone has cause, and it is this common cause MDD (judgement 1) or possibly that which explains why a number of psy- Considerations that are relevant in whatever that person has is a causal chological features have the tendency making the disorder attribution network (judgement 2). But, not a rea- to cluster. This reminds one of the include (a) the extent to which the son for thinking that MDD is a disorder essentialist idea that all mental disor- person has entered a psychiatric (judgement 3). ders have something in common which symptom network. The most im- Now consider criterion (b). Though unifies the category. This is not to sug- portant criterion is the presence of Zachar seems to think that the intransi- gest that this shared thing in the essen- a decline in functioning, although ence and inflexibility of networks tialist account of class membership is it is not a necessary criterion. makes them more disorder like necessarily a shared cause, of course. Also, (b) those symptom networks (judgement 3), I think the judgement But essentialists have sometimes sug- that are locked in rather than tran- they actually help with is whether the gested that all mental disorders have a sient and flexible are also more person’s behaviour represents a causal shared causal characteristic. For exam- disorder-like. Additionally, (c) network (judgement 2). Being inflexi- ple, according to Wakefield, what char- more severe symptoms and more ble and intransient are features of caus- acterises all disorders is a causal rela- complex symptom networks sup- al networks in general. Based on Zach- tion between a dysfunction and an un- port the disorder attribution. For ar’s criteria, there are several reasons wanted harm to which it gives rise distressing psychological symp- for thinking that MDD is a causal net- (Wakefield, 1992). toms such as anhedonia, (d) if work. The temporal existence criteria Zachar clearly thinks there are links there are compensatory factors is encompassed, because the diagnosis between the idea of an imperfect com- that allow the person to continue requires A1, A2 and three or more of munity and that of a causal network. to function (and flourish) then a the other symptoms of MDD to have The link I’m interested in relates to the disorder attribution is more war- been present all at the same time for at 18 least 2 weeks. The inflexibility criteria Volume 24, Number 1 2017 would presumably be met by the re- We can now see a clear link be- clear separation between MDD as a quirement that A1 and A2 be present in tween the judgements as to whether causal network and other aspects of all diagnoses, and in so far as inflexi- MDD is a member of the class of life. It appears that it is going to be bility also means that there wouldn’t be disorders, and as to whether MDD difficult to have it both ways. dramatic change over time, the 2 week represents a causal network. Second, this also poses a threat to requirement would contribute to this as Are there any threats to this ac- the claim that causal networks create well. count? I shall offer one, but attempt a features which underpin the judgement But this still leaves untouched the defence to it. rd that conditions such as MDD are disor- 3 judgement as to whether MDD is a The explication of Zachar’s ideas ders. For causal chains seem to cross disorder. Among the criteria that Zach- being considered relies on causal net- very easily from patterns of behaviour ar mentions, the ones that seem to works giving rise to features which in such as those found in MDD which are count in making this judgement are the turn are to be found to some degree in considered pathological, to patterns of presence of a decline in function other causal networks, so that these behaviour such as those which consti- (which is part of criterion a) and the networks can reasonably be said to be tute social isolation and loneliness, presence of factors which compensate members of the same class. For ex- which are not considered pathological. for decline in function (criterion d). On ample, decline in functioning may This problem is exacerbated by the these grounds, there are some reasons arise in the causal networks of MDD desire to find causal links between the for thinking that MDD is a disorder. and of Bipolar disorder and of schizo- pathological and the non-pathological. The decline in functioning requirement phrenia. But chains of causal connec- Is there an answer to this problem? appears to be met by symptom A2, at tions and feedback loops can be There may be. In a study published in least if we hold that taking an interest greatly extended, in such a way that 2010, Cacioppo et al. considered the in things is a characteristic human they seem to cross boundaries be- question what causal relationship could function or evidence of functioning. tween the disordered and the normal. be found between loneliness and de- Decline in functioning may also be For example, one might predict the pression. Simplifying their analysis contributed to by fatigue [A6] and cog- following causal chain would exist: without distorting it too much, I hope, nitive problems such as loss of concen- sleeplessness leads to fatigue, which their study suggested two things of tration [A8]. leads to a person being less likely to particular interest here. First, it sug- We can leave aside judgement (1) at accept invitations to go out with gested that statistically, symptoms of this point, as it is the relation between friends, which may lead to a gradual depression and symptoms of loneliness judgements (2) and (3) which is of pri- cooling of the person’s friendships were separable contributing to the mary interest to me. and contraction of their circle of ‘growing evidence for the conceptual, But what of the link between these friends, which may in turn lead to stochastic, and functional distinctions two – between the criteria which sup- fewer invitations to go out, which between loneliness and depressive port the judgement that MDD is a caus- may contribute to the person often symptoms’ (p.458). And second, that al network, and the judgement that being alone (social isolation), which while loneliness predicts changes in MDD is a disorder? I would suggest may then contribute to subjective depressive symptoms, the opposite is that the link lies in the causal network feelings of loneliness. not true: depression did not predict relations between the disorder-like fea- This extension of causal chains changes in the symptoms (if we may so tures within the diagnosis of MDD. seems to bring with it two problems. -call them) of loneliness. These disorder-like features are not First, it brings into the causal network How do these findings – and others merely co-present but are co-present of MDD a state of mind (loneliness) that may support them – contribute to because of causal connections and which is not one of the symptoms of the question whether the approach to feedback loops among the symptoms of depression (not at least one of those the class of disorder based on Zachar’s MDD. For example, it might be argued in the DSM 5 account). Where in the work is valid? It supports the claim that the presence of the criteria for be- causal chain from fatigue to loneli- that – as a matter of fact – it is possible ing a disorder within the MDD diagno- ness does one draw the line and say to distinguish the state of loneliness sis over time is explicable by the sort of that at this point we have moved out- from the state of depression. If both causal and feedback connections sleep- side the causal network? There are considered to be causal networks lessness, fatigue and loss of concentra- doesn’t seem to be any obvious place (though this is not a claim that Caciop- tion have with one another and with at which one can draw this line in the po et al. make) then there is empirical decline in functioning. Anyone who causal chain just illustrated. What evidence to suggest that they are sepa- has spent a sleepless night knows that makes this problem potentially even rable from one another, i.e. two distinct the resultant fatigue is not simply for more serious is that we may want to causal networks. This then supports the next day, but may last several days; look into systematic causal and feed- the claim that Zachar’s approach sup- and that fatigue lessens your ability to back links between MDD and such ports a distinction between a state that concentrate – and may be made worse experiences as loneliness, objective is disordered, and a state that is not. by attempts to concentrate. This causal states such as social isolation and Given that the symptoms of loneliness loop is likely to ensure temporal dura- socio-economic deprivation, and so are distinct from those of depression, tion of these features of the network on. In short, the causal network ap- we can assume that the major features and of a causally connected decline in proach faces us with a conundrum. of loneliness are not likely to be the functioning – that is to say the presence On the one hand one wants to make same as those of depression and hence of a feature which makes MDD part of causal connections between MDD loneliness is not likely to have suffi- the class of disorders.. and other features of a person’s life, cient numbers of the features which but on the other one wants to retain a make any state or condition a member 19 Volume 24, Number 1 2017 of the imperfect community of mental Medin, D.L. 1989. Concepts and grief entails being sad and ruminating disorders. conceptual structure. American Psy- about a loss, but it is also interspersed One further remark is in order here. chologist 44, no.12:1469-1481. with positive memories. With abnor- It will be noted that the approach de- Schmittmann, V.D., Cramer, mal grief, patients can get “locked rived from Zachar’s work in this com- A.O.J., Waldorp, L.J., Epskamp, S., into” sad ruminations such that they mentary relies upon empirical findings. Kievit, R.A., and Borsboom, D. 2013. interfere with life functions. In con- There is no a priori presupposition Deconstructing the construct: a net- trast, folk views require that the be- about what features might characterise work perspective on psychological reaved must work through their suffer- the imperfect community of mental phenomena. New Ideas in Psychology ing, in a very literal sense. They align disorders. They have to be discovered 31:43-53. grief with physical pain (Radden by consideration of the stable, inflexi- Wakefield, J.C. 1992. Disorder as 2008) and worry that science would ble features of various causal networks harmful dysfunction: a conceptual pathologize all grief as depression. such as that of MDD, and other diag- critique of DSM-III-R’s definition of The challenge before psychiatrists nostic categories. In short, this sup- mental disorder. Psychological Re- and “the folk” is to agree upon criteria ports a move towards an empirical ap- view 99, no.2:232-247. that move grief from being considered proach to defining disorder, which is to Zachar, P. 2014. A Metaphysics of normal to being considered abnormal. be found among some recent commen- Psychopathology, Cambridge, US: The difficulty is that there are no clear tators (Lemoine, 2013). These com- MIT Press. criteria. The folk in general do not mentators say that the question of what find psychiatrists’ reassurances that a mental disorder is, and where it is to *** they can diagnose the disorders from be divided from non-disordered states, how the grief symptoms unfold over is a scientific question. The approach When Grief Becomes a Disorder: time comforting. At the same time, described here involves abandoning Pain, Addiction, and the Brain both sides agree that the grief symp- conceptual analysis of mental disorder toms, and whether they demark a dis- in favour of awaiting the results of em- Valerie Grey Hardcastle order, depend heavily upon individual University of Cincinnati circumstances, so detecting some sort pirical scientific exploration of specific [email protected] of underlying essential cause for disor- mental disorder diagnoses. dered grief seems a fool’s errand. In his chapter, “Can Grief Real- I aim to help with this errand. References ly Be a Disorder?” (2014), Peter What we now know about the underly- Zachar argues that dysfunctional ing brain activity in normal grief and American Psychiatric Association. grief is both real and exists as a clus- pathological grief can help us in deter- 2013. DSM 5. American Psychiatric ter of entrenched symptoms for clin- mining which cases fall under which Association. ical depression. I believe that we can heading, without having to rely on Borsboom, D., Mellenbergh, G.J., do better than this: in this commen- unstable and variable patterns of and van Heerden, J. 2003. The theoreti- tary, I agree that dysfunctional grief symptoms. Let us start by looking con- cal status of latent variables. Psycho- is real, but suggest that it has an un- trasting the neurobiology of unprob- logical Review 110, no.2:203-219. derlying biological signature that lematic grief with that of “complicated Borsboom, D., and Cramer, A.O.J. should trump a disjunctive set as its grief.” Normal grief activates the ante- 2013. Network analysis: an integrative definitive marker. rior cingulate, the insula, and the peri- approach to the structure of psycho- Zachar focuses his discussion acquiductal gray areas – all regions pathology. Annual Review of Clinical by examining the recent debate over associated with acute pain processing Psychology 9:91-121. whether bereavement should be ex- (Baliki et al. 2010). Cacioppo, J.T., Hawkley, L.C., and cluded as a disorder in the DSM-5 It appears that the folk were not Thisted, R.A. 2010. Perceived social (2013). In some ways, this was a wrong in analogizing one to the other. isolation makes me sad: 5-year cross- silly debate, as it really focused on a Perhaps, if we could understand the lagged analyses of loneliness and de- six-week period between the average neurobiology of pain, then we could pressive symptomatology in the Chica- time course for normal grief and the use that to explore the neurobiology of go Health, Aging, and Social Relations two months of on-going symptoms normal grieving. Study of these two Study. Psychology and Aging 25, required to diagnose a depressive phenomena, and how they go awry, no.2:453-463. disorder definitively. But the silly could mutually inform one another. Lemoine, M. 2013. Defining dis- debate was standing in for a deeper “Complicated grief” refers to grief ease beyond conceptual analysis: an conversation about who gets to de- that continues unabated at least six analysis of conceptual analysis in phi- fine mental states as disorders: sci- months beyond the time of the loss. In losophy of medicine. Theoretical Med- entific psychiatry or the “folk”? some cases, grief does not subside as it icine and Bioethics 34:309-325 DOI Psychiatry holds that while should. As Zachar explains, the symp- 10.1007/s11017-013-9261-5 emotional pain is a normal facet of toms can become entrenched and the Lilienfeld, S.O., and Marino, L. human experience, sometimes emo- grieving then becomes a disorder. Its 1995. Mental disorder as a Roschian tional pain can devolve into a mood principle symptom is a yearning for concept: A critique of Wakefield's disorder. That is, grief per se is not the missing loved one so intense that it "harmful dysfunction" analysis. Jour- a disorder, but when grief meets the crowds out other wants and needs. nal of Abnormal Psychology 104, criteria for clinical depression, then Complicated grief also persists long no.3:pp.411-420. it has moved from something normal beyond its expected trajectory, which to something pathological. Normal

20 Volume 24, Number 1 2017 is exactly how chronic pain behaves as “relief” phase felt after the cessation Many contemporary theories of addic- well. of an acute pain. Normal subjects’ tion identify impulse control difficul- From a biological point of view, brain activity signals quite reliably ties as well as compulsive behaviors. complicated grief activates the nucleus that a reward is coming as a pain Patients with impulse control disorders accumbens (NAc) – part of our reward ends, but chronic pain patients’ brain feel an increasing sense of tension or system —in addition to (some of) the show activity that reflects a lack of arousal before committing an impulsive pain areas mentioned above (O’Connor predicted reward. Chronic pain pa- act, and then pleasure, gratification, or et al. 2008). This too is what happens tients are, in effect, disappointed that a sense of relief at the time of doing the in cases of chronic pain. (In contrast, their acute pain is ending. Of course, act itself. These types of disorders are the activity of the NAc is depressed in they would still have their chronic generally associated with positive rein- cases of normal grief, just as it is in pain when an acute pain stimulus forcement mechanisms (American Psy- cases of acute pain.) Activation of ends. Indeed, quite often an acute chiatric Association 2013). In contrast, NAc appears to be correlated with the pain covers over the chronic pain. patients with compulsive disorders feel sense of yearning for the lost love, Under those circumstances, it makes anxiety and stress before engaging in which O’Connor (2008) compares to sense that they experience no relief some compulsive behavior, and then a the craving one finds in addiction when a pain ends. sudden release from the stress as they (more on this below). This change in brain connectivity perform the compulsive behavior. Let us explore the parallel between is a functional rewriting not specific These disorders are associated with grief and complicated grief with acute to pain processing, for we see similar negative reinforcement mechanisms. pain and chronic pain more thoroughly. effects for monetary rewards in Impulsivity often dominates early One might reasonably think that a chronic pain patients – their brains in addiction, and impulsivity combined chronic pain is just an acute pain that show no real response to reward or with compulsivity dominates later in does not go away. But this is not the loss (Apkarian 2012). In other words, the disease. As addicts move from im- case. Acute pains and chronic pains chronic pain puts stress on our protec- pulsivity to compulsivity, the driving are quite distinct kinds of bodily tive and adaptive motivational sys- force motivating their addictive behav- events, with different impacts on the tems such that our motivational sys- iors shifts from pleasure and positive body and on one’s psychology. Chron- tem fundamentally changes how it reinforcement over to anxiety, stress, ic pain is represented in different areas operates. And this change in func- and negative reinforcement (Koob and in the brain from acute pain, largely tionality is so large that it distin- Le Moal 2001, Edwards and Koob because the brain rewires itself with guishes between normal subjects and 2010). We see a similar pattern in chronic pain. For example, the way the chronic pain patients with an accura- complicated grief: the yearning that NAc is connected to the rest of the cy of more than 90% (Baliki et al. accompanies the loss is not one of brain differs in chronic pain patients. 2012). The evidence surrounding pleasant memories, but of sadness. We In normal subjects, the NAc and the chronic pain processing indicates that also see a similar pattern in the shift insula are highly interconnected, and it is intimately tied to our reward cir- from acute to chronic pain: the patient the insula indicates the appearance and cuitry. Chronic pain thus appears to shifts from being motivated to seek a magnitude of acute pain (Apkarian be a disorder of our motivational/ pleasurable relief to being unable to 2012). But in chronic pain patients, the affective system. experience such relief at all. NAc shifts its functional connectivity Disorder is the operative word, The transition from normal con- to the medial prefrontal cortex (mPFC). for there are additional symptoms sumption to genuine drug or alcohol And, the greater the chronic pain, the associated with chronic pain, beyond dependence involves includes the NAc stronger the correlation between activi- the pain itself. Chronic pain patients and prefrontal cortex (Gilpin and Koob ty in NAc and mPFC. In other words, also experience neuroendocrine 2008, Modesto-Lowe and Fritz 2005, in normal subjects, when the NAc is dysregulation, fatigue, dysphoria, Gianoulakis 2009, Egli et al. 2012). As active, the insula is as well, but in diminished physical performance, and discussed above, similar areas are in- chronic pain patients, when the NAc is impaired cognition and executive volved in comparing normal grief with activated, mPFC responds (Baliki et al. function (Chapman and Gavrin complicated grief and in the transition 2010). In short: chronic pain shifts 1999). One hypothesis is that the near from acute pain processing to a chronic what would be a normal pain reaction continuous activation of the limbic pain syndrome. It does indeed appear to a more emotional one. areas shifts reward valuation, and that grieving, pain, and pleasurable Perhaps counterintuitively, when these shifts in turn modulate learning consumption (and their related disor- chronic pain patients also experience an and memory (Apkarian 2012). In ders) all share the same underlying acute pain, their insula responds just as other words, being in chronic pain neural circuitry. All are very complex normal subjects’ do under similar con- fundamentally changes how one reactions that stem from our reward ditions (Bakili et al. 2006). That is, thinks, learns, remembers, and feels. circuitry. Our reward system gives us people with chronic pain can experi- Perhaps the same is true in cases of both pleasures and pains. But with ence two distinct types of pain – chron- complicated grief. unremitting grieving, chronic pain pro- ic and acute – and these differences are Interestingly, the same changes cessing, or extended episodes of intoxi- reflected in differences in their patterns that we see in NAc and insula activa- cation, our brain circuitry and function- of brain activity. Nevertheless, as a tion across complicated grief and ality change – and change in very simi- result of the rewiring, NAc activity chronic pain also occur in cases of lar ways – such that we can become differs between healthy subjects and addiction. Could it be that they are lost in our disappointment chronic pain patients for instances of all of a piece, and that they are all I side with Zachar in believing that acute pain, especially during the disorders of our reward system? science should define disorders. With 21 good science, we should be able to Volume 24, Number 1 2017 identify underlying structural bi- nous opioids and addiction to alcohol and psychology, and his wide-ranging omarkers for psychiatric disorders. and other drugs of abuse. Current erudition is brought to bear to great While it is true that mood disorders like Topics in Medicinal Chemistry 9: 999 effect in the present volume. Although clinical depression can manifest them- –1015. his subject is psychopathology, his selves in a myriad of ways, depending Koob, G.F., and Le Moal, M. book is perhaps more accurately char- upon the individual circumstances of (2001) Drug addiction, dysregulation acterized as a primer on the philosophi- the patient, we should also expect that of reward, and allostasis. Neuropsy- cal constructs that are most useful – I each disorder has a definitive set of chopharmacology 24: 97–129. would argue necessary – to understand, neural underpinnings. We should use Modesto-Lowe, V., and Fritz, practice, and teach psychiatry and clini- these structures to diagnose and define E.M. (2005) The opioidergic-alcohol cal psychology with a level of sophisti- mental disorders. If we could do so in link: Implications for treatment. CNS cation commensurate with their com- the case of grief, then perhaps scientific Drugs 19: 693–707. plexities and importance. This mono- psychiatry and the folk would be able O'Connor, M.F., Wellisch, D.K., graph is, however, anything but a dry to agree on how to distinguish normal Stanton, A.L., Eisenberger, N.I., recitation of conceptual esoterica. grieving from something pathological. Irwin, M.R., and Lieberman, M.D. Zachar’s expertise in clinical psycho- And then they could just debate wheth- (2008) Craving love? Enduring grief pathology allows him to use multiple er either is something one needs to activates brain's reward center. Neu- personality disorder, bereavement and work through. roimage 42: 969-72 depression, narcissism, and hysteria, Radden, J. (2008) A confusion among other psychiatric constructs, to References of pains: The sensory and affective illustrate his philosophical lessons and components of pain, suffering and insights. And although facility in psy- American Psychiatric Associatio hurt. In L. Charland and P. Zachar chology and philosophy would be suf- (2013) Diagnostic and Statistical Man- (Eds). Fact and Value in Emotion. ficient for two successful academic ual for Mental Disorders, Fifth Edition Amsterdam: John Benjamins Press. careers, Zachar’s knowledge of the (DSM-5). Zachar, P. 2014. A Metaphysics history of science, evolutionary biolo- Apkarian, A.V. (2012) Chronic of Psychopathology. Cambridge, gy, astronomy, and physics expand pain and addiction pathways. Society MA: The MIT Press. both the explanatory and entertainment of Neuroscience Annual Meeting, New value of his work. (Any book on psy- Orleans. Essential Reading chopathology that includes the sen- Baliki, M.N., Chialvo, D.R., Geha, tence, “For example, photons first ap- P.Y., Levy, R.M., Harden, R.N., Par- peared after the Higgs field broke elec- rish, T.B., and Apkarian, A.V. (2006) G. Scott Waterman, M.D. troweak symmetry, but they have exist- Chronic pain and the emotional brain: University of Vermont [email protected] ed for most of the history of the uni- Specific brain activity associated with verse” (p. 149) deserves a wide reader- spontaneous fluctuations of intensity of ship!) chronic back pain. Journal of Neurosci- Despite periodic and generally use- ence 26: 12165–12173. The suicide three years ago of ful digressions, Zachar’s mission is Baliki, M.N., Geha, P.Y., Fields, comedic genius Robin Williams in- clear: “Our purpose is to examine psy- H.L., and Apkarian, A.V. (2010) Pre- evitably prompted another round of chiatry and psychology’s use of meta- dicting value of pain and analgesia: what have become the well-rehearsed physical concepts such as real, true, Nucleus accumbens response to nox- pronouncements of the psychiatric and objective; to refrain from assuming ious stimuli changes in the presence of establishment. Depression, the public that the meaning of these concepts is chronic pain. Neuron 66: 149–160. is instructed, is “a real disease” self-evident; and to not forbid the use Baliki, M.N., Petre, B., Torbey, S., whose diagnosis can be established of such concepts as the traditional em- Herrmann, K.M., Huang, L., Schnitzer, reliably, whose causes are increasing- piricists tried to do” (p. 210). That sen- T.J., Fields, H.L., and Apkarian, A.V. ly understood, and whose treatment tence gives the impression that he (2012) Corticostriatal functional con- is usually successful. If only its suf- steers a middle course between the nectivity predicts transition to chronic ferers would bring themselves to the scientific realists’ belief in a knowable, pain. Nature Neuroscience 15: 1117- attention of clinicians (never mind mind-independent reality and the em- 1119. that in Williams’s case clinical atten- piricists’ allergy to such metaphysical Chapman, C.R., and Gavrin, J. tion was hardly in short supply), a elaborations. While he is respectful of (1999) Suffering: The contributions of great deal of suffering and death the range of schools of philosophical persistent pain. The Lancet 353: 2233- could be avoided. Unpacking the thought, he leaves no doubt about his 2237. many presumptions and misrepresen- own. Drawing heavily on the American Edwards, S., and Koob, G.F. tations entailed in this recurring mes- pragmatist tradition of William James (2010) Neurobiology of dysregulated sage would require several books. In and , Zachar motivational systems in drug addiction. A Metaphysics of Psychopathology, explains and illustrates compellingly Future Neurology 5: 393–401. Peter Zachar begins, appropriately, at with examples his scientifically in- Egli, M., Koob, G.F., and Ed- the beginning: what does the word spired pragmatism, two major compo- wards, S. (2012) Alcohol dependence ‘real’ in “real disease” mean? nents of which are radical empiricism as a chronic pain disorder. Neurosci- Zachar has, over the past decade and instrumental nominalism. ence and Biobehavioral Reviews 36: or so, become one of the brightest Philosophical categories such as 2179-2192. lights in the philosophy of psychiatry those in the foregoing sentence can be Gianoulakis, C. (2009) Endoge- forbidding to readers unacquainted 22 Volume 24, Number 1 2017 with them, but in Zachar’s hands they lored to specifiable psychopatholo- Let’s Get Metaphysical: The serve to bring metaphysical constructs gies; in which consensus about the Practical Sinificance of A Meta- down to earth. Radical empiricism and status of psychiatric disorders would instrumental nominalism seek to result in destigmatization of patients physics of Psychopathology ground abstractions in experience and and cessation of internecine conflict; insist that they be invoked only if they and in which excitement and justified Douglas Porter, M.D. Algiers Behavioral Health Center serve to illuminate particular distinc- optimism about the field and its ac- New Orlears, LA tions in particular contexts. Thus, the complishments would attract the [email protected] notion of ‘real’ (as in “real disease”) is brightest and most promising students only meaningful when contrasted with to careers in psychiatry. Perhaps less In his work The Metaphysics of constructs such as ‘fictional’, interesting in this context than the Psychopathology Peter Zachar ‘imaginary’, ‘artificial’, or ‘fake’, and question of why that golden age has demonstrates an uncanny ability to is hopelessly obscure in the absence of not arrived is the observation that if bring difficult philosophical concepts such explicit contrasts brought to bear one were to listen to the psychiatric ready to hand. I would like to high- on particular questions. Through that establishment and its allies, s/he light the practical significance of his framework, Zachar astutely diagnoses would conclude that it has. Our high- work for clinical psychiatry and the where conceptualization and classifica- ly elaborated and reified system of science that informs it. So long as tion of psychopathology can go awry. psychiatric diagnosis has indeed re- metaphysical assumptions remain Specifically, he identifies essentialism, sulted in breathtaking profits for the implicit they cannot be made thematic a construct whose enormous im- pharmaceutical industry and a robust and called into question. Zachar’s portance in this context he has played a market for DSM desk references, brand of pragmatism provides con- major role in illustrating in recent diagnostic guides, casebooks, and ceptual tools to challenge essentialist years, as a human propensity that lies study guides. For patients and the assumptions that are virtually a matter behind psychiatry’s current conceptual public, however, our age is considera- of common sense. Zachar notes that muddle. bly less golden. Zachar’s conceptual the essentialist bias leads to two types As Zachar points out, research in tools are not sufficient correctives, of error. I will underscore the signifi- developmental psychology suggests but they are surely necessary for the cance of Zachar’s work by exploring that the impulse to consider taxonomy discipline to advance. His book, the consequences of introducing these as an exercise in “carving nature at its therefore, should be required reading errors into the world of psychiatry. A joints” has deep roots in human cogni- for all students and trainees in psychi- perverse inversion of clinical priori- tion. We seem primed to view catego- atry and clinical psychology and – ties can take place when a clinician ries of psychopathology (among many especially – for their teachers. introduces the first type of error, mis- other domains), at least aspirationally, The majority of corrections to placed literalism, into the clinical as natural kinds, each possessing an Zachar’s text I could suggest would encounter by treating the disorders “essence” that has been or eventually be mere cavils. More substantive, delineated in the DSM as if they were will be revealed through research. De- however, is an observation about his natural kinds. The second type of er- spite the DSM’s explicit disavowal of apparent belief that metaphysical ror that Zachar outlines involves dis- it, an essentialist bias appears to be claims regarding the disease status of missing diagnostic constructs as both instantiated in and perpetuated by psychotic conditions merit less skep- merely fictional if they do not fulfill psychiatry’s categorical diagnostic sys- ticism than such conceptualizations as essentialist expectations. I believe this tem. Any reader who other- applied to “milder” forms of psycho- type of error is having a pernicious wise need only accompany a psychiat- pathology. Although such a stance is impact on the development of scien- ric team on its rounds in which talk of consistent with that of McHugh and tific nosology and only serves to rein- “ruling out” particular diagnostic enti- Slavney and has a certain intuitive force the clinical ethos associated ties, and debates about whether this appeal, Zachar’s pragmatism suggests with misplaced literalism. patient has a “true depression” or that other possibilities. Specifically, we Zachar notes that when the essen- one is “actually bipolar,” are certain to should take seriously the observations tialist bias is applied to psychiatric be heard. Moreover, as Zachar also of some members of the “recovery” disorders these disorders are consid- demonstrates, the most philosophically community that the disease model of ered to be “natural kinds” that have an complete definition of psychiatric dis- psychotic states – contrary to the sal- inherent and invariant underlying order currently available – Wakefield’s utary motives of its proponents – nature that determines their proper- “harmful dysfunction” model – is fun- serves to increase stigma and reduce ties. When the disorders denoted in damentally essentialist and thus prob- hope, while implying (spuriously but the DSM are appropriated with an lematic. nonetheless compellingly to some) essentialist bias errors of misplaced Zachar’s well-informed anecdotes that pharmacotherapies are indicated literalism will ensue. For example, regarding the process of formulating in all cases despite their ineffective- anyone meeting criteria for the diag- the DSM-5 are deeply revealing of a ness for some and adverse effects for nosis of Major Depression would be discipline in crisis. Not long ago many many. After all, as Zachar so articu- regarded as “having” Major Depres- expected the imminent arrival of a lately reminds us, the question of sion in the sense of having the same golden age of psychiatry in which an whether something is “a real disease” underlying abnormality as anyone understanding of the genetic and envi- is only meaningful in the context of else with Major Depression, and this ronmental influences on neural devel- the consequences of its potential an- underlying abnormality would be opment and functioning would result in swers. regarded as the cause of the signs and the advent of effective therapies tai- ***

23 Volume 24, Number 1 2017 symptoms experienced in cases of de- es would always have to present the mechanism” (ibid). The reference to pression. The practical concern to re- same symptoms and the same post- the real here is a nice cue to the meta- lieve suffering certainly discloses the mortem result” (Kraepelin 1899). physical assumptions at play. It is importance of discerning underlying Thus, there was a belief that the diag- important to note that while the scien- causes. But, a metaphysical bias that nostic constructs outlined in the DSM tific integrity of the DSM 5 leader- construes the underlying nature of Ma- represented “diseases” or the type of ship led them to recognize that DSM jor Depression as the “real” story of “natural kinds” that would live up to constructs were not valid; it did not depression tends to discount the signs essentialist expectations. And, there lead them to question the metaphysi- and symptoms of depression, and the was a belief that the diagnostic con- cal assumptions guiding that notion suffering that goes along with it, as structs contained in the DSM were of validity. Instead, it was confidently mere epiphenomena. Misplaced literal- valid only insofar as they represented proclaimed that psychiatric nosology ism would then tend to discourage clin- natural kinds. Importantly, Robins would eventually “carve nature at the ical sensitivity to the many ways of and Guze (1970) developed a means joints” (Regier & Narrow, et al, expressing, interpreting, and explaining of testing the validity of a diagnostic 2009). The take home message being depression. We can see that misplaced construct. They developed a are, indeed, real literalism discourages what Nancy Pot- five external validators for diagnostic diseases and it is just a matter of time ter (2009) has referred to as the constructs: clinical description, labor- before we discover them. This is, of of giving uptake in the clinical encoun- atory studies, differential diagnosis, course, not a matter of scientific evi- ter. Giving uptake involves attending to studies of outcome, and studies of dence but rather of metaphysical the patient’s values and perspective prevalence rates among relatives. A faith. It is not clear that phenomena about the meaning of their experience. valid construct that represented a nat- better understood with, for example, The mission of clinical work is first and ural kind that unfolded in the same the more complex causal narrative foremost to reduce suffering and im- law-like manner because of a shared associated with the causal network pairment. But, bringing the misplaced genetically determined abnormality theory could ever be understood in literalism associated with an essential- would be validated by all five factors; the disease realist terms delineated by ist bias into the clinical encounter runs it would share family prevalence due Robins and Guze. What if a genetic the risk of needlessly increasing suffer- to genetic factors, it would unfold influence on mental disorder were in ing by discouraging recognition of the differently than other disorders be- turn modified by a social or environ- mental health service user’s interpreta- cause of its unique etiology. It could mental factor? Even if these influ- tions of salience. But, the implications be confirmed through laboratory stud- ences could be accounted for epige- of Zachar’s work extend well beyond ies due to its unique physiological netically we could no longer expect the need to apply scientific knowledge imprint, etc. While the neo- the diagnostic construct best validated in an ethical, person-centered manner. Kraepelinians expected the diagnostic by genetic history to also be best vali- An exploration of the second type of constructs contained in the DSM to dated by clinical outcome because error associated with the essentialist represent natural kinds, Robins and clinical outcome is impacted by fac- bias reveals the depth of Zachar’s in- Guze developed a means of scientifi- tors other than the genetic blueprint. sight. It demonstrates that the essential- cally verifying the expectation. And Zachar challenges the assump- ist bias does not solely impact the ap- true to the of science delineat- tions associated with a metaphysical plication of a value-neutral science. ed by Zachar, there was an ultimate faith in natural kinds with his notion Instead, these matters go to the very recognition that empirical evidence of a practical kind. Rather than a heart of the production of scientific resisted these “natural kind” expecta- world of predetermined kinds out knowledge. tions. DSM disorders demonstrated there waiting to be discovered, the Zachar wants to avoid certain inter- heterogeneity with regard to heritabil- world can be carved in a myriad of pretations of science. He specifically ity, course and response to treatment. ways depending upon one’s interests. wants to eschew a reliance on the type The leadership entrusted by the “There is no single best carving of of transcendent experience that defin- American Psychiatric Association nature’s joints that is adequate to all ing objectivity as a “correspondence to with the development of the 5th edi- purposes” (Porter and Zachar, 2012). reality” would entail. But, he does find tion of the DSM conceded that the For example, the nosological concep- value in concepts of fact and objectivi- diagnostic entities contained hereto- tion of mental disorders best suited to ty that remain tied to experiences of fore in the DSM were not “valid” in meet the needs of a research scientist compelling evidence that resist wishes the specific sense of the term devel- would not necessarily be best suited and preferences to the contrary. He oped by Robins and Guze (Regier & to meet the needs of a clinician. Ken- therefore finds rigorous standards of Narrow, et al., 2009). dell and Jablensky recognized that evidence and justification to be em- Kendell and Jablensky (2003) diagnostic constructs that did not blematic of the virtues of scientific underscored the metaphysical meet the needs of a disease realist practice. To some extent the recent “disease realist” assumptions at play could still have practical utility. But, history of the science of psychiatric in the notion of validity developed by their commitment to natural kinds nosology can be seen to demonstrate Robins and Guze. The assumption is was such that they believed that de- just those kinds of virtues. The neo- that a real disease is one in which we termining constructs according to Kraepelinian revolution in psychiatric understand the causal mechanisms pragmatic interests was tantamount to nosology that was ushered in with the behind the signs and symptoms, and determining them arbitrarily, “As a third edition of the DSM was Krae- validity can be considered synony- result, the boundary between normali- pelinian in the sense that it assumed mous with “delineating a specific, ty and disorder has to be decided ar- that “cases arising from the same caus- necessary, and sufficient biological

24 Volume 24, Number 1 2017 bitrarily on pragmatic bunk simplistic linear models of neu- schizophrenia. American Journal of grounds” (Kendell and Jablensky, rocircuitry development and reveal Psychiatry, 126:983-987 2003). But, if we eschew metaphysical the need for more complex dynamic Wakefield, J. (2014) Wittgenstein’s assumptions about “real” diseases, it is models that can account for feedback nightmare: why the RDoC grid needs a possible to turn this type of thinking on loops and the role of sociocultural conceptual dimension. World Psychia- its head and instead recognize that the influences (Kirmayer & Crafa, 2014). try 13 no. 1:38-40. demand that mental disorders be natu- Whether or not such empirical de- ral kinds may be completely impracti- bunking will result in a recognition *** cal. that mental disorders with practical The Research Domain Criteria significance are more complex than (RDoC) project was born partly out of disease realists would expect/demand, Symptomontology frustration with the failure of DSM or simply jettisoning RDoC for the constructs to align with natural kinds. next great that will Melvin Woody “Perhaps most important, these catego- at last discover real mental disorders, Connecticut College ries, based upon presenting signs and will depend on the ability to address [email protected] symptoms, may not capture fundamen- the metaphysical assumptions made tal underlying mechanisms of dysfunc- thematic by Zachar. The Metaphysics of Psychopathology tion” (Insel et al., 2010). RDoC is char- set me thinking about the being of acterized by a distrust of signs and References symptoms, the particular constituents symptoms as superficial and potentially of the imperfect communities upon misleading. The belief that underlying Insel, T., Cuthbert, B., Garvey, which Zachar proposes to base psy- mechanisms are fundamental has led to M., et al. 2010. Research Domain chopathological categories. The meta- a neurocircuitry first approach to re- Criteria (RDoC): Toward a New physical status of the communities search in RDoC. Cuthbert and Insel Classification Framework for Re- must depend upon the ontological (2013) characterize psychiatry as lag- search on Mental Disorders. Ameri- status of these particular constituents. ging behind other branches of medicine can Journal of Psychiatry 167, no. Do symptoms exist only in or for the and envision a future in which psychia- 7:748-751. mind of the diagnostician – or mustn’t try becomes a form of “precision medi- Kendell, R., Jablensky, A. 2003. they somehow also belong to the diag- cine” in which small genetic variations Distinguishing between the validity nosed mind? Standard medical usage would lead to specific targets for treat- and utility of psychiatric diagnoses. describes objective evidence observed ment. But, how well can the neurocir- American Journal of Psychiatry, by the physician as “signs” and re- cuitry first approach tie to the overall 160:4-12. serves “symptom” to refer to subjec- clinical mission of reducing suffering Kirmayer, L., & Crafa, D. 2014 tive evidence observed by the patient, and impairment? While the signs and What kind of science for psychiatry? but Zachar does not draw that distinc- symptoms delineated in the DSM may Frontiers in Human Neuroscienc,.8:1 tion and clearly does not mean to ex- not reflect specific underlying mecha- -12. clude objective observations from his nisms, they are tied to matters of suf- Kraepelin, E., 1899. Psychiatry: A communities of symptoms. He allows fering and impairment that do concern Textbook for Students and Physi- for a variety of ways in which some- patients and the community at large. cians, 6th ed. Repr. Canton, MA; thing can count as a symptom. They Wakefield (2014) points out that the Science History Publications 1990. may, but need not, belong to the DSM therefore contains a form of con- Cited from Murphy, Dominic, “world of pure experience” of Jame- ceptual validity that the neurocircuitry "Philosophy of Psychiatry", The Stan- sian radical empiricism. The rea- first approach of RDoC lacks. Cuthbert ford Encyclopedia of Philosophy sons for this latitude about the nature and Insel (2010) evince a skepticism (Fall 2010 Edition), Edward N. Zal- of symptoms are obvious enough upon about the value of scientific research on ta (ed.), . tions are, after all, subjective experi- the science of nosology. Perhaps ac- Porter, D. & Zachar, P. 2012 Re- ences while the patient’s subjective cordingly, RDoC seems to eschew the covery and the Partitioning of Au- experiences are only available for type of qualitative phenomenological thority in Psychiatry. In Recovery of diagnosis through some form of overt and narrative research methods that People with Mental Illness: Univer- expression observable by the diagnos- could reveal what is fundamental, not sity Press. tician. Thus observed, symptoms are in the sense of an underlying mecha- Potter, N. (2009). Mapping the simply one species of sign in the ge- nism, but fundamental in the sense of Edges and the In-Between: A Critical neric sense of that word. Whether in discovering what is relevant to the con- Analysis of Borderline Personality psychiatry or any other branch of di- cerns of the patients served. The search Disorder. New York: Oxford Uni- agnosis, symptoms are signs of pa- for the holy grail of a mental disorder versity Press. thology. What counts as pathology that unfolds in a law-like manner on the Regier, D., Narrow, W., Kuhl, E., differs from one domain to another – basis of a specific genetic abnormality & Kupfer, D. (2009). The Conceptu- from psychiatry to endocrinology to may be wholly impractical with regard al Development of DSM-V. Ameri- cardiology to economics, say, and to the fundamental concerns of pa- can Journal of Psychiatry, 166:645- what counts as a symptom within any tients. More likely, in view of growing 650. such domain must vary accordingly evidence of neuroplasticity, empirical Robins, E. & Guze, S. (1970). Es- and vary still further from one illness research on neurocircuitry will eventu- tablishment of diagnostic validity in to another. Not all signs point to ally provide enough evidence to de- psychiatric illness: its application to pathology, of course. Traffic signs are

25 Volume 24, Number 1 2017 not symptoms, for example, nor is The diagnostic process is there- an egregiously disordered room and thunder a symptom of lightning. A fore a process of interpretation, an argues that if the disorder merely re- symptom is a specific kind of sign, so exercise in , the art or flects the family culture in which the an ontology of symptoms must identi- process of interpretation, which is occupant was raised, it is only a causal fy their manner of being more exactly. often characterized as a circular pro- manifestation that “expresses nothing Susanne Langer highlighted the dis- cess of reasoning from parts to whole about the owner’s personality.” (56) tinctive character of symptoms in a and back again to parts. To under- But if the occupant has chosen the chapter on “The Logic of Signs and stand a spoken or written sentence, I disorder as a protest against conven- Symbols” in Philosophy in a New Key: have to interpret each word in light of tional feminine stereotypes – or as an its role in the meaning of the whole adolescent rejection of the “fake, de- There is a fine distinction be- sentence, -- which of course depends tested values of his terrible and hypo- tween sign and symptom, in that upon the constituent words. An un- critical bourgeois parents,”(57) the the object signified by a symp- expected final word or phrase may room can be recognized as a symbolic tom is the entire condition of require a drastic revision of my origi- self-expression. which the symptom is a proper nal interpretation of the opening of part; e.g., red spots are a symp- the sentence. To distinguish symbolic expres- tom of measles and “measles” on The “hermeneutic circle” does not sions from manifestations re- the other hand, may be one part often close with understanding a sin- quires that we recognize how the of a total condition which we gle sentence, however, since the former demands an interpreta- associate with another separate meaning of a sentence usually de- tion, itself at the border of the part. Thus, a ring around the pends upon how it functions as part kinds of interpretation that works moon is part of a weather condi- of a larger whole: the paragraph or of art exact. A manifestation tion, but what it signifies is rain stanza or conversation in which it merely requires an explanation. – another proper part – and not occurs – and that, in turn, will usually German theorists draw a distinc- the entire state of “low-pressure” depend upon some wider context -- tion between Verstehen and Erk- weather.(Langer 1953, 57) an entire conversation, novel, legal laren – hence between interpreta- statute or love affair, for example -- tion and explanation. The dis- (Langer later recognized the need to or the course of development of an tinction was to facilitate a divi- distinguish between “sign” as desig- illness. Successful interpretation sion between the so-called hu- nating the genus that includes both often also depends upon understand- man sciences and the natural symbols and signs as distinct from ing the source of the signs in question sciences. But my distinction symbols and therefore substituted – be it an individual speaker or an overrides that, if outwardly the “signals” when referring to either nat- organ of the state or of the human same thing is either manifesta- ural signs such as thunder or artificial body, which will require further en- tion or expression and explained instances such as traffic signs. The larging the hermeneutic circle, which or interpreted depending on danger of confounding the genus with may have to be further enlarged to which it is. ”(58) its specific varieties crops up through- take account of social, historical or out the literature cited here.) ecological circumstances. Where the Danto thus links manifestations to Langer’s account opens the way to circle remains open, the interpreta- signs whose meaning derives from understanding the ontological status of tion must remain tentative. causal relations. as in cases like thun- symptoms and seems quite congenial An illness is not a text, however, der and lightning or smoke and fire. with the role of symptoms in Zachar’s and the pathologist does not seek the Both signs and symbols may serve as imperfect communities. As signs, sort of coherence that we expect in a symptoms, since diagnosis engages symptoms are semiotic . Their sentence or a paragraph, a sonnet or a both explanation and interpretation, being consists in their meaning or sig- statute. On the contrary, diagnosis which therefore poses the problem of nifying. No sign, whether signal, may well depend upon discovering balancing or integrating these two symptom or symbol, can exist in and some incoherence among the symp- forms of signification, a problem ag- of itself. Its significance consists in a toms and seeking a pattern or mean- gravated by the fact that, as Danto reference beyond itself to whatever it ing for that incoherence. Moreover, stresses, the same overt symptom may means or signifies. Nor can that rela- the model of textual interpretation be either an expression or a manifesta- tion between sign and signified exist in does not contend with the fact that tion, “but possibly never both at the itself. A sign can only be significant the symptoms of illness may include same time nor in the same way.”(55) for an interpreter. As Langer puts it, both signs and symbols and that the Psychiatrist and anthropologist “if there is not one thing meant and most significant symbols may not be Arthur Kleinman meets this problem one mind for which it is meant, there is linguistic. Arthur Danto explores head on in “The Meaning of Symp- not a complete meaning.”(55) But non-verbal symbolism in “Symbolic toms and Disorders,” the opening there is more than one thing meant by Expressions and the Self,”(Danto, chapter of The Illness Narratives a symptom, since a symptom refers to 1998) where he focuses attention (Kleinman, 1988), where he describes “the entire condition of which it is a upon the different hermeneutic roles how the interpretation of all symptoms proper part,” or, in Zachar’s terms, the of signs and symbols by drawing a as manifestations of causal relations entire imperfect community of which contrast between self-manifestation transforms illness into disease: it is a member. That imperfect com- and self-expression. He illustrates the munity may include both signs and difference by calling up an image of symbols.

26 Volume 24, Number 1 2017

Illness problems are the principle hand: even the superficial signifi- symptom refers is not an available difficulties that symptoms and cance of symptoms qua symptoms is whole so that here, too, the hermeneu- disability create in our lives…. embedded in the meanings and rela- tic circle cannot be closed and diagnos- Illness complaints are what pa- tionships that organize our day to day tic categories must remain tentative tients and their families bring to world, including how in interaction Furthermore, the meaning of each the practitioner…. The healer – we recreate our selves. This makes symptom is liable to be as dependent whether a neurosurgeon or a fami- of even superficial symptoms a rich upon the symbolic or causal context ly doctor, a chiropractor or the metaphoric system available for whence it arises as a jurist’s interpreta- latest breed of psychotherapist -- many kinds of communication.(16). tion of a statute depends upon prece- interprets the health problem On the other hand, is the semiotics of dent. the particulars of the case at hand within a particular nomenclature diagnosis: “For the practitioner, the and the legislative history of the stat- and taxonomy, a disease nosolo- patient’s complaints (symptoms of ute. But whereas the purpose of legal gy, that creates a new diagnostic illness) must be translated into the interpretation is to issue in a determina- entity, an “it” – the disease. signs of disease…. Diagnosis is a tive verdict, therapy aims to transform Disease is the problem from the thoroughly semiotic activity: an anal- the community of symptoms in ques- practitioner’s perspective. In the ysis of one symbol system followed tion so to eliminate the deficit. narrow terms of the biomedical by its translation into another…(16)”. Finally, the therapeutic purpose of model, this means that disease is As a result, practitioners “not trained psychiatric diagnosis precludes closing reconfigured only as an alteration to be self-reflective interpreters of the hermeneutic circle in any case, be- in biological structure or function- distinctive systems of meaning….are cause the diagnosis is not simply a cog- ing.”(4 - 6 passim) led to believe that symptoms are nitive conclusion, finding the right clues to disease, evidence of a universal to fit the available evidence. Psychiatrists who hope that neuro- “natural” process, a physical entity to The diagnostic category functions as a physiology or genetics will solve the be discovered or uncovered.”(17) hypothesis rather than as a verdict. It problems of diagnostic taxonomy seek At this point, the hermeneutics of enters both symbolically and causally to realize just such a hermeneutic symptoms converges with Zachar’s into the therapeutic process and there- transformation of illness into disease. metaphysics of psychopathology, by may provoke or cancel further Kleinman’s book is primarily con- since the translation of all symptoms symptoms that thereby change the im- cerned with chronic illness rather than into signs entails the essentialist met- perfect community and may require psychopathology. Even so, he com- aphysics of mental illnesses as natural revision of the original diagnosis, much plains that, “In the practitioner’s act kinds that Zachar seeks to replace by as the end of a sentence requires rein- of recasting illness as disease, some- a more Darwinian, evolutionary mod- terpretation of the beginning. For dec- thing essential to the experience of el. What counts as correct or suc- ades, psychiatrists interpreted schizo- chronic illness is lost; it is not legiti- cessful interpretation depends on the phrenia as a deteriorative disease, so mated as a subject for clinical concern, interpreter’s purpose. Reflection on that if a patient recovered, the diagno- nor does it receive an interven- the criteria of reliable interpretation sis must have been mistaken. But stud- tion.” (6) To put the matter in Danto’s originally developed in response to ies by John Strauss and others showed terms, the translation of illness into the challenges of interpreting sacred that that diagnosis was a vicious circle disease ignores self-expression and texts and legal documents. The pur- that had misled therapeutic responses confines the community of symptoms pose of psychiatric diagnosis poses to psychotic patients.(Strauss, 2014) If to signs that manifest causal relations rather different challenges. Zachar’s the outcome of an illness is hopeless, between the sufferer and his or her insistence upon the pragmatic charac- therapy can offer no more than sympto- physical world. Of course, this prom- ter of diagnostic categories places the matic relief. Yet even that “verdict” ises to simplify the tasks of diagnosis link between correct categorization alters the symptomatic “whole” and and taxonomy by eliminating all sym- and therapeutic purpose in the fore- hence the significance of the symp- bolism from the field of symptoms, ground of . That therapeutic toms. The individual’s response to which conveniently forecloses the her- purpose recalls us from general re- various psychotropic medications and meneutic circle. But in so doing, the flections on semiotics and hermeneu- to other therapeutic interventions— diagnostician abstracts from the facts tics to the specific nature of symp- may also prompt changes in the inter- that the sufferer belongs to a family toms as signs of pathology, which pretation of particular symptoms – and and community who apprehend and entails that the aim of interpretation is thence of the whole. Therapy thereby report the experience of illness in to identify or classify failures – dys- absorbs diagnosis into a dialectical or terms supplied by their culture and the functions or unexpected diminish- dialogical process consonant with the ways in which the illness itself may ment of functions. As noted above, evolutionary model of explanation with play a symbolic role in the relations of that means that one cannot count on which Darwin displaced the appeal to a patient to himself and to his social coherence of meanings as a reliable natural essences and which frames the world. Kleinman analyses several criterion of successful interpretation. beginning and ending of Zachar’s levels of meaning in illness, beginning Moreover, if we accept Zachar’s book. An imperfect semiotic commu- with the meaning of symptoms as account of psychopathological cate- nity of symptoms invites comparison symptoms. His analysis is far too gories as based upon “imperfect com- with the interbreeding populations of lengthy and subtle to summarize here. munities” of symptoms, then the organisms with which Darwin replaced For present purposes, it must suffice to “entire condition” in which the symp- the enduring species of traditional bio- focus on his contrast between two toms participate and to which each logical taxonomy. However, a taxono- models of interpretation. On the one my of pathologies seeks to identify and

27 Volume 24, Number 1 2017 ameliorate dysfunctional patterns or Kleinman, Arthur, 1988, The behavioural responses to patterns of complexes of symptoms rather than Illness Narratives, New York, Basic stimuli with ethological (not a term in successful adaptations, so that therapy Books. use at his time) significance. For exam- might better be compared with artifi- Strauss, John, 2014, ple, if a child is confronted by adults cial selection directed by normative “Reconceptualizing Schizophrenia”, who often make unpredictable and dis- aims rather than with the aimless Schizophrenia Bulletin (2014)40 tressing responses to what he or she course of Darwinian natural selection. (Suppl2):S97-S100.doi: 10.1093/ does, then the development of normal Yet in both cases, the displacement of schbul/sbt156 First published online: human behaviour and attitudes towards timeless essences by temporal process- November 13, 2013 others will be disrupted. The longitudi- es challenges the task of diagnosis, as Zachar, Peter, 2014, A Metaphys- nal series of dynamic interactions, Zachar comments in the conclusion of ics of Psychopathology, Cambridge, moderated by speech, from which a Chapter 10: The MIT Press. human being abstracts a structure of “propositionising” (composing mean- With a diagnostic category, psy- *** ingful utterances and thoughts) about chiatrists freeze a particular the events concerned, produces centres symptom configuration and ab- Cognitive Neuroscience, constituting “reservoirs of energy” and stract it away into a type or kind. Discourse and the Nature of “resisting positions” in neural connect- This allows them to ask how this Psychiatric Disorder edness (1887, 32). These are constitut- kind came to be, to describe it ed in part by “structures of nervous

thoroughly, and to develop ex- energy organised according to word Grant Gillett pectations of what might happen meanings.”(1878, 323) Alexandr Luria, to it in the future. When thinking University of Otago, NZ [email protected] the great neuro-psychologist, agrees: in terms of the abstract type, they “higher mental processes are formed ignore the flow in which it was Peter Zachar’s in depth and com- and take place on the basis of speech initially embedded. Mental activity”(1973, 93-4); speech, we could health professionals are often prehensive analysis of the science and metaphysics of mental disorder is a say, derives the information we intro- perplexed at how a case of de- duce into the control of our behaviour pression can start to look like a welcome stimulus to further discus- sion and clarification of psychiatric from our shared (intersubjective) world case of generalized anxiety disor- where human beings construct and ex- der and still later seem to be nosology and its scientific basis in an era where the RDoC framework is change tricks or strategies and go on to more like a case of obsessive- devise coordinated courses of action in compulsive disorder, but like influential in the philosophy of psy- chiatry and psychiatric research. In the light of reason and truth.(Mercier & clouds in lava lamps, that is what Sperber, 2011) symptom networks are some- fact the debate echoes the work of John Hughlings-Jackson (JHJ) at the Thus human mental function, in times like. (Zachar, 2014 175-76) th JHJ’s words, becomes “the least auto- end of the 19 and beginning of the 20th century in championing the rele- matic”, and most integrated complexifi- Indeed, the flow of symptoms is cation of sensori-motor activity (1887, essential to the therapeutic purpopse. vance of neurological science to a scientific theory of mental disorder. 41) supremely orchestrated by the Insofar as therapy succeeds, it must frontal lobes and their pre-motor asso- dispel or alter undesirable symp- As such, an exploration of the relation between the neural and the mental is ciation areas (Franz & Gillett, 2011) toms, thereby changing the available and hugely influenced by the ways in population of symptoms, which timely. which we talk to each other and make means that the very purpose and sense of what we are doing. process of therapy conflicts with Evolutionary neurology and mental science. JHJ notes that those of achieving a stable essential- “propositionizing” (or language-related ist taxonomy. Attention to the ontol- John Hughlings-Jackson’s evolu- activity), and ongoing problem-solving ogy of symptoms thus places the and goal related plans and strategies metaphysics of psychopathology in a tionary neurology began with the stance that states of mind are properly (mediated by Dorso-Lateral Pre-Frontal fresh perspective that prompts a re- areas) cannot happily be localized and consideration of the enterprise of analysable by examining higher order patterns of neural integration in the we have now learnt to display the inte- psychiatric nosology by bringing the grative and distributed activity charac- problem of meaning into the fore- light of their evolutionary signifi- cance (1887). He portrays mental teristic of that wider cognitive plat- ground of attention. form especially in the (human) cogni- processes as higher and more inclu- sive levels of representation (and re- tive neuroscience of action (Roskies, References 2010). The same widespread integra- representation) to construct a complex repertoire of responses to our human tion and coordination in human cogni- Danto, Arthur, 1998, Beyond the tive neuroscience emerges in several Brillo Box, Berkeley, University of environment. The coordinated activity of a whole organism is thereby related human cognitive functions that elabo- California Press (55-71). rate simpler animal capacities. Langer, Susanne, 1943?, Philoso- to abilities to over-ride reflex (mechanistic) sensori-motor connec- Human memory is a catch all term phy in a New Key, Cambridge, Har- for a whole series of processes that vard University Press.(53-78) tions by using learning and integrative neural inter-connectedness to create include learning, procedural skill devel- opment, semantic memory, autobio-

28 Volume 24, Number 1 2017 graphical memory and source memory. The integration and connection more penetrating analysis of mental It fluidly or dynamically reconstructs of the present moment to experiences disorder. and consciously draws on past experi- remembered, conditions not present, An intuitive philosophical re- ence to inform present behaviour and human conversations place each sponse to this threat to objectivity and a (Gillett, 2008, 84ff). The relevant neu- of us in a unique trajectory enabling natural or well-grounded account of our ral capacities not only enact similar both personal integration over time being-in-the-world is to assert a causal problem-solving routines (adjusted if and discursively mediated coordina- link between mind and world so that necessary for variations) but also allow tion with others through speech, sto- our meanings are derived, in a system- directed revisitation of past action con- rying, and imagination, the currencies atic way, from the causal connections texts through off-line processing. In of human mental lives. These become mediated by our sensory systems. The human beings these skills use central not only in human social cog- trick is then to spell out how we should “representations” that combine the nition but also in action, intention, conceptualize those causal connections meanings of words (JHJ) with mnemic and personality formation as each of to account for the selectivity and inten- residues including limbic and paralim- us adapts to our shared world of op- tionality of perception. Straight causal bic activity (Freud, 1986, 445-8) and a portunities, subtle awareness of dan- impingement will not do as a theory of record of past activity so that we in- gers (physical and mental), and the perception because of the active top- dwell subjective/intersubjective histo- need to become somebody through down editing and construction of expe- ries that can either straitjacket or liber- combining intellect, appetite, and rience through multiple and complexly ate the subject from the effects of the action into a unique sustainable life inter-related layers of possible meaning past and a present set of conditions. among others. The action of these in any human situation. These different Emotional resonance with others broad factors that must be integrated layers meet in our shared moments adds to reasoned and conscious control in any human being’s response to a where the possible meanings brought to of behaviour strategies of coordination situation or series of events depends the situation by different people are that, once again aided by speech, use on real top-down control of lower “quilted” together to produce a nuanced information about the feelings and levels of neural processing by the responsiveness between them (Gillett, behaviour of others to organise patterns at the highest level that have 2016). But that “quilting” implies al- “centres whereby the organism as a become attuned to our complex social ready multiply articulated layers of whole is adjusted to the environ- reality and most express our individu- meaning rather than merely causally ment”(1887, 34). Human agents take al modes of coping with the world by and contingently connected situations into account the intentions, plans, intelligent participation in it (Gillett and unified, coherent, representations needs, vulnerabilities and moral de- and Liu, 2015). apt for truth. mands of others (based on this inter- The idea that truth is affected by a subjective resonance) as, for instance, Objective facts and neuro- selective articulation characteristic of when I realise that a person to whom I (these days). language such that it only partially re- am talking has been deeply hurt by a veals the world (and even obscures friend of mine and subtly acknowledge John Locke, in seeking to relate significant aspects of the world as seen that fact. the human condition and human un- by some of us) is a corollary of philo- JHJ notes the pervasive influence derstanding to the science of his day, sophical views linking sense to differ- of words in our semantically informed remarks: “Words in their primary or ent collectives of language-using sub- processing assemblies: “Words are immediate Signification, stand for jects in which those subjects learn to required for thinking, for most of our nothing but the Ideas in the Mind of deal with the world through the great thinking at least but the speechless him that uses them, how imperfectly mirror of a propositional structure and man is not wordless; there is an auto- soever, or carelessly those ideas are its cultural realisation in human con- matic or unconscious service of collected from the Things which they texts (Gillett, 2015). That broader view words”(1878, 323). This unusual are supposed to represent”. (Locke undermines any simple debate between stance, for an evolutionary theorist, is 1689, [1975], 405). Linking Locke’s correspondence and coherence views of prescient of two major Twentieth cen- analysis to a representationalist phi- knowledge and truth. Given that our tury thinkers – Luria (mentioned losophy (according to which we are dealings with things occur in a real and above) and Ludwig Wittgenstein, only directly acquainted with the con- shared world about which we com- whose famous claim “meaning is tents of our own minds or brains), municate, this analysis undermines the use”(1953, #43) is also prefigured by implies that the relevant ideas inter- view that the way a thinker thinks of an JHJ; “an utterance is or is not a propo- pose between the mind and the world object is always and only a function of sition according to how it is so that our thoughts (or the proposi- a particular way of thinking about that used”(1879, 210) such that tions we understand) relate only indi- thing (as might be held by social con- “superiority of speech is precision of rectly to actual objects and lose their structivism), even though it does allow application to new relations of direct grounding in a shared, objec- for the role of diverse experts in a phil- things”(1879, 218). JHJ here indicates tive, world. But the need to closely osophical understanding of semantics. the “complex of cues and connections” relate human adaptation to a genuine- It also makes room for collective mis- arising from speech-related activity ly ethological understanding of our takes and linguistic change, innovation, (Luria, 1973, 306) noticing that word function requires a more grounded or discovery. Consider, for instance the meanings relate contexts of action to and embodied form of objectivity term “electron” - arguably, conceiving the communication that so influences than that provided by indirect repre- electrons as small negatively charged our shared human lives. sentational realism and it also offers a particles at the outer reaches of atoms

29 Volume 24, Number 1 2017 and of negligible mass (a view that spondence-realism and social con- the basis of the explanation of certain might have sufficed for classical phys- struction. characteristic patterns of excitation and ics) is sufficient to understand the term inhibition in neural circuits (Gillett & even though it is not really true, a fact and biopychosocial pro- Harre, 2013). We are led to ask why he that raises two normative problems: duction: the case of hysteria. has developed a conversion reaction (a (i) who sets the standard for translation of emotional and interper- what counts as understanding a given Hysteria is a case in point where sonal stress into a quasi-neurological term; changing science has shifted the con- presentation) and what is sustaining it? (ii) how can one can successful- ception of the disease from a wholly The resulting enquiry is broadened ly refer to an entity and claim under- mental or spiritual problem to a neu- beyond the neural sphere. When we standing of it even though one’s under- rological, to a non-neurological, to a subsequently find out that he had his standing of the term being used is bio-psycho-social or discursive analy- “left sided stroke” when trying to ac- largely mistaken or metaphorical. sis with implications for disease pro- count for his being in a car at a well- These problems make it tempting to duction, maintenance, and nature known trysting spot with a woman who adopt a collectivist view such as: (Gillett, 2009). In fact hysteria is a was not his wife, and that his wife was The sense of a given term is given perfect stalking ground on which to overbearing (to say the least), we might by the ways of thinking about that hunt for the metaphysics of mental get closer to the understanding we need thing accepted by the group of people disorder. and begin to glimpse a formulation who count as rule-makers for the Imagine a young middle aged leading to a therapeutic response to his meaning concerned. (Call this The man who cannot move his left side quasi-neurological disorder (the Rule Maker claim.) when conscious but can when partly “dissociation” or “disruption” in his The Rule Maker claim entails that a disinhibited by a short-acting anaes- psyche). We should perhaps ask, privileged group defines just which thetic. The type of phenomenon at the “Under what strains is he trying to subset of the truth conditions count as heart of this clinical scenario became translate his bodily state into a self- grounding the correct use of a given of intense interest during the debates report and what positions are open to term. So that: about spiritual and natural causes of him in this complex moral-emotive- (a) collective discourses recog- mental disorder in the latter part of interpersonal and culturally loaded dis- nise experts who dictate the contents the Nineteenth Century. The spiritual- course?” This contrasts markedly with of terms used to express knowledge; ists believed that disease without a Zachar’s discussion of hysteria. Within (b) such experts can hold a co- biological basis was a proof of the his view that a “symptom network is herent cluster of beliefs arising in their immaterial nature of the human psy- also embedded in networks of personal- own cultural (or sub-cultural, e.g. sci- che whereas the naturalists (or posi- ity traits, networks of normal cognitive entific) practices; and tivists) believed that all behavioural abilities, emotional states, and social (c) the collective practices of manifestations must be caused by and cultural networks”(166) personality talking about an object define what physiological mechanisms in the hu- style (heavily “cognitivised”) and prag- we notice and can think in relation to man body (Hacking, 1995, 163). matism about the disorder as it presents the entity concerned and together Charcot and Freud opened the way yield a sparse formulation of what is provide a maximally intersubjective for neurological explanations of men- troubling the hysterical personality and conception of the target object. tal disease but their legacy was taint- what could possibly be so distressing However there is room in the anal- ed by poor science and their own as to lead to suicide. Psychology, and ysis for the touch of the real to intrude highly tendentious forerunner to “a hence psychotherapy, is deep, and here in such a way as to modify or force a thoroughly functionalist view of the that does not mean neuroscientifically reconsideration of the conception of soul”(Hacking, 1995, 216). In the arcane but deep in a personally and the phenomenon being referred to that new era of cognitive neuroscience as morally troubling way for a caring hu- is in play. Thus the analysis, cashed the fount of all wisdom, we can try man being. out in terms of human discourse and and explain what is going on in terms Discursive explanation explores the idea that concepts are tools for of changed patterns of inhibition and the reality of human souls as beings-in- rendering the world in ways apt for excitation in the young man’s sub- relation who do things to each other well-adapted cognitive systems in a cortical emotional and motor path- with words and demand certain ac- discursive milieu, undercuts any sim- ways and thereby finesse any attempt countings of each other. In this they ple-minded debate between those who to locate the young man as a human read what is happening in part from claim that scientific discourse pictures being in an ethological context part of their interpretations of events going on or corresponds to the world and those which is “a widely diffused, all per- in their own brains and in part in terms who claim that science is a culturally vasive system of thought in which of their social and interpersonal skills. inflected construction that obeys only doctor and patient acted”(Tomes, In the normal course of events they do its own rules of internal coherence. We 1994, 361). We can however, take not stumble very much in that task, are, instead, forced into the view that seriously the situated discursive na- exercising techniques they have learnt our scientific concepts present the ture of the young man’s adaptation to to map a situation and their neural re- world in ways suited to our interests a demanding world and its sometime sponse to it onto a structure of shared and practices and may function hege- distorting effects on human relation- rules that positions us within “the com- monically if misconstrued according to ships. mon behaviour of man- the stark traditional bipolarity of corre- That realisation prompts an ex- kind”(Wittgenstein, 1953, #205). Al- amination of discursive formations as lowances are made for disability and

30 Volume 24, Number 1 2017 illness that draw on the discourses “shift” (Bolton, 2008) e.g. in cere- our discursive world or because of the structuring medical life and biomedi- bral synchrony. world itself “screwing you up” and cine as a system within which both The impairments of the way- making the state of yourself unable to doctor and patient experience and act in ward husband and others like him be acknowledged or properly made relation to what is (patho- can be “lost in translation” because sense of in terms that you can effec- physiologically) causing distress and their “neurological conditions” have tively cognize and live with. Zachar’s dysfunction. By contrast, the discourses a discursive significance – they are study of essentialism, realism, social of the soul, lay bare the significance of supposed to tell us something even constructivism, and the metaphysics of events to the individuals concerned in if the message is markedly effaced. mental disorder allows us to re- personal and socio-cultural terms. A The person at the heart of the disor- examine the subject of psychiatry phil- story must be made out of the meanings der cannot be as they are expected osophically and therefore, if our phi- discerned according to the rules we use to be and the inability or mismatch losophy is up to it, both existentially to interpret each others’ behaviour and is partly explained by the rules and thematically. Zachar gives us phi- it must ring true to the human situation. (including moral rules) that govern losophy, traditionally framed, but does These two different layers of under- treating and assessing neurological not really give us existential inquiry. standing are necessarily related because disorders and those suffering from We are notoriously bad at looking of our embodiment but the discursive them. Their disabling breakdowns awry at our ability to translate from story reveals a person’s self-positioning cannot be dealt with by insight or our individual indwelt, neural, innen- or self-presentation in the midst of ex- reflective self-examination and the welten to our storied lives via the many pectations in terms of language games underlying causes and es- culturally nuanced connections be- where, among other things, we evaluate cape them. If that sounds uncon- tween language and our being-in-the- each other and react accordingly. A vincing, try holding your arm flexed world, in part because “What is mir- discursive account of the psyche allows and fist clenched until it goes numb rored in language I cannot use lan- us to “distinguish among events … and then move it and feel what af- guage to express.”(Wittgenstein, 1962, differentiate the networks and levels to flicts you. This auto-experiment 42e) and in part because what lan- which they belong, and … reconstitute helps bridge the gap between con- guage reveals about me must be able to the lines along which they are connect- sciousness of the self and a conver- be indwelt by me. ed and engender one anoth- sion reaction (Gillett, 2009). The er” (Foucault, 1984, 56) so as to place intense “pins and needles” (or, for References. our reactive and responsive doings ap- some of us, “searing pain”) is neu- propriately within human ethology and rally generated and as we experi- Bolton, D. 2008. What is mental interpersonal life. ence it we link it to a story – disorder? An essay in philosophy, sci- Foucault’s phrases are pregnant voluntarily entering into an auto- ence and values. Oxford: University with meaning: events are moments in experiment as a normal person. Im- press. the enactment of a story; they contrib- agine you are otherwise, you feel Bolton, D., and Hill, J. 1996. ute to our understanding of how people helpless and hopeless and a minor Mind, meaning and mental disorder. interact with each other and influence injury has further unsettled you; you Oxford: University Press. each other. The diverse ways that state- cannot bring yourself back to your Foucault, M. 1984. The Foucault ments engender or connect to one an- normal embodiment and your pain reader, Ed. P.Rabinow. London: Pen- other reveal the (influential even if or neurological state is a vindica- guin. patchy) narrative production of a per- tion. We could say that you are en- Franz, E., and Gillett, G. John son’s life. Why has this man got a “left ervated or alienated from your fa- Hughlings Jackson's evolutionary neu- sided stroke” and what has to be done miliar lived bodily experience, it is rology: a unifying framework for cog- to relieve the (non-arterial/psychic) experienced as a cognitively impen- nitive neuroscience. Brain, 134; 3114 “blockage” causing it? An assessment etrable breakdown within you and –3120. doi: 10.1093/brain/awr218. of useful interventions and investiga- so conveyed. Freud, A. 1986. The essentials of tions now takes on a quite distinctive .London: Penguin. profile focusing on life skills, emotion- Scientifically informed prac- Gillett, G. 2008. Subjectivity and al wounds, and relationships within an tice with real people. Being somebody: human identity and intense discursive context. The dis- neuroethics. (St Andrews series on tressed human being who comes to us Real people constantly translate philosophy and Public Affairs), Exeter: cannot do this work himself and we brain states into an account of them- Imprint Academic. must help him see and negotiate the selves using skills produced in an Gillett, G. (2009) The Mind and domain of decision (Bolton and Hill, ethological setting that is embodied its discontents, 2nd Ed. (esp Ch 12) 1996) where we face up to and, one and discursive and where the train- Oxford: University Press. hopes, learn to give reasons for our ing has been both caring and good Gillett, G., Liu, S. 2012. Free will choices and actions and take responsi- enough. The events befalling us and and Necker’s cube: reason, language bility for what we do. That moral or our bodily experiences related to and top-down control in cognitive neu- value based dimension to the work of them are, as a result, normally and roscience. Philosophy, 87.1 29-50. psychiatry is never far away even if the typically smoothly translated into Gillett, G. and Harre, R. 2013. neural “fit” between a person and their self-reports. That smooth translation Discourse and diseases of the psyche. discursive milieu may be profoundly can break down because of loss of In The Oxford handbook of Philosophy affected by a physiological or cognitive properly functioning neural circuits and Psychiatry, Ed. By W.K.M. Ful- that adapt us as whole organisms to

31 Volume 24, Number 1 2017

ford et al, 307-320. Oxford; Universi- derstanding, thinking and feeling the ty Press. Mentality and Ontology of world, is the fruit of the maturation of Gillett, G. 2015. When the Mirror the Lifeworld in Psycho- the organism –especially the brain– but Cracks: Well-Being, Moral Responsi- pathology also of the maturation of one’s personal- bility, and the Post-Colonial Soul. ity, mentality, and attitudes. Studies in the Sociology of Science, Hector Pelegrina Cetran MD No wonder that this new discipline 6.2: 1-7. Member of Medicine Academy of Chile of psychiatry, so diffuse and profuse, of Gillett, G. 2016. Post structural [email protected] so many well or poorly integrated di- methodology at the quilting point: (trans O. Dörr & J. Phillips) mensions, appears even today so con- intercultural encounters. Kennedy fusing. Something that clearly exposes Institute of Ethics Journal, I thank Dr. James Phillips for this situation is the fact that we still (forthcoming). his invitation to participate in the don’t have a clear concept of mental Hacking, I. 1995. Rewriting the discussion of Dr. Peter Zacher’s illness or pathology, at least not one Soul. Princeton: University Press. book A Metaphysics of Psycho- with adequate consensual agreement. Hughlings-Jackson, J. 1878. On pathology. This failure accounts for some of the affectations of speech from disease of It is not necessary to insist on urgent problems facing our specialty at the brain (1). Brain, I.III 304-330. the present importance of the themat- ethical, procedural, and epistemological Hughlings Jackson, J. 1879. On ic field approached by Zacher in his levels. Thus for example, the ethical affectations of speech from disease of text, both for psychopathology and problem indicated by Zachar of decid- the brain (2). Brain II.II 203-222. for all human knowledge. In fact, he ing when a state of sadness or sorrow Hughlings-Jackson, J. 1887. Re- explicitly points to it in the war be- passes from being a normal fact of hu- marks on the evolution and dissolu- tween philosophy and science started man life to constituting a state of illness. tion of the nervous system. Brit. J at the end of the 19th century, persist- Or the enormous, current epistemologi- Psychiatry, 33: 25-48. ing until today. cal problem of comorbidity, also ana- Insel, T. 2014. The NIMH Re- Zacher’s position throughout lyzed by Zachar in relation to all the search Domain Criteria (RDoC) Pro- his text is always measured, avoiding “ontological dualisms” of the different ject: Precision Medicine for Psychia- a fall into the absolutist reduction- anthropologies underlying in the differ- try. American Journal of psychiatry, isms so frequent in the 20th century ent psychiatric schools or positions. An 171.4; 395-397. http:// in all the items included in the field example thereof would be Ionesco’s ajp.psychiatryonline.org/doi/ of psychopathology: reality, truth, book Catorce enfoques de la psico- abs/10.1176/appi.ajp.2014.14020138. discourse, experience, certainty, veri- patología (FCE, México, 2001). What is Locke, J. 1689 [1975]. An Essay fication, speculation, issues of the the ontologically “dysfunctional” level concerning Human Understanding concrete and abstract, of being and at which each mental or psychic pathol- (ed. P. Nidditch). Oxford: Clarendon. existence, of the absolute and rela- ogy is originates? There is a serious Luria, A. R. 1973. The Working tive, of description or interpretation, procedural problem of where to search Brain. Harmondsworth: Penguin. of objective data or theoretical infer- for the basic alterations of the psycho- Mercier, H., and Sperber, D. ences, etc., etc. All that at the end of pathologic structures. 2011. Why do humans reason? Argu- the last century in which several This question includes the ments for an argumentative theory. epistemological revolutions have “mereological” problem of discriminat- Behavioural and Brain Sciences, 34: occurred and in which ing differential characteristics between 57-111. have shifted somewhat in all the sci- the whole and the parts of an entity – a Roskies, A. 2010. How does neu- ences. All this nonsense becomes problem highly topical in all the con- roscience affect our conception of even more confusing in the field of temporaneous sciences and one that has volition? Ann Rev. Neurosci., 33:109- psychiatry, a discipline of recent been very well emphasized for the field 130. origin in both knowledge and prac- of psychiatry in the book about Neuro- Tomes, N. 1994. “Feminist histo- tice, exercised over a system –human science and Philosophy: Brain, Mind, ries of Psychiatry.” In Discovering the behavior– surely the most complex and Language by Bennett, Dennet, Ed. by M. Mi- field of things, facts and events of Hacker and Searle. I am interested here cale & R. Porter, 348-383. Oxford: the universe we know. Let me indi- in highlighting the overarching im- University Press. cate in passing that the study of hu- portance of this theme for settling the Wittgenstein, L. 1953. Philosoph- man life involves physics, chemistry, character of psychopathological symp- ical Investigations (tr. G.E.M. biochemistry, biology, ecology, se- toms. Are they “signs”? Mere indica- Anscombe). Oxford: Blackwell. mantics, symbolism, social and cul- tions revealing an underlying illness? Or Wittgenstein, L. 1962. Notebooks tural history (both at the social and are they rather parts of a deconstructive 1914-1916. (Tr. G.E.M. Anscombe) individual levels), and evolution of process that constitutes the psycho- Oxford: Blackwell. “mentalities” as different forms of pathology? This last has been indicated grasping the world and oneself. And by several authors, for some time now, *** this last as a maturation process both among them by Juan José López Ibor of humanity and of each individual (Senior), in his book about “Las Neuro- in his psychologic and cognitive de- sis como Enfermedades del Ánimo”, p. velopment. This is a theme to which 139. Zacher dedicates several passages. This is also the position I will as- I emphasize that the maturation sume in this commentary, addressing of the individual, in the way of un- the ontological foundations of psycho-

32 Volume 24, Number 1 2017

pathology, along with the studied by the psychologist Nick Has- Finally, is not anxiety, the most lam, among which I underline the fol- “mereological conflicts” that are part frequent and ubiquitous symptom of of the of psycho- lowing: Homogeneous and uniform – psychopathology, perhaps less an Naturally occurring – Has necessary pathology. As an initial clinical/ experience of “threat to the self” than pragmatic framework for my attempt identity–determining features – Possess- a destruction of the active subject in es inherent, underlying properties – to clarify the “mentality-ontology” constituting his own human identity? relation as a ground of the psycho- Unchangeable and immutable – Stable From these few clinical exam- across time and culture. These dimen- pathologic deconstructions, and of ples, I postulate that mental illness is their comprehensive difficulties, I sions of essences are the constitutive of a destruction or threat of destruction the “substantialist ontology” of Western indicate some data from clinical prac- of the identity of the living individual, th tice. thought from the Greeks up to the 20 stemming from a disturbed, century! And it is that of Western Is the destructive aspect of pho- ‘in-appropriate’ structure of behavior bias the panic in front of the phobic adults. It is not even that of children, it – understanding that the identity of a is not even that of other cultures, such object or situation? Or is the avoidant human being is the result of self- behavior based on an impossibility of as the Eastern. construction through behavior This metaphysic horizon of per- taking possession of the resources of ‘appropriate’ to one’s own reality and the world for realizing the own life? ception of the being of entities has lived to the reality of one’s circumstances. on since the Greeks as a vision of the The dramatic element in agoraphobia “The emancipation of the biological patient is not so much the insecurity essential identity of all entities, underly- and psychic functional symptoms in ing their sensory appearances. This is a experienced in a public space, or the front of the personal whole does not panic attacks that can appear in it! The vision of essences as adynamic, perma- involve, in its personal, a nent, non-material, and eternal vision of dramatic element is that the individual disorder? Perhaps the fundamental cannot take possession of the im- the identity of the entities, supported in disorder of neurosis?” As Gebsattel that non material essence, under all not mense spatial atmosphere available indicated already in 1953.1 for living well and realizing the major essential and changing characteristics of My objective in this text is not to the entities in time. This essentialist part of her life activities. develop this entire field of inquiry. I conception of the being is shared by two On the other hand, is the reason have already done that in a “general for phobic panic the present factual variables of Greek thought, the Platonic psychopathology” (Fundamentos An- vision of the essence as Idea, and the aggression of the phobic object, or is tropológicos de la Psicopatología, it the “physiognomic figure” of the Aristotelian vision as Form. Ed. Polifemo, Madrid, 2006), as well This perception and conceptualiza- object and the ideal concept of the as in a “regional psychopatholo- category to which the object abstractly tion of the being of what appears to us gy” (now in press). My objective here in our surrounding, including human belongs? The answer is obvious from is only to present this problem in rela- clinical experience. A fear or phobia beings themselves, was at origin of the tion to Zachar’s book. concept of phyysis, nature. This meant for dogs is not the panic in the fact of For this goal to indicate the a dog actually attacking one. That is that the things were not perceived any origin of psychopathology as decon- more as being manifestations or fruits of fully normal in life. The phobic expe- struction of behavior, and at the same riencing panic in front of a dog, even the actions of supernatural beings, but time as the origin of the problems of as being things in themselves, based on a photograph of a dog, is reacting to exploration and knowledge of psy- their substantial essences. (Thus was the the expressive figure, to the physiog- chopathology, I start with what Zach- origin of the substantivation of the verb nomy that makes imaginarily present ar presented in his Chapter IV about to be as being, which did not exist in the essential threat for him of the spe- “Psychological and Scientific Essen- early Greek ). This substantialist ontolo- cies dog. tialism”. gy of classic Greek thought constituted In another area, is the pathologic Zachar rightly indicates the rela- element of a manic phase in bipolar a great overcoming of the previous tion of the essence of something to its “magic-mythic” mentality, and the be- disorder perhaps the feeling of total “identity”, to what it really is, what wellbeing, of exaltation of mind, and ginning of the development of the logi- specifically constitutes that something cal knowledge of the onto-logy of the of expansive mood? Is the destructive as such. And he shows from his re- physics, as meta-physics and as epis- element the affective state of happi- view how this relation of the perma- teme. This inquiry into the being of ex- ness, or is it rather the biographic con- nent identity of something with “an isting things through the instrument of sequences of his unmeasured and in- empirically non-verifiable essence” reason, came to be called logos (idea, appropriate behavior with respect to constituting it is present not only in word, criterion). It was the rise of criti- his world and with respect to the own philosophy, but also in all the scienc- cal knowledge, in face of the old mythic resources that occur in the manic es, including current microphysics. In -religious dogmatism. phase? my judgement the problem of essen- This substantialist metaphysical And in a major depression, is it tialism lies in the “type of essential- horizon constituted the ontology at the loss of the joy of life that predomi- ism” evoked in each type of origin not only of philosophy and sci- nates in the melancholic mood, or is it knowledge, and that implies different ence, but of western culture itself. It the conviction that one’s personal life ontological conceptions that support perceived entities of nature not only as is threatened by the inaccessibility of different types of identity of the enti- being each “for itself”, but also as being resources or possibilities for realizing ties of the universe. something “in itself”, isolated from its them in this world? It is undoubtedly Thus Zachar indicates the char- environment. This is the perception that this last, as Glatzel indicated, and that acteristics of the adult conceptualiza- supports the experience and the concept appears confirmed in Cotard syn- tion of the structure of essentialism, drome. 33 Volume 24, Number 1 2017

of something as real being. From Synthetic Biology (p. 233), contempo- piricism an inferential reification, in rary biologist Pier Luigi Luisi tells us this vision entities would maintain the case of idealism a deductive reifi- relations with other entities accord- that “Each living system is a complex cation. of circular interactions with its environ- ing to the constitutive essence of This substantialist ontology, each type of entity. Essential rela- ment, and this whole can be contemplat- applied to the field of somatic medi- ed as a continuous flow of mutual and tions between entities would funda- cine, gave rise to the vision of disease mentally be of two types: causal coherent changes, whose end is the as a deterioration of the structure of maintenance of the balance of self- relations between entities or compo- the organism by an external, environ- identity. And in his The Phenomenon of site relations among the individual mental cause. Applied to psychiatry, it entities, whose properties would be Life: Toward a Philosophical Biology, gave rise to the vision of madness as a the great philosopher Hans Jonas, the summatory result of the individu- loss of the human essence, of reason. al entities. Thus Zachar underlines, knowledgeable in scientific work, tells And in a materialist vision, it was us: We must “consider organisms to- quite rightly, the privileged role of seen as a loss of the “rational func- causal relations. While such causal gether with their environment, as a tions” of the brain, necessarily at- unique systems” (p. 70). thinking might be thought of as an tributed to genetics as the only basis innate tendency of human beings, This “autopoietic” vision of life of the neural structure of the homo corresponds to the current ontological epistemological criticism has shown species. Following from the genetic that this way of thinking has existed vision of the General Systems Theory, in force in the last decades – in which every local structural unity is a only in Western adults, and only gene → protein → (brain) function → th continuous dynamic process of differen- from the 5 century until the end of behavior -- “the gene” of each taxo- the 19th century. tiation of that structure with respect to nomical entity has been intensely the environmental field. As Niklas Luh- This atomistic, objectivist, on- searched, be it depression, anorexia or tological vision, prevailing in all mann informs us in this treatise about alcoholism. Complexity and Modernity (p. 35): “The cognitive theories, whether idealist But as the scientific investiga- or empirical, is the origin of almost th relational theory (among substantive tion of reality progressed in the 20 entities) has problems with identity and all the conflicts of the contemporary century, in intimate contact with phi- knowledge as well as of the war be- difference. The theory of systems al- losophy and pragmatically maintain- ways starts from the fact that identity is tween science and philosophy. This ing contact with the real world, it end- is better understood if we realize that constituted through a difference with the ed up, though not fully, overcoming environment”. And this happens “in all this vision is not only applicable to the substantialist persective. the factual or material relations complex systems where dynamic sys- (Scientific investigation at the highest tems of formally similar functional or- among the entities, but also to the level is today multidisciplinary, inte- structure of knowing between hu- ganization emerge, although the con- grating different perspectives, includ- crete causal relations be very diverse”, mans and things. On the one hand, ing the philosophic. As simple exam- empiricism has understood the phe- as the Nobel prize winner Prigogine ple let me mention in USA the Santa maintains in La estructura de lo comple- nomenon of knowledge as the result Fe Institute, dedicated to the study of jo. (Nicolis G. y Prigogine I., Alianza of the action of objects of the world Complexity. An example of this work on the senses of the human being. Ed., Madrid, 1994). Thus we see this is S. Kauffman Investigations. Com- only in the field of human life, but even The organs of the senses would be plexity, Self-organization and New in the field of consciousness. A. Gur- passive, and the action of things on Laws for a General Biology. Thus the them would produce data of the ob- witsch already indicated this in his book epigenetic revolution –with the dis- of 1962, El campo de la conciencia. jects of the world, creating a re- covery that the “expression” of genes presentation of the external object (Alianza, Madrid, 1979, p. 163), writing depends on a very complex system of of “The structure (Gestalt) as a unity within the brain. relations among them, together with In the case of “idealism”, that is consolidated and separated from the rest of the non-genetic DNA and the field”. Contemporary neurobiolo- knowledge would be the product of others factors, like a great quantity of the human spirit or of universal rea- gists Edelman and Tononi move in the cytoplasmic proteins, the cellular po- same direction, writing that “integration son, the essence of the human as sition with respect to the organism “rational animal”. The object of con- and differentiation are the fundamental and the behavioral relation of this properties of the conscious experi- sciousness would here be an with the environment - has overcome 3 “abstract creation”, recreating the ence”. the substantialist vision of genes, inte- This has given rise to an emer- reality of the external world from the grating them into the general living, power of reason, without possibility gence ontology, in which entities are ecologic system of which they are a local products of the dynamics of gener- of true access to reality itself. In both part. cases the objects perceived would be ic processes of the field that create con- This is a changed ontological crete structures, which in turn locally products of a unidirectional causal vision of reality, from the substantial- action, be it material action in em- realize the field dynamics. The philoso- ist to a / communicational pher Whitehead already maintained this piricism, or action of the thought (the model of the complexity of every sys- th spirit) in idealism. Indeed, the cogni- 2 at the beginning to the 20 century in tem as life systems. Life is not some- his book Process and Reality (“there are tive result in both cases would be an thing within the organism (be it a artificial object with the appearance no things, only processes”), in accord functional-mechanical essence as in with what western science was discov- of being something real in itself. In Cartesianism or be a subtle essence as current terminology, this is a reifica- ering at the turn of the century. Philoso- in ). In his book, Emergence pher of science Mario Bunge articulated tion of the object. In the case of em- of Life: From Chemical Origins to this position in his book, Emergence 34 Volume 24, Number 1 2017

and Convergence: Qualitative Novelty it requires being integrated into an ing objects with an aim to attack the and the Unity of Knowledge. ecologic system. individual. (University of Toronto, 2003). In the case of psychopathology, This brings me, finally, back to the This comprehension of essences in becoming mentally ill, alteration beginning of my commentary, where I as dynamic processes shaping the becomes alienation and expropria- postulated the mental disease is a de- structural identity of entities is funda- tion becomes dis-appropriation, as struction or threat of destruction of the mental for general medicine and even processes of the configuration behav- identity of a living entity, based on a dis more for psychiatry. Today allergic ior. I mentioned above phobias as -appropriate structure of behavior, on a illnesses are not seen as an organic clinical structures. The basic cause of misuse of the information provided in effect on the organism caused by al- every phobia is feeling threatened by normal behavior. Regarding the latter, lergens, but rather as a disharmony of the phobic object. This means that the biologist/philosopher has maintained: the informational relation between subject –in the phobic situation– does “Perception and action, sensorium and molecules of the environment and the not perceive the object as within his motorium, are linked together as suc- immune system of the organism. Dis- space of action, but perceives himself cessfully emergent and mutually select- harmony that can cause the death of as within the reach of the threatening ing patterns”. (Francisco Varela in The the organism – by an over-reaction of space of action of the object. This embodied Mind, p. 163.) It is the inte- the immune system, as in anaphylactic situation already implies the aliena- gration of the sensibility and the motor shock or autoimmune diseases. How- tion of the active subject, transformed function in the shaping of the perceived ever, the empiricist thrust of current into a reified object by the disappro- forms (Gestalten), magisterially ana- classifications asserts that stress is a priation or loss of his own space of lyzed by Viktor von Weizsaecker in his normal reaction of human life to the action and of the things that are in that book Der Gestaltkreis, from 1939, and stressors. This is a reification of the space. The threat of destruction expe- anthropologically described by Maurice “stressors” as facts or life circum- rienced by the personal subject is al- Merleau-Ponty in The structure of be- stances that in themselves threaten the ready completed, hence the anxiety. havior from 1942: “The properties of individual, ignoring the informational This accords with Zachar’s point with the object and the intentions of the sub- character of the situation, that is respect to the “new scientific essen- ject (…) are not only intermingled, they “shaped both by the circumstances, tialism” of a passage from passivity to also constitute a new totality”. and by the interpretation of the expe- activity of natural structures, as indi- What studies of infant psychology riential subject, conditioned by his cated by Ellis. But Ellis’ activism (beginning with Piaget) and evolution- personality, his biography, and by his expressly referred to the “capacities ary epistemology (as in the book Mind personal ontology”. “Objects of per- that things have to actively respond to from Matter?: An essay on evolutionary ception are the result of the contribu- relevant circumstances”. In the new epistemology, by Max Delbrück) show tions both of our theories and of the horizon of the general systems theory, us is that:

action of the external world over our essential activism does not mean the st sensory organs”.4 In contrast, capacity to react to circumstances, but 1 .- Activity between the infant and its “Empiricism at a epistemological lev- rather an active process of differenti- environment begins to generate a pro- el is usually associated with antireal- ating each structure of the environ- gressive distinction of permanent forms ism at an ontological ambit”, as ment from the others, constituting with their operative qualities. In the Wulff H., Pedersen S. A. and Rosen- one’s own identity and clarifying the first months there are not permanent berg R. inform us in their Introduc- identity of the other. As Jonas writes, forms. As of 6 months, the child begins ción a la Filosofía de la Medicina “The differentiation of sentience, with to perceive the inter-sensory object, (Triacastela, Madrid, 2002, p. 44) the central integration of its diversi- which corresponds to what “Disease” is also a reification of fied data, furnishes the beginnings of called common sense (Koinos Aisthe- the experience of “being ill”, of a de- a true world of objects; the active sis). With this there begins a specifica- structive way of being in the world in commerce with this world through the tion of sensory things, with recognition one’s own life. The reification does exercise of motility (in turn implying of their operative qualities - pragmatic not take account of the fact that life is centralization, viz., of control) sub- objects - along with the rise of an active a autopoietic, self-constructing pro- jects it to the self-assertion of free- subject. “Up to now there is a formal cess that is based on the appropriation dom, which thus answers on a higher structuring of the child/environment and incorporation of environmental plane to the basic necessity of the pragmatic relation, based on the sensory and personal resources. For this rea- organism.” motor organization”. This period is son, the condition of somatic disease While this is the ontology of the analogous to the development of the is essentially an “alteration”, an “ex- contemporaneous science, product of sensory distinction in animals, between propriation”, a loss of one’s inherence critical ontological and epistemologi- stimulus and sensation. “Animals per- as an organism in the self- cal investigation, it is not the opera- ceive Gestalten (…) men Gestalten and constructive, dynamic unity of life. tive ontology of everyday life. The things”. Gemelli A., Introduccion a la But the harmony of this constructive phobia example shows us that the psicologia Luis Miracle, Barcelona, p. process is based on the informational triggering stimulus is not the real ob- 213.

harmony that distinguishes and inte- ject itself but rather what to the sub- nd grates the different molecular, cellu- ject is the threatening suggested char- 2 .- As of the second year, real human, lar, and organic structures of the sub- acter of the object. Such character cognitive development occurs, based on systems that integrate the coherent belongs to the ontology of a magical/ sensory experience. holistic unity of the organism. To live animistic world, as in the way a pho- gives way to perception of relational bia of scissors might represent sting- structures. The object is separated from

35 Volume 24, Number 1 2017

of the world and one’s own capability the pragmatic context and acquires This transcendence of a natural to develop realistic goals. permanent identity in the face chang- ontology, constitutive both of the Psychotic psychopathology devel- ing circumstances. The child begins to things of the world and of my own ops from disturbances of the global designate things with names, begin- identity as acting on those things, is brain networks responsible for shaping ning denotative language. He recog- what is initially lost in schizophrenia, the ontological forms of the basic, nizes things as independent of his described by Blankenburg as the “loss pragmatic world. These disturbances of activity with them. The self is recog- of the natural evidence,” as well as at the formal fundamental structures of nized as involved in operative matri- the origin of other symptoms such as the world and of oneself are responsi- ces with things, including causal rela- strange behavior and delusional think- ble for serious psychotic illnesses such tionships. These relations with things ing. as schizophrenia, non-schizophrenic do not follow the perception of things The permanence of the objects psychoses, and the dementias. They are but are constitutive of the things them- of this pragmatic ontology is what disturbances of the basic ontology of selves. “What we call things only enables the denomination (denotation) the individual, originating in its pre- exist in knots of relations,” as Zubiri and the generation of an idea of the 5 reflexive and pre-theoretical behavior. tells us. This is a basic onotology that thing. As Gehlen informs us in his The psychopathologic structures is pragmatic, pre-linguistic, and pre- anthropology (El hombre, 1974, p. of the neuroses or affective disorders reflectively interpretative of the enti- 186), “The constancy and the trans- are structures that alter the person and ties of the world. posability (…) are the conditions for his behavior, for their “affecting sense” The pragmatic interaction con- man to be able to see things.” Cogni- of the appropriative realization of the structs both the identitarian perma- tive deteriorations are manifestations subject life. They are perturbations of nence of the object and the subject of of the loss of the formal capacities of the “ways of feeling” affectively the perception. Another thing is that after- the brain for distinction and synthesis, “modal senses” of the things and cir- wards the behavior seems to take its that generate the ontology of the cumstances of the given world have for world. origin only from the perception of rd.- the realization of the own life of that objects. As Hans Jonas indicates in his 3 Between the 18 and 24 months person. Senses not only conditioned, indicated book of Philosophical Biol- the mental sphere is constituted as an but determined by the “type of concep- ogy (pp. 48/9): “The apparent constan- articulated and spoken world. In this tual world” the person has, depending cy of the object of perception in the symbolic domain semantic structures face of how it is handled constitutes are developed that represent material The Mind-independent an inversion of the real genetic rela- things that are not sensorially present. World, Metaphysical Heuris- tions”. It is this pragmatic genesis of Things can be presented as images tics, The Nature of Psychiatric the natural, pre-verbal, pre- and concepts, and discussed in words. conceptual, pre-reflexive object that Initially the child does not differenti- Disorder, and the Relationship gives the perceived the character of ate concrete from imaginary reality, between Psychiatric Classifi- being something prior to perception, nor designate the thing by its name, as cation and Psychopathology: and to the perceived thing the formal Zachar himself indicates, and which Response to the Commen- character of “being beyond” the sub- we see in many psychopathologic taries. structures ject. Starting with this period formal This stage –from 12 to 18 Peter Zachar structures of thought and language months– constitutes the moment of are developed in progressive levels of becoming human, of the apparition of Introduction a pre-linguistic, praxic world, a pre- maturation up to adolescence. These verbal and pre-conceptual ontology, different formal levels of thought im- I would like the thank Jim Phillips that will allow the further possibility ply different mentalities, with differ- for devoting an issue of the AAPP Bul- of a world whose logos becomes ex- ent logical forms, that form different letin to A Metaphysics of Psycho- pressed, shaped as verbal expression mentalities and life worlds at each pathology and thank him also for maturational stage. In a simplified and a world of thought. It is the mo- st) working so hard to both assemble and ment of constitution of what we have scheme: in the 1 stage of infancy the edit the commentaries. mentality is magical and the world is been accustomed to call transcendence nd) Writing the book was an all- since the pre-Socratics. It is not the physiognomic-animist. In the 2 consuming project for three years. It is exercise of a faculty of the human stage the mentality is mythic and the a pleasure to be able to return to it and world in dogmatic/ideological. In the spirit of going beyond (metà) the rd explain myself, elaborate, and rethink physical things, but the construction 3 stage and into adolescence, there some of what I wrote. of the cognitive duality: the perceived appears a critical mentality, question- I have grouped the commentaries and the act of perception of the per- ing dogmatic beliefs, with the possi- in clusters so that my responses can ceiver! This pragmatic construction of bility of developing one’s own stand- approximate a coherent progression the world, between the praxis of the ards and participating in the structure from beginning to end. Prior to each child and the power of consistent and of one’s life. This is the period of cluster, I will make some preliminary persistent structures of the environ- developing one’s own personal identi- remarks and then respond to each com- ment over the child, is a co- ty: at first immaturely, grandiose pre- mentary separately. My individual organization of the perceptual world. tentions of an ideal world, and then responses were written with the as- In phenomenology, primary con- maturely, with a more realistic sense sumption that readers would first re- sciousness is “I can,” not I am. view the preliminary remarks.

36 Volume 24, Number 1 2017

Empiricism and the Mind- it is a mistake, even epistemological- feature of human psychology? No. independent World (Rego, ly irresponsible, to reject the notion Viewing an objective versus subjective Thornton, Cooper) of a mind-independent world. I set distinction as lying within but not be- out to examine this problem with the yond experience does not diminish the According to basic realism, the eyes of a pragmatist. In adopting a notion of mind-independence any more world/universe exists independent of pragmatist perspective, one asks: than abandoning the idea of a vital force our knowledge of it, it existed before what is important about the concept diminished the specialness of life and humans came to be, and would con- of a mind-independent world, or what death. The significance of each of these tinue to exist whether or not we were work does that concept do for us. concepts remains intact. I will further still around. It does not exist because More specifically, how does it helps address the “psychologism” charge in we perceive it. us to adapt (survive or thrive). my response to Mark Rego. It would not be useful to doubt What is important about the con- What do such philosophical consider- basic realism any more than it would cept of a mind-independent world is ations have to do with psychiatric disor- that it means things can be very dif- ders? Quite a bit, actually. For instance be useful for anyone living to doubt th that there were people and societies ferent than we believe, or want them we can ask if anyone in the 12 century before us and there will be people and to be, and that we might be mistaken. developed PTSD even though that con- societies after we die. In the book, two norms I articulated cept was not introduced until 1980. Are Empiricism is often understood as with respect to this insight are: Do psychiatric disorders what George Gra- asserting that human knowledge is not fool others and do not fool your- ham calls “act of classification inde- limited to what is available to us self. Adherence to these norms pendent.” My answer is: Sort of– it all through experience. That does not makes us more likely to notice and depends on how you look at it. mean, however, that what we know is admit mistakes, and in the long run Locke is illuminating on the topic of limited by immediate experience. For correcting mistakes is adaptive, no mind-independence, particularly with instance, we make inferences that go matter what your goals. respect to the concepts we have for beyond immediate experience when These important insights, that one naming the ways that things and events we accept the premise of object per- can have conviction yet be mistaken are ordered or patterned. He called these manence: that things continue to ex- and that things do not conform to our patterns modes, and contrasted them ist even when we are not sensing wishes, can be fully formulated with with self-subsisting entities. Examples them. thought of this as the resources that experience pro- of modes include , beauty, and an automatic and habitual inference, vides. We do not need to get beyond murder. Jean Piaget a cognitive achievement. I experience to grasp them. Under- Consider murder. Is murder some- agree with each of them. standing this is a cognitive achieve- thing that is out there in the world inde- The empiricist tradition’s emphasis ment, and “the mind-independent pendent of whether we know about it? on experience was a response to a world” is a handy everyday meta- Sort of. Let us assume that a group of deep mistrust of abstract concepts, physical framework for explaining it. forensic scientists discover that a well- especially metaphysical concepts. Taking a more Humean view, we known historical figure did not die of a John Locke, in particular, was appre- can say that experience is ordered in natural illness as previously believed, hensive about our propensity to adopt many ways, and some of those ways but was poisoned. A murder occurred an attitude of certainty about abstract we name, “subjective,” others though even we did not know about it. doctrines. For example, in Locke’s “objective,” some “fiction,” others Consider, however, the following dis- lifetime there were violent conflicts “fact.” For Hume, the “external tinctions - infanticide, matricide, patri- over abstract concepts such as papal world” is an ordering of experience cide, suicide, manslaughter, euthanasia, infallibility and the divine right of that is distinct from those orderings animal slaughter, insecticide, and herbi- kings. An important goal of Locke’s of experience that we identify with cide. People would disagree about Essay was to regiment our speculative imagination and preference. In his whether these are all types of murder. abstractions by asking that their links view, these distinct orderings have a For instance, is euthanasia murder? My with experience be better mapped out. different feel to them. The same is dog has no concept for any of these Typically, Locke’s project of link- true for our beliefs about abstract types of killing, nor for murder itself. ing abstract concepts with something concepts versus our beliefs about the These concepts are what Locke called in sensory experience is narrowly particulars of daily life. The Lockean the workmanship of the human under- interpreted as a doctrine regarding the worry discussed earlier refers to the standing. They refer to actual phenom- experiential origins of mental content. mistake of adopting about abstract ena that occur whether or not we want An important metaphysical claim that concepts a feeling of certainty that is them to and so are not constituted by is often attached to Lockean ideas only appropriate to the particulars of our naming practices, but the distinc- about content is that we cannot get daily life. tions are also made by us – often for beyond all experience to know things One potential criticism of this view particular purposes. Very importantly, as they are in-themselves. This raises is that it twists things around by using “workmanship” entails that some as- an important problem. If human un- experience to explain the idea of the pects of phenomena are included in our derstanding is bounded by the limits mind-independent world rather than concepts, and others aspects elude them. of experience, what justifies us in using the mind-independent world to Another way of saying this is that accepting basic realism and the notion explain our experience. Does an ex- abstract concepts are inadequate to the of a mind-independent world? perience-centered approach diminish rich particularity of experience in one Most people who think about these the very notion of a mind- way or another. Things have histories independent world by making it a and they are related to other things in things, including myself, believe that 37 Volume 24, Number 1 2017

many particular ways. No concept or Rego’s concern is that pragmatist to inform what it means to be a fact. If classifications can capture all that scruples do not offer an adequate ex- so, the correspondence theory depends, particularity. This inherent limitation planation of our limitations. For in- in part, on the pragmatic and coherence of concepts and classifications is the stance, consider the claim that obses- theories. basic insight of nominalism. sive-compulsive disorder can be suc- For , the correspondence Psychiatric disorders work the same cessfully treated by exposure- theory of truth was a useful regulative way, to varying degrees. Psycho- habituation theory. How are we to ideal, but did not have anything to do pathological phenomena occur wheth- make sense of that truth claim? Is the with how we decide what assertions to er or not we want them to, but con- claim true because we can act on it if accept. He considered correspondence cepts such as hysteria and schizophre- properly trained (pragmatic theory of to be a type of verificationism, which he nia are the divisions of human under- truth)? Is it true because it is con- rejected in favor of falsification. Un- standing, as is “psychiatric disorder” sistent with others things we know like Popper, I believe that that for some itself. They are patterns that we hap- about human behavior, cognition, and kinds of assertions, checking for corre- pen to recognize and name, thus echo- (coherence theory of spondence with the facts can be an epis- ing Locke’s notion of workmanship. truth)? What I read Rego saying is temic guide. For cats on mats and the The reason for calling this that the truth about treatment with shapes of planets, correspondence is “workmanship” is that the patterns we exposure-habituation is out there in something we know how to check, and name are (hopefully) systematic regu- the world – in the metaphysical nature do, but those kinds of assertions form larities, but also interest-relevant sam- of OCD. only a small part of what accept as true. ples of the many patterns that are For Rego, pragmatic considerations Arthur Fine defines the natural onto- there. and coherence are factors in deciding logical attitude as follows. When we To what patterning of phenomena what is true, or guides to truth, but not accept the everyday facts of our life and does hysteria refer? Interestingly, that adequate theories about the nature of the claims of abstract science to be true, has changed over time. In the not too truth. Many philosophers would say we accept them to be true in the same distant past many of these cases we that the nature of truth is represented way (despite different levels of confi- currently name histrionic, borderline, by the correspondence theory, i.e., a dence in what we accept). According to narcissistic, PTSD, somatic symptom statement is true if it corresponds to Fine, realist arguments supplement the disorder, and conversion disorder reality, or alternatively – is true if it natural ontological attitude in one way would have been included in the ex- corresponds with the facts. (i.e., metaphysically construed corre- tension of hysteria. At one time hys- My concern about this formulation spondence with reality), and pragma- teria was considered to be obviously is that the pragmatic theory and the tists and empiricists do so in another. real, but few hold that view now. coherence theory were developed to For example, Fine says some pragma- The construct of schizophrenia is address flaws with the correspond- tists treat the pragmatic theory of truth also in dispute. Some see schizophre- ence theory, not as competitor univer- as a universal theory of truth. nia as a valid medical disorder; others sal theories about the nature of truth. Hopefully I have made clear that my see it as a reified category that distorts Empiricists and pragmatists– as nomi- pragmatism is not of that sort. I will of understanding of a broad class of nalists – are suspicious of considering say a little more on this topic in my psychiatric phenomena. truth as correspondence with the facts response to Tim Thornton and refer Are hysteria and schizophrenia real? as a universal – as a property that is back to it again when I address Jim Did they exist before we noticed fully present in all true statements. Phillips. them? The phenomena occur whether They might still utilize handy episte- Let me also address Rego’s post- we want them to and so are real in one mological notions like “confirm,” apocalyptic rocket launch. A rocket sense. The critics of these classifica- “mistake,” and “correct,” but not in- was designed by NASA to automatical- tions, however, claim they do not live variably define them in terms of cor- ly launch on a specific day and time, up to our evolving norms for valid respondence with the facts. but before that day arrived, all humans psychiatric disorders. In the critics’ One flaw of the correspondence on earth perished. Despite that unfortu- view, what past thinkers meant by theory relates to Rego’s notion of the nate occurrence, the NASA computers hysteria and schizophrenia misinter- disconnect between our understanding would still launch the rocket into space. preted and distorted the phenomena, of the natural world and the natural The reason the launch would be suc- so they are not real in another sense. world as it exists. Given such a dis- cessful, says Rego, is because the connect, how can you ever know that knowledge used to automatize the Mark Rego your concepts correspond to the world launch was representing an objective, as it exists in itself? Is there only one mind-independent truth about the Mark Rego and I agree on our en- way to correspond? How would you world. And that is what we should seek demic epistemological fallibility - check that the correspondence is to know, even if we fall short. what he refers to as the disconnect there? I agree with the sentiment, but not the between our understanding of the nat- In addition, how do we know if implied metaphysical augmentation. ural world and the natural world as it what our statement corresponds to is Rego declares that my claim that the exists. We also agree that our indeed a fact? It would be circular to resources of experience are adequate for knowledge is limited, partial, and of- claim that a fact claim is true if it cor- making metaphysical distinctions ex- ten biased. Where we part ways responds to the facts. One way to cludes something important. It excludes seems to be about the degree to which avoid circularity is to allow pragmatic what is beyond experience, the mind- our fallibility needs to be metaphysi- tests and considerations of coherence independent world, or objective reality. cally augmented. In his view we need a concept of the

38 Volume 24, Number 1 2017

with metaphysical assumptions that external world - out there, and inde- Descartes, must be an innate idea subsequent generations of philosophers pendent to adequately explain our placed in our minds by God. have learned should be rejected, such as limitations. This argument is not the least bit the subject versus object split or the One of the best responses to this convincing. It is well within our ca- representational theory of perception. challenge can be found in Tim pacities to grasp a concept such as This might be a valid point. I will try to Thornton’s commentary. He uses degrees of power and imaginatively explain my interest in metaphysical is- Wittgenstein’s claim that we fail pay extend this to a notion of omnipo- sues more specifically in my response to attention to the details of language and tence. An actual all-powerful being is Rachel. practice because we do not believe not needed to explain having the con- Second, an important consideration that they are relevant to some of the cept of omnipotence. The same for in writing the book is that psychologists, questions we are asking – such as why omniscience, perfection, and infinite- psychiatrists, and other mental health we utilize the metaphysical distinc- ness. professionals freely use metaphysically tions that we do. Included in “we” are Analogously, we do not need to elaborate concepts. In introducing more those who believe that only something know something beyond all experi- minimalist concepts, it is important to behind or beyond the details of lan- ence to formulate concepts such as contrast them with the commonly used guage and practice are needed to ex- mind-independence and reality. Both elaborate concepts. For example, in plain metaphysical distinctions. The of them are important parts of experi- chapter 7, I proposed a minimalist ac- problem is that a “reality” that lies ence. A person who assumes that only count of the objective as a word we use outside of experience cannot explain something totally outside of experi- to flag things that some people may the distinctions we actually make in- ence can explain mind-independence wish were not the case, but nevertheless ternal to experience. According to and reality would see the specter of are the case. I contrasted that with The Tim, not only are explanations for our idealism in the empiricist approach, Objective as that which lies outside ex- distinctions to be found in the details but that assumption inflates mind- perience. of language and practice, those are the independence into something unnec- Tim questions me for comparing a only resources any of us have. For essarily “metaphysical.” partial and minimal notion with an elab- instance, none of the information or orate metaphysical notion that is disal- Minimalist and Deflationary Meta- technology that was used to program lowed in my framework. There is a physics (Thornton, Cooper) the rocket was beyond language and deeper problem about “the reality that

practice. lies beyond experience” here that I will Both Tim Thornton and Rachel As I noted in the book, qua pragma- address in my response to Tim. For Cooper are sympathetic to my attempt tist, I purposely chose to use William now, let me say that part of what I was to formulate a more metaphysically James’ concept of “experience” rather doing was contrasting my proposed no- minimalist approach to psychopathol- than Richard Rorty’s term “language,” tion of the objective as resistance to ogy, but each also argues that I fall but I do not believe that the difference what we prefer with what I assumed is short and make unnecessary meta- matters here. the more usual and elaborate notion of physical assertions. I begin with two Rather than repeating Tim’s exam- The Objective that most people vaguely preliminary comments. ples which people can read for them- adopt. The purpose of making that First, in writing the book I began selves let me propose another analogy comparison was to show readers that with the minimalist metaphysical for Rego’s claim, specifically, one of there is an alternative to the more usual commitments of an empiricist and Rene Descartes’ arguments for the and elaborate notion. was attracted to deflationary accounts. . To simplify great- I then tried to expound on those from ly, according to Descartes there must Tim Thornton a specific kind of pragmatist frame- be at least as much reality in the cause work. In the book, I called it scientif- as in the effect. For example, he says Tim argues that mixing the epistemic ically-inspired pragmatism in contrast that the energy in a hot object can guides of the pragmatic and the coher- to the neo-pragmatism of Richard only be produced by something that ence theories with the metaphysical Rorty. In retrospect, I could have also has at least as much energy itself. correspondence theory of truth is shot- called it Anglo-pragmatism Analogously with respect to ideas, he gun wedding of what is dependent on (encompassing Scotland (Hume) and says the degree of reality represented and independent of human judgement. Ireland (Berkeley) of course). Prag- in an idea must be produced by some- To some extent I addressed this in my matism in my framework is a varia- thing that has at least as much reality commentary on Rego with respect to tion on the empiricism of Locke and itself. epistemic guides versus universal meta- Hume that was articulated after the In Descartes’ view, our ideas about physical definitions, but let me say more publication of Charles Darwin’s material objects, animals, and other here. Origin of Species. This variation was people could have been produced Although it is important to recognize solely within our minds, but this is not formulated by some Americans in the th how our psychological make up plays a late 19 century – including William the case for our idea of God. The real- role in what we believe (i.e., naturalized James - who were at just the right age ity in the idea of God, and his attrib- epistemology), it is also important to not to quickly accept evolution by natural utes such as omnipotent, omniscient, conclude that what “is true” is only a selection without preformed opinions perfect and infinite could not be pro- function of human psychology. I am getting in the way. duced by our imperfect and finite hu- not convinced, however, that the prag- It may be that in looking back to man minds. The only thing with the matist and coherentist perspectives are James and Locke, I end up working required degree of reality is God. only dependent on human judgment. Therefore, our idea of God, claims

39 Volume 24, Number 1 2017

For example, pragmatists believe that humans ever evolved. We can assume the claim “it is raining outside,” partly living will ever know about. It is not that in the future scientists will have means “if you go outside you will get possible to make factual assertions evidence for accepting things about the wet.” When you go outside to run that about that which we can have no in- world that are beyond us now. It is a test to decide if that claim is true, formation. way of seeing that part of what we mean whether or not you get wet is not de- If we cannot access any information by reality is that some things are the pendent on human judgement. Conse- about what Doyle ate on that day, we case independent of what we happen to quences have a degree of independ- cannot make factual assertions about believe and know. ence. The same for coherence. If a that either. For all practical purposes, Second, Tim notes that despite my reconstruction of evolutionary history it is not a possible fact for us. That is claims to the contrary, it is not clear that using the fossil record coheres with an what I meant. I in fact succeed in trying to stay within independent reconstruction using This was also part of the thinking the limits of human experience without DNA, that is more than dependence behind my criticism of Jerry Wake- becoming some kind of an idealist. on human judgement. field’s harmful dysfunction model. Tim’s worry with respect to my empiri- Next, I would like to try to better Given that we lack information about cism would seem to be that empiricists explain myself on an issue raised by the selection pressures operating dur- advocate for a gulf between the subject both Tim and Rachel. Specifically, ing human evolution, our menus of and the object, and thus are vulnerable my claim that what Arthur Conan natural psychological functions are to being idealists about what we know. Doyle ate and drank on a particular only speculative, and the same for It is a fair and good point to make. day in 1903 was once a matter of fact, failures of those natural functions. We From a pragmatist standpoint, however, but is now not a fact because the in- therefore cannot check to see if there I would not absolutely disallow making formation is not accessible to us. Tim is a factual dysfunction to demarcate a distinction between subject versus wonders if this commits me to an anti- disorders from states of normality. object, inside versus outside my body, realist view of the past. He and Rachel That demarcation is done using other or in my head versus in the world. There both ask, did Doyle or did Doyle not resources that are available to us in are a lot cases in which these can be eat breakfast on that day. If the an- experience (i.e., the perception of informative distinctions to make. swer is either true or false it would particular kinds of impairment) Tim suggests that a resort to direct seem to be a matter of fact. And My final two responses to Tim’s realism could solve the problem posed therefore real. commentary also serve as a transition by an implicit idealism. I cannot confi- I doubt that the King Arthur of leg- to my responses to Rachel Cooper. dently respond because I am only mini- end is a real historical figure, but the First, Tim observes that I set out to mally familiar with direct realism, but Saxons did invade Britannia. More to write about how we actually make understand its attractiveness from a the point, I agree that on logical important metaphysical distinctions practical standpoint – beautifully ex- grounds alone, Doyle did or did not on the basis of experience alone, but pressed by Hume in his characteristical- eat breakfast. Yet on logical grounds that I also have a tendency to talk ly optimistic and open-minded conclu- alone, Tony Soprano was or was not about what is beyond experience. sion to book 1 of the Treatise: shot in the scene that would have fol- For instance, Tim suggests that, in Most fortunately it happens, that since lowed the conclusion of the final epi- part, I harbor an idea about reality as reason is incapable of dispelling these sode of The Sopranos. This truth of something that exists independent of clouds, nature herself suffices to that logic, however, does not commit any- experience and thereby beyond expe- purpose, and cures me of this philosoph- one to realism about the Soprano- rience. Furthermore, it is something ical melancholy and delirium, either by verse. that we cannot access because we are relaxing this bent of mind, or by some Furthermore, I did not ask whether trapped in our heads or in our lan- avocation, and lively impression of my Doyle had breakfast, I asked what he guage. I appreciate Tim’s calling my senses, which obliterate all these chime- ate and drank for breakfast. I intro- attention to the difference between ras. I dine, I play a game of back- duced the question about what Doyle “mind-independence” and “beyond gammon, I converse, and am merry with ate and drank because I was working experience.” And it is correct that in my friends; and when after three or four with my notion of what we mean one of the examples he discusses tak- hours’ amusement, I would return to when we say something is a fact. en from chapter 1, I talk about what these speculations, they appear so cold, When we say something is a fact we lies outside our experience, i.e., reali- and strained, and ridiculous, that I can- effectively mean: you are obligated to ty is one of the names we give for not find in my heart to enter into them what lies outside the limits of our accept this assertion no matter what any farther... Here then I find myself you to want be the case. In part, I was current experience. absolutely and necessarily determined to I did not, however, mean what lies working with a concept of information live, and talk, and act like other people used by some physicists. For exam- outside the limits of all possible expe- in the common affairs of life. rience. It was just a way of saying that ple, if a star 100 light years away was Not only do we adopt common sense currently exploding, we could not there is more to the world than we realism about the activities of daily life, know, but we accept that based on know about that explosion for 100 we also do so about the discoveries of years. Whatever causal factors are experience. We have good reasons science when we adopt the natural onto- for accepting that matter-energy is operating in our area of space time, logical attitude. My worry though, is that explosion is not one of them. In both particle and wave, but that infor- that this is a few steps away from being mation was beyond human experience addition, anything that is more than 15 a very unphilosophical attitude – and billion light years away from us is until recently, even though matter- least from the standpoint of modern energy was particle and wave before something whose existence no one philosophy. Hume also wrote, some-

40 Volume 24, Number 1 2017

what critically, about those honest metaphysical assumptions, including the use of medication and treatments gentlemen whose thoughts extend hard cores/negative heuristics that are such as exposure-habituation. very little beyond their domestic af- immune from being tested and more For similar reasons, I believe a con- fairs and common recreations – and flexible positive heuristics that are sistent empiricist-nominalist-pragmatist such a direct realism seems just as tested. With respect to psychopathol- perspective is worth pursuing – espe- unpalatable as idealism. I would ar- ogy, folk metaphysical assumptions, cially for one who has a temperamental gue that a more philosophical attitude scientific metaphysical assumptions, inclination to metaphysical minimalism. is anchored by the distinction between and philosophical metaphysical as- The goal is to develop a deeper, more primary and secondary qualities or the sumptions all play a guiding role. I comprehensive, and subtler perspective broadly Kantian metaphysics of the do not believe that Rachel and I than would ensue from a shopping cart structure of experience. would agree on substantive issues in approach to metaphysical heuristics. If In writing the book I emphasized psychiatric classification and psycho- looking back to James and Locke makes several general guidelines that I con- pathology unless we shared an im- me vulnerable to using outdated doc- sider to be not readily compatible with plicit metaphysics, however minimal. trines such as a subject versus object idealism. These include the belief that As I wrote in the book – and agree dichotomy, it is important to try to ac- there have been people and societies with Rachel - metaphysical concepts commodate my perspective to newer who lived before us and there will be are often obscure, all the more so frames of thought. people and societies after we die; the because they tend to be defined in On the topic of my metaphysical decree that we should conceptualize terms of other obscure abstractions. commitments to non-essentialism, I will the world the way it is, not how we In order to navigate through the fog discuss that in my response Jim Phillips want it to be; and the judgment that of metaphysics, it is useful to have and Jeff Bedrick in the following sec- experimenting, trying something out, some accessible anchor points., i.e., tion. and putting our beliefs to the test gets respected authorities around which us out of our heads and into the world. you develop a philosophical identity. Am I a Closest Essentialist? In combination with philosophical (Phillips, Bedrick) Rachel Cooper temperaments, chance factors related to your professors’ expertise what we I am addressing Jim Phillips and Jeff Like Tim Thornton, Rachel Cooper were exposed to in school and play a Bedrick together because they adopt calls me to task for aspiring to a mini- role in the development of our philo- interestingly distinct attitudes toward malist metaphysical account, but then sophical identities and habitual com- my non-essentialism. According to Jim, promulgating a host of metaphysical mitments. I am arguing against a Platonic straw- commitments. These would include Rachel mentions John Dupre’s pro- man and according to Jeff I am a closet non-essentialism, pragmatic and co- miscuous realism was an anchor point essentialist. These are serious charges herence views on truth, nominalism, for her. For me at various times that and both worth pondering. I am sympa- and radical empiricism. She and I would have been Richard Rorty, Ian thetic to Jim’s concerns because essen- largely agree on many substantive Hacking, Nelson Goodman, William tialism, like all metaphysical abstrac- issues regarding psychiatric classifica- James, and earlier my former profes- tions, can be obscure. If essentialism is tion and psychopathology, and ac- sor Mark Johnson and his colleague expected, it can be readily seen even cording to her nothing that we agree George Lakoff. Johnson and Lakoff when it isn’t there. I am also sympathet- on depends on the metaphysical com- are particularly good about showing ic to Jeff’s concerns because we are all mitments we make. In her view, this how some metaphysical commit- prone to essentialist thinking, and get- makes these commitments optional. ments are readily apparent in lan- ting beyond it on an intuitive level is a In this respect, I plead guilty as guage, yet not seen as metaphysical. struggle. That I might not always do so charged and see how this could be My attitude about metaphysical is a distinct possibility. considered problematic. Yet, there commitments partly has to do with Before proceeding let me note that are also reasons for acknowledging my training in counseling and psy- both of them use a similar argument, metaphysical commitments and for chotherapy as well. When I was in i.e., they declare that my statements “the developing them further. Let me ex- training there was a lot of thought truth of any claim is an inference sup- plain. being put into theoretical orientations ported by evidence” and “psychiatric My attitude about metaphysics part- and the value of eclecticism. Many disorders involve a decline-in- ly has to do with the perceived failure came to believe that adopting a rigor- functioning” are general definitions in on the part of the mid-20th century ous eclecticism would result in hav- the spirit of essentialism. In response, logical positivists to banish metaphys- ing a fragmented perspective on cli- let me say that offering a definition does ics to the realm of the meaningless. ents. It would be better, they be- not commit one to metaphysical essen- As Karl Popper noted, metaphysical lieved, to commit to mastering a tialism. Unless one specifically propos- commitments might not be scientifi- broad theoretical model and thereby es necessary and sufficient properties in cally based, but they are not meaning- achieve a coherent and comprehen- a definition, it does not commit one to less. For him metaphysical status was sive perspective on clients. This also essentialism about meaning either. a matter degree, and many important assumed a willingness to accommo- scientific propositions, such as date the theory to new approaches Jim Phillips “matter is composed of atoms,” begin that are shown to work. For instance life metaphysically. an object relations theorist would Although Jim fears that I am focusing talked about research programs have to conceptually accommodate to my efforts on a Platonic strawman, he (largely, paradigms) being guided by does not believe that I am, on the whole,

41 Volume 24, Number 1 2017

being quixotic and tilting at essential- formation, and distinguishes them used in a foot-stomping and desk- ist windmills. He views himself as a from those on the other side. Academ- thumping way: “Our rights come for non-essentialist in the Wittgenstein ically-inclined intellectuals who iden- God, truly!” My question at the time mode. tify with the reality-based community would have been what is your evidence Wittgenstein comes up a lot for me, have a tendency to make those who for this claim or what do you mean by from “sounds like Wittgenstein” and prefer the faith-based community into fact? “why didn’t you mention Wittgen- ignorant cartoon figures, but that is In describing scientific empiricism as stein” to “your failure to mention harder to do when you live and work a contrast to the epistemological view of Wittgenstein is the major flaw of the around them. When either side is not my acquaintance, it might have been book.” The reason I do not mention reduced to a cultural stereotype, this better to say that the empiricists base Wittgenstein is I am not familiar epistemological rift becomes very their beliefs on a consideration of evi- enough with him to do so. Of course philosophically significant. dence and a systematic attempt put be- Wittgenstein’s influence is wide- What I suggested later in the book liefs to the test to see if they may be spread and his ideas are unavoidable, is that we won’t make progress on faulty. This eye on progress should be but his purposes are a quite opaque to this clash unless we accept that very balanced with commitments – which me so I pass over him in silence. few of our beliefs are based on an play a useful role by fortifying us to not Attributing metaphysical beliefs to individual assessment of the evidence. immediately concede to every criticism. others is a risky business, especially Much of what we believe is based on Furthermore, considerations of coher- when those beliefs can be used as the testimony of “experts” who are ence and consistency are always im- terms of insult, like essentialism recognized as authorities in one or portant in deciding what to accept. To sometimes is. For articulate and able more communities with which we accept something, ideally, we balance defenders of essentialism such as Bri- identify. the different considerations just men- an Ellis, I was willing to make an at- To some extent what I said about tioned, and select from the best alterna- tribution, but otherwise, I tried to talk truth in chapter 1 was signaling my tives. Also, later in the book I would about essentialist thinking as a tenden- attraction to deflationary accounts. have said that they expect that a similar cy about which we should all be wor- Many philosophers hold that truth is a check and test process influenced the ried. property of propositions, but defla- beliefs of the authorities upon whom As for , I use him as contrast to tionists deny that truth is a property. they rely. nominalism because of his advocacy To believe that the proposition “Snow With respect to psychiatry and psy- for universals. Advocacy for univer- is white” is true, does require believ- chology, in many cases we accept that sals is still common in philosophy. ing that this proposition has the prop- things are true, often with conviction, Focusing on universals, I referred to erty of being true. If by properties we but no single person can comprehen- Socrates’ claim in Meno that just as mean “the way things are,” a quality sively survey the evidence and reasons all bees must share a single nature in called trueness is not the way any- supporting truth claims about the history common as bees, so all the different thing is. This was reflected in my of psychiatry, DSM categories, the virtues must share something in com- nominalist claim that true proposi- causes of psychiatric disorders, and mon as virtues. What made this claim tions do not share a universal property what works in psychotherapy and psy- about virtues persuasive at the time called truth. chopharmacology. Even in our areas of was the comparison with bees. For Such deflationary considerations expertise, we are dilettantes in many many nominalists, what decisively motivated my assertion that in making respects. My worry is that believing undermined it was Darwin’s view of truth claims we are not detecting the that truth is a real property out there in species as populations of individuals presence of the property of truth. the world amplifies a disposition to be- that vary. When I said that to make a truth claim lieve with conviction. The problem Another potential strawman Jim is to make an inference supported by with conviction is that, in practice, it addresses is the creationist belief in evidence, my point was that scientifi- rules out the possibility of being mistak- “Truth” as a contrast for the scientific cally-inclined thinkers do not accept en. empiricist’s belief that truth claims are something like the theory of evolution I am fully sympathetic with Jim’s inferences supported by evidence. by means of natural selection because argument that the distinction between Jim writes that creationism is a straw it possesses the property of being true, coherence and correspondence to the man, but it would be harder for him to they accept it based on evidence. One reality depends on how language is assert this if he lived and worked in problem with saying that valid truth used, as can be seen in my responses to the deep south as I do. claims are based on the evidence is Mark Rego and Tim Thornton. As part of the broader project of the that it does not address who decides book that Tim Thornton mentioned, I what counts as evidence, or how, with Jeff Bedrick was trying to make sense of a mutual evidence, in hand we make inferences epistemological rift between what to abstract and general truth claims. Jeff begins by wondering if combin- some call “the reality-based communi- In in addition to deflationism, an- ing pragmatism with nominalism is a ty” versus “the faith-based community other inspiration for this material in way of preserving psychopathology, or between those who accept facts the book was being informed by a psychiatry, and psychology as scientific versus those who use terms such as close acquaintance that all of our disciplines. I don’t believe they need “alternative facts.” Interestingly, both rights come from God, and that this is preserving as scientific disciplines. It groups readily claim that rationality, a fact and the Truth. It seemed to me would be more correct to say that prag- critical thinking, and informed opin- that the word truth here was being matism and nominalism offer a way to ion describe their approach to belief

42 Volume 24, Number 1 2017

be scientific without leaning on cer- seek to validate putative disorders as tain metaphysical illusions. is that some symptoms are considered much as tell a historical story about how Jeff’s commentary also obligates symptoms because they are inherently the psychiatric domain came about. In me to tackle the thorny task of defin- impairing, such as psychomotor retar- that story various symptom clusters ing terms with precision. It is im- dation. Others such as grandiosity are were added to the domain because they portant to try to define terms clearly, not inherently impairing, but they are were similar to other presentations al- but in those cases where meanings are symptoms because they can be im- ready in the domain and they seemed to somewhat open, seeking a precise and pairing. At the very least, a psychiat- be relevant for the skill set of psychia- complete definition is like a working ric symptom cluster should make it trists. puzzle that has no final solution. Ab- harder to function as usual – which is This historical story is problematic stract concepts such as essence, im- impairment. Clinically significant because it only begins in the 19th centu- pairment, and psychiatric disorder are suffering is also impairing to the ex- ry with the rise of the asylum doctors. I potentially problematic in this way. tent that it can be harder to function could have just as easily begun it earlier. Nevertheless, some clarification with it than without it. For instance, had it begun in the early would help. So it would seem that I do advocate modern era, rather than psychosis I Jeff’s main claim is that, for me, for some necessity about impairment might have started with melancholia and decline-in-functioning serves as an with respect to psychiatric disorder. hysteria-hypochondriasis, but a radial essential feature of psychiatric disor- Let me qualify this in two ways. structure would still have made sense. der. The term essential feature is of- First, the “necessity” of impairment On two issues, what I intended to say ten used as a synonym for is established by the goals and pur- was not how Jeff read me. First, he “necessary.” Do I believe that decline poses of psychiatry. The World claims that I commit myself to a hypo- -in-functioning is necessary for psy- Health Organization Disability As- thetical view of the course of human chiatric disorder? No. Decline-in- sessment Schedule (WHODAS) con- evolution and its teleological goals. I functioning does not seem to be a nec- ceptualizes impairment dimensional- am not sure how I gave that impression essary property of personality disor- ly, suggesting that there may be a as I critique Jerry Wakefield for specu- ders, ADHD, and some learning and fuzzy boundary region between im- lating about natural functions. communication disorders. The autis- paired and not impaired. Impairment Second, Jeff says I implicitly claim tic spectrum is more variable, but does not is a universal property equally that personality disorders are in the do- not always involve a decline. present in all psychiatric disorders; main because they are similar to “real” Although I do not propose that de- rather it is a collection of ways we fail disorders. That is a metaphysical gloss cline-in-functioning is a universal to live up to a variety of norms such that I did not employ largely because feature of psychiatric disorder, Jeff is as “you should be able to start a con- the term real disorder can be obscure. on to something. A more difficult versation” or “you should be able to Although the chapters in A Metaphys- question for me would focus on im- join in community activities.” ics of Psychopathology were all written pairment because decline-in- If impairment is a necessary feature to be understandable within the context functioning is a feature of some im- of disorders, it is partly because it is of the book, a couple sections in chapter pairments. Do I believe that impair- an external entry rule for something 11 were based on some of my earlier ment is necessary for psychiatric dis- being considered a disorder. A condi- work. This work includes a 2011 article order? In the book I argued that, be- tion that did not involve actual or po- titled The Clinical Nature of Personality cause we lack information about natu- tential impairment would not be de- Disorder which was written as a friend- ral psychological functions and dys- serving of treatment and not consid- ly response to Louis Charland’s claim functions, we use either actual or po- ered to be a psychiatric disorder. This that Cluster B personality disorders are tential impairment as a dysfunction gives a stipulative aspect to the moral, not medical conditions. This indicator. “necessity” of impairment. For in- model was revised slightly in a 2013 Does it make sense to say that stance, there is some debate about book chapter co-authored with the Uni- someone could have a psychiatric whether the successful psychopath or versity of Minnesota clinical psycholo- disorder, but not be impaired in any the successful narcissist have person- gist Bob Krueger. It was titled Person- ality disorders. The problem is that way? Some thinkers associated with ality Disorder and Validity: A History of the World Health Organization on the surface, some cases of psy- Controversy. A 2010 article co-authored chopathy and narcissism do not meet (WHO) believe that it does. Accord- with Nancy Potter titled Personality the entry rules for being disorders. ing to them, disorder and impairment Disorders: Moral or Medical Kinds – or Second, I would not call impair- are separable. What they seem to Both was also an important precursor to ment a metaphysical essence. Impair- mean, however, is one can have a psy- chapter 11. ment is a feature of psychiatric disor- chiatric disorder, but still function Like Jeff suggested in his commen- ders, not a cause. So impairment is adaptively. In addition, they suggest tary, rather than use the term “real disor- not a causal essence. Furthermore, that the relationship between the se- der,” what we wrote about were the people can be impaired for a variety verity of a disorder and the degree of variety of factors make that personality of reasons yet not have a psychiatric impairment is moderated by the envi- disorder “clinically-relevant.” The back- disorder. So impairment is not a sort- ronment, and by the resources and ground assumption was that in the psy- al essence. vulnerabilities of the person. So im- chiatric domain, some disorders are Jeff also raised a good question pairment is not an inherent feature of more disorder-like and other less so. about justifying the inclusion of par- disorders. The models we articulated were summa- ticular disorders in the domain. The The problem with the WHO goal of rizing the considerations offered in the imperfect community model does not separating disorder from impairment professional and scientific literature that

43 Volume 24, Number 1 2017

make personality disorders clinically- bereavement and uncomplicated depres- relevant (or more disorder-like.) To this model they may never develop. sive episodes related to all other stress- summarize the models in brief: For instance, the pathology of the ors. Independently, Jerry Wakefield The vulnerability model claims that psychopath may include the failure to and his colleagues discovered the same personality disorders are clinically- develop certain moral capacities. thing. relevant conditions in the same way Jeff suggests that we should consid- Kendler-Zisook and Wakefield each that conditions such as hypertension er personality disorders to be disor- had different ideas about how to resolve and hypercholesterolemia are clinical- ders in their own right. I am less sure. this inconsistency. Kendler and ly relevant. They are clinically- Although I disagreed with Louis’ Zisook’s solution was to group uncom- relevant because they are risk factors Charland’s claims about the exclu- plicated mood disturbances related to for the development of less controver- sively moral nature of the borderline, the loss of a loved one with uncompli- sial disorders like depressive disor- psychopathic, and narcissistic person- cated mood disturbances related to other ders, anxiety disorders, eating disor- ality disorders, I would not have writ- stressors by removing the bereavement ders, and psychosis. ten about what he said unless I had exclusion. In their view, they are all The pathoplasticity model claims believed that it posed a legitimate stress-related depressive reactions. that personality disorders are clinical- challenge to psychiatric nosology and Wakefield and colleagues’ solution was ly-relevant conditions because they that others might be inclined to dis- to group uncomplicated mood disturb- affect the course and outcome of other miss such claims out of hand. Person- ances related to the loss of a loved one psychiatric disorders. Those with a ality disorders are controversial, in with uncomplicated mood disturbances personality disorder develop other some cases because they do seem related to other stressors by extending psychiatric disorders earlier in life, more bad than mad, or in other cases the exclusion rule to all uncomplicated have more severe symptoms, and because they approach the boundary mood disturbances preceded by stress. worse outcome. with normality. To say they are disor- In their view these are all normal reac- The spectrum model claims that ders in the own right does not do jus- tions to stress. personality disorders represent milder tice to imperfect distinctions that we Kendler is opposed to making major expressions of the same genetic pre- use. changes without overwhelming evi- dispositions that underlie more serious dence, and because extending the exclu- On the Nature of Grief and De- disorders. Examples of personality sion would be a major change, he pre- pression (Gaier, Pickering) disorders that have been hypothesized ferred making the smaller change of

to exist on a spectrum include schizo- deleting the exclusion rule. Kendler In the past year, Ken Kendler, Mi- typal, cyclothymic and depressive also believed it was important to under- chael First, and I have been working personality disorders. stand the role of stress in precipitating on a history of the debate about the The decline-in-functioning model depressive episodes. Wakefield be- bereavement exclusion during the refers to developmentally unexpected lieved that the more important problem development of the DSM-5. As I declines in function. This is not con- was to correctly demarcate the normal have revisited this topic since writing sidered to be a feature of personality from the abnormal. In his view, the the book, let me briefly summarize disorder, but of personality changes change Kendler and Zisook advocated my current understanding of the main due to a) severe emotional trauma, b) for would increase false positive diag- points in the debate. a previous psychiatric illness, or c) a noses, and the change Wakefield et al. An uncomplicated depressive epi- general medical condition such as a proposed would reduce them. sode refers to cases that meet DSM brain injury. This is largely a histori- This debate attracted a great deal of criteria for a major depressive epi- cal model related to the relationship media attention and stimulated consider- sode, i.e., two weeks of symptoms between degeneration theory and per- able activity in the blogosphere and nearly every day, but does not feature sonality pathology. But to some ex- journals. As you read through the argu- severe symptoms such as suicidal tent, if these symptoms are medical ments across the different platforms, ideation, psychomotor retardation, conditions in the context of injury and three distinct views about the nature of psychosis, or degradation of self- insult, they gain some medical rele- depression emerge. esteem. Beginning with the DSM-III, vance in the context of personality The first view construes intense grief uncomplicated depressive episodes disorder. and depression as lying on a continuum. that occur after the death of a loved The impairment-distress model ar- This view is congruent with dimension- one were considered to represent nor- gues that personality styles and traits al models of psychology in which nor- mal bereavement, not major depres- can be considered disordered if they mal mood and depression are continu- sive disorder. This was called the be- reliably lead to distress or impairment ous in the population. In the boundary reavement exclusion rule. in social and occupational function- region that transverses both, it can be Ken Kendler’s research has indicat- ing. Based on what I wrote earlier in difficult to decide what is normal or ed that the onset of a depressive epi- this response to Jeff, all of the other abnormal. sode is commonly preceded by stress. models would have to refer to this The dimensional model for depres- This made him wonder why one model in some way or another. sion is quite similar to the classical so- stressor – the loss of a loved one – The capacity failure model em- rites problem in the history of philoso- was being treated differently from all phasizes the failure to develop one or phy. Sand scattered on the floor and a other stressors. Working with Sid more psychological capacities that heap of sand are clearly distinct. If you Zisook, he discovered that there were contribute to normal functioning. gradually add one grain of sand to some very few differences between uncom- Unlike the decline-in-functioning sand scattered on the floor, eventually plicated depressive episodes related to model where capacities are lost, in you will produce a heap. This raises a

44 Volume 24, Number 1 2017

question - at one point does adding People who are trained in psychologi- one more grain of sand create a heap? cal assessment learn that DSM symp- Many thinkers believe that there is no Robin Gaier toms are selected, ideally, to be both precise point at which adding one sensitive to the presence of a disorder more grain will constitute a heap. As Robin Gaier’s commentary was and specific to that disorder. Specific Lying between scattered sand and a largely an attempt to augment what I means they are indicative of that disor- heap is a vague boundary region wrote in Chapter 10, to return the der only, and not indicative of other where a precise distinction between favor I will augment her commentary. disorders. One consequence of these non-heaps and heaps cannot be made. The first point I would like to make selection rules is that DSM diagnostic The same may be the case for making is on treatment. Gaier is certainly criteria do not provide a comprehensive a categorical distinction between in- correct that much of the controversy or content valid description of a disor- tense grief and mild depressive epi- about eliminating the bereavement der. For instance, anxiety and deperson- sodes. exclusion was directed at the implica- alization are common features of de- With respect to Rachel’s Cooper’s tions for pharmacological therapy, not pression, but not specific to depression comment about bivalent logic, I doubt counseling and psychotherapy. and therefore not DSM diagnostic crite- that it can be applied to sorites type For instance, Allen Frances is sym- ria. This is one reason why being too vagueness, i.e., whether something is pathetic to a dimensional model in literal about DSM definitions, or reify- a heap is not always either true or which the threshold between normal ing them is a problem. false. The claim that all vagueness is and abnormal is fuzzy. For him, in- For this reason, in addition to being epistemic vagueness (meaning that tense grief is like an unambiguous trained in diagnosis, it is important to be there actually is a precise point at subthreshold condition. One of his trained in the study of psychopathology which adding one more grain of sand main concerns was that giving sub- – scientifically, conceptually, and his- will create a heap) is more like a credo threshold conditions diagnostic labels torically. Assigning a diagnosis, devel- about what the world should be like. would result in aggressive treatment oping a classification/nosology, and The two other views construe grief with medication, even if it was not working with patients are somewhat and depression as qualitatively dis- needed. This risk for harm would be distinct activities. Each of these can tinct. One of these views was promul- increased, he believed, once the drug benefit from expertise in psychopathol- gated by Jerry Wakefield. According companies spotted a potential new ogy. to Wakefield, in a depressive disorder market and began advertising the ben- The bereavement debate calls atten- there is an objective dysfunction in the efits of medication during bereave- tion to the importance of understanding person, whereas in intense grief our ment. psychopathology in assigning a diagno- normal loss response mechanisms are One of the arguments for deleting sis when operationalized diagnostic functioning properly. Grief and de- the bereavement exclusion was that it criteria fall short. My book emphasized pression can look similar because would make it easier for people in the role of understanding psychopathol- symptoms such as depressed mood bereavement to obtain treatment if ogy in classification. Working with and inability to feel pleasure are not needed. Those who wanted to retain patients benefits from a more varied and specific to depression; they are also the bereavement exclusion did not clinically richer understanding of psy- common features of normal grief. believe that it interfered with people chopathology than is encoded in the Although we cannot directly observe obtaining treatment because the DSM DSM -as emphasized by both Grant dysfunctions, Wakefield proposes that -IV was flexible. If a physician want- Gillet and Héctor Pelegrina Cetran in we can indirectly detect them because ed to treat a patient with a bereave- their commentaries. they manifest as symptoms that are ment-related uncomplicated depres- In her commentary Gaier argues that not proportionate to the stressor. Ex- sive episode they could code them as information gleaned from the first- amples of symptoms that lack propor- depressive disorder not otherwise person perspective can also play a role tionality are suicidal ideation and psy- specified. Even if the clinical presen- in determining disorder status. I would chomotor retardation. For him what tation did not meet criteria for a major agree. In his commentary Mel Woody are qualitatively distinct are stress- depressive episode, they could code points to my tendency to refer to all related uncomplicated depressive epi- adjustment disorder with depressed diagnostic criteria as “symptoms.” sodes and major depressive disorder. mood. Let me also note that Jerry Technically, symptoms refer to first- A different view was articulated by Wakefield even argued that some person reports and signs refer to observ- Sid Zisook and Ron Pies. According features of normal grief are inherently able behaviors, so first-person reports to them, having the symptoms of de- impairing, and in certain cases treat- are included in the DSM. To some ex- pressed mood, lack of ability to feel ment may be appropriate. tent, however, the considerations Gaier pleasure, fatigue, concentration prob- One of Gaier’s more important explores about the importance of a first- lems, and sleep disturbance most of points is that the clinical task of diag- person perspective are more relevant to the day nearly every day for two nosis (determining if someone meets psychopathology with respect to work- weeks or more is a depressive DIS- criteria for a disorder) is not the same ing with patients than for constructing ORDER. In contrast, during normal as nosology (determining whether a and revising a general classification. For grief, a symptom such as inability to particular phenomenon should be instance, learning from Mary’s first- feel pleasure is not all encompassing; classified as a disorder). In other person report that some of her symp- rather, it occurs in waves and alter- words recognizing that someone toms of depression are a manifestation nates with positive memories of the meets criteria for a depressive episode of an existential crisis is therapeutically lost love one. For them what are quali- requires a different skill set than justi- relevant, but this might not be a feature tatively distinct are normal grief and fying the claim a depressive episode of depression-in-general. With a con- uncomplicated depressive episodes. is a psychiatric disorder. Let me ex- cept such as depression-in-general, pand on this. 45 Volume 24, Number 1 2017

many particularities of individual cas- al network. Being a causal network tain nodes in a depression network es are dropped out. would not make well-being a disor- would have a causal connection to lone- It is also true that a role for the first- der. From my perspective, the net- liness. Does this make loneliness a part person perspective has been men- work model is interesting as a less of the depression network? The same tioned in the literature on the bereave- essentialist alternative to the more could be asked of other correlated fea- ment exclusion over the years. For traditional latent variable model, and tures, such as anxiety and depersonali- example, in her groundbreaking work has some important advantages for zation. How do we decide what is to be on normal bereavement in the late thinking about issues such as comor- considered part of depression and what 1960s and early 1970s, Paula Clayton bidity. I am skeptical, however, about is to be considered something correlated claimed that even if those in mourning adopting it as universal model for all with depression? This is important if are depressed, they do not view them- psychiatric disorders. Denny Bors- we accept that DSM signs and symp- selves as ill. This includes people boom seems to be moving in this di- toms are only partial representations of with a history of depressive disorder. rection and I am disinclined to follow the phenomena being classified. In some cases, they want to feel bad him there. This is partly an empirical issue – about the loss. Second, my historical reconstruc- especially in determining if the features So one possible consideration in tion of how the domain of psychiatric are actually correlated. For instance, making a diagnosis is whether or not disorder was built (as an imperfect Neil refers to research by John Caciop- the person believes that their distress community) was not intended to justi- po and colleagues about the relationship is normal, or valuable. This is, howev- fy the putative disorder status of eve- between loneliness and depression. er, deservedly controversial as a gen- rything in the domain. It was primari- What Cacioppo and colleagues found eral rule. Some people may seek to ly an attempt to describe how we got was that loneliness measured in one occupy the sick role, even if they can here and to note that the domain year was positively correlated with de- function adequately. Others may ig- “hangs together,” giving it an inde- pression in the next year, but depression nore or deny symptoms that are unam- pendent identity that makes it more measured in one year was not correlated biguous declines-in-functioning and than just what psychiatrist decide to with loneliness in the next year, i.e., threats to health. For instance, treat. loneliness predicted depression but not whether those with severe cognitive The example I used at the end of vice versa. This suggests that loneliness impairments related to a traumatic chapter 8 was major depressive disor- is a risk factor for depression, but the brain injury or with der. If we adopt a more dimensional reverse is not true. That seems like a view themselves as being ill probably perspective on depression, we should good reason for not considering loneli- shouldn't play a very large role in di- expect that there will be a boundary ness to be part of depression. agnostic decision-making. For condi- region that shares features with a nor- My philosopher colleagues will tell tions that transverse the boundary mal mood disturbance on one side and you that the part versus whole issue is between the normal and the abnormal, a depressive disorder on another. an important metaphysical problem. however, considering a patient’s own What I am doing at the end of chapter From the perspective of network theory, norms might be a practically relevant 8 is asking, for an individual case lonely feelings experienced by a person part of clinical judgment. manifesting depression symptoms that who is vulnerable to depression could are part of the domain of psychiatric be one pathway into a depression net- Neil Pickering disorder, what features makes it more work, which it would then be part of. If like normal cases or make it more like we could intervene on loneliness to also Neil Pickering and I adopt a very disordered cases. ameliorate a case of depression, we similar perspective when choosing Any specific occurrence of a psy- might be more inclined to see it as part what to write about. We both are in- chiatric disorder can be seen as hav- of depression. These are very prelimi- terested in picking a position that we ing bundles of features. These fea- nary thoughts and this requires further are inclined to disagree with, such as tures are not limited to lists of sensi- pondering. For now, I would say that we antipsychiatry, but to also take it seri- tive and specific DSM symptoms. can draw the boundaries around an indi- ously rather than dismiss it. As a re- Not all features need to be present in vidual depression network widely sult, we call attention to what might every case, but the more of them that (including loneliness) or narrowly be valuable in the opposing position, are present, the more confident we are (excluding loneliness). If we drew the but also articulate reasons for not ac- in calling something a disorder. For boundaries differently in response to cepting it. We also adopt a non- instance, features such as a past histo- different goals, each would then be a essentialist perspective on disorder ry of depression, a depressive episode practical kind in my menu of kinds. concepts, although we get there from that appears without apparent cause, different starting points. depression lasting more than six The Biological Revolution and the However isomorphic our views, months, and an absence of compensa- Current State of Psychiatry Neil’s reconstruction of what I wrote tory factors all would make a mood (Hardcastle, Waterman, Porter, & in chapter 8 was not what I intended disturbance more disorder-like. My Woody) to say. I begin with two brief clarifica- list was not meant to be a complete tions. list of relevant features, far from it. In the 1960s Thomas Szasz triggered First, I did not intend to say that Neil also asks a question about the an intense controversy by declaring that being a causal network makes some- boundaries of causal networks, raising mental illness was a myth. Also during thing more disorder-like. For instance, an important issue I did not explore. this decade, it became publicly evident some psychologists have suggested For instance, we can expect that cer- that American psychiatrists could not that well-being could represent a caus- reliably agree on something as funda-

46 Volume 24, Number 1 2017

mental as whether a patient has schiz- come one of the least competitive and than saying that grief reactions might, ophrenia. Thus began a still ongoing least lucrative medical specialties. like pain and addiction, involving altera- conflict about whether psychiatry is a This situation does not look like it tions in our reward system, however, legitimate medical discipline. will improve soon because the devel- she does not say much about grief, com- During the same decade, a minority opment of new and better drugs has plicated grief, and depression. of psychiatrists believed that, under stagnated, and even the drugs that Others have said more. For instance, the dominance of the psychoanalytic were supposed to be better than what in the 1980s Donald Klein observed that paradigm, psychiatry was not a legiti- preceded them have mostly turned out there are to two distinct grades of de- mate medical discipline. In the early to be different, not better. pression. In the milder version the de- 1970s, some members of this minority Part of psychiatry’s problem is due pressed person does not anticipate at Washington University in St. Louis to the economics of health care. Many pleasure (wanting), but they still can began publishing work that contribut- psychiatrists spend their days, unsatis- enjoy typical pleasurable experience ed to what some have called a revolu- fyingly, seeing one patient after an- when they occur (liking). In the more tion. Surprisingly quickly, this revolu- other for brief medication manage- severe version, the depressed person tion swept away the psychoanalytic ment sessions. According to current does not anticipate pleasure nor enjoy hegemony in favor of a more biologi- conventions, one way to make a drug typical pleasures when they occur. cally-oriented psychiatry. Although more effective is to boost it with a This distinction within the reward had been intro- second prescription and then another system has been part of how I have duced in the 1950s, it was still a tod- and then another. This practice is also thought about depression for over two dler in the early 1970s – but ready to contested. I have seen many people decades. It is quite useful. Klein was take off with the development of new who function well on multiple medi- also one of his generation’s leading bio- classes of drugs. cations, but also encountered others logical psychiatrists. Biological psychia- The DSM-III is often, incorrectly, on such an intense polypharmacy trists, therefore, have known about this seen as being designed to promulgate regimen that, at times, rather than distinction for over twenty years, but it this revolution. The main architect of feeling normal, they feel muted. For a has not led to the isolation of diagnosti- the DSM-III, Robert Spitzer, was not variety of reasons, economics includ- cally useful biomarkers for depression. trained as a biological psychiatrist but ed, the biological psychiatrists’ strate- How is it that promising leads such as as a psychoanalyst. He had also been a gy for enhancing the reputation of anticipating pleasure versus enjoying psychology major in college and pre- psychiatry within medicine has had pleasure have so far tended to not work ferred doing psychometric research, the opposite effect. out as expected, i.e., what are the rea- such as developing rating scales. In sons that diagnostically useful bi- fact, at Columbia’s New York State Valerie Hardcastle omarkers have not been discovered here Psychiatric Institute he worked in psy- or elsewhere in psychiatry. Tentatively, chologist Joseph Zubin’s biometrics Valerie Hardcastle claims that dis- from the perspective of clinical psycho- department and his main collaborator coveries about neural function can logical science, one of these reasons was the psychologist Jean Endicott. potentially contribute to a better, might be a problem with external and The psychiatrists in St. Louis were more refined conceptualization of ecological validity. When you experi- themselves developing an operational psychological phenomena. This is mentally isolate a particular structure or approach to diagnosis that would in- sometimes called biological- functional circuit in the brain, that sig- crease reliability and, they believed, psychological co-evolution. One of nal gets lost in the noise that exist out- assure that people in the same diag- my favorite examples of a co- side that artificial experimental situa- nostic category shared the same ill- evolutionary process occurred in ad- tion. For instance, neural activation ness. This cohered well with Spitzer's diction studies, specifically in the may be somewhat “pleiotropic” for psy- interest in psychological measurement research supporting the distinction chological function, depending on what and many people associated with the between liking and wanting. This else is activated. This external validity St. Louis Group became members of distinction has been popularized by problem is enhanced further by the high his leadership team for developing the Kent Berridge and colleagues based levels of measurement error that are DSM-III. Although Spitzer did not on their discovery that liking and tolerated in imaging studies – as has intend the DSM-III to usher in a bio- wanting have different biological sig- been pointed out by Scott Lilienfeld. logical revolution, and the DSM was natures. With respect to addiction, if As I described in my preliminary re- not biologically-based, several mem- an addict reaches a satiation point marks, there exist different theoretical bers of Spitzer’s Task Force saw the where the drug is no longer associated perspectives on the nature of grief and DSM-III as supporting the goals of the with pleasure (liking), he or she will depression. If either Zisook and Pies or biological psychiatrists. still have a strong desire (wanting) for Wakefield is correct about grief and The biological revolution, however, the drug and continue to use. Prior to depression being qualitatively distinct, has resulted in an unforeseen irony. this discovery, it was assumed that then we could be more hopeful that the During the years of psychoanalytic wanting a drug was a function of the psychological distinctions we make dominance, psychiatry was a sought reward of pleasure, but wanting ap- might map onto isomorphic distinctions after specialty and attracted some of pears to be a reward system phenome- somewhere at the biological level. If, the brightest medical students into its non that is independent of pleasure. however, the two exist on a continuum ranks. This was also the case in the I agree with Valerie that under- with a fuzzy boundary region separating early days of . standing the biology of the reward clear cases, we might expect that the Thirty years into the biological revo- system should be relevant for under- same gradations that are observed at the lution, however, psychiatry has be- standing grief and depression. Other psychological levels will occur down

47 Volume 24, Number 1 2017

below, and a categorical distinction are useful for both panic disorder and in a population, and develop empirically between normal and abnormal will be generalized anxiety disorder, are as valid treatments. difficult to make at lower levels as the higher potency benzodiazepines. That is not the same as saying that well. In addition, family studies in behav- scientific research alone determines Where do such considerations leave ioral genetics indicate that panic dis- whether a particular condition is a disor- Locke’s concept of workmanship that order and generalized anxiety disorder der. Consider sexual orientation. If was introduced in the opening sec- aggregate separately, but in structural some researchers at the NIMH were to tion? Let me discuss this with refer- equation modeling where the variance discover unambiguous biological sub- ence to a psychological distinction is partitioned into genetic and envi- strates for being lesbian/gay versus het- that was initially made using a biolog- ronmental factors, they appear to erosexual, would this mean that being ical intervention, the distinction be- share the same genetic risk factors. lesbian/gay is a psychiatric disorder? tween panic disorder and generalized What implications does this have Would these substrates constitute the anxiety disorder. Ken Kendler has for the workmanship of human under- disease etiology of homosexuality? written about this in chapter 38 of standing? Once a signal is detected, Most thinkers would say no. Different Philosophical Issues in Psychiatry IV an important task for workmanship is kinds of evidence suggest that being edited by Kendler and Parnas for Ox- to boost that signal in ecologically lesbian/gay is better considered a bio- ford University Press in 2017. realistic settings. As Kendler notes, in logically-based normal variation, not a In the DSM-II of 1968, the category both the DSM-III-R and the DSM-IV disorder. For instance, lesbian/gay of anxiety neurosis referred to anxious the diagnostic criteria for generalized relationships are not compulsive and over-concern that often included feel- anxiety disorder were altered, in part, short-term as once considered. This too ings of panic. The anxiety also mani- to create a greater separation between is a research finding, but its informa- fested in any circumstances rather panic disorder and generalized anxie- tional value also depends on norms than being restricted, like phobias, to ty disorder. For instance, in DSM-III- about healthy relationships. specific situations or objects. In the R the minimal duration criterion for For the present, I side with thinkers DSM-III of 1980, anxiety neurosis generalized anxiety disorder was in- such as Derek Bolton who are skeptical was split into panic disorder and gen- creased six fold, and the focus of wor- about fully naturalizing the concept of eral anxiety disorder (GAD). The jus- ry was specified to not be about panic. disorder. For instance, Bolton argues tification for this split was Donald In the DSM-IV, the number of symp- that psychiatric disorders are identified Klein’s discovery that the tricyclic toms was reduced from eighteen to for being violations of psychological antidepressant imipramine was specif- six by deleting any motor symptoms norms – as ways of interfering with the ically useful for treating inexplicable and autonomic symptoms that were valued activities of daily life (i.e., dis- panic attacks. Klein referred to this related to panic. tress and impairment). The initial work approach to classification as pharma- Using my terms from a 2012 chap- making the normal versus abnormal cological dissection. ter titled Progress and the Calibration psychology distinction is the perception In addition to being biologically of Scientific Constructs: The Role of of particular kinds of norm violations, meaningful, this distinction between Comparative Validity, the DSM’s and without either current violations or panic disorder and GAD is psycholog- generalized anxiety disorder construct possible future violations, the psychiat- ically meaningful. The different thera- was calibrated to achieve the goal of ric disorder attribution could not be jus- peutic approaches adopted for panic clearly differentiating generalized tified. disorder and generalized anxiety dis- anxiety disorder from panic disorder, For severe depressions that involve order further validate the distinction. scientifically and clinically. Calibra- deficits of wanting and of liking (called The validity of a panic disorder tion is a form of workmanship. It is the melancholic subtype), the norm vio- syndrome was further confirmed by not that the DSM-IV construct for lations are numerous. For milder defi- the discovery that sodium lactate in- generalized anxiety disorder corre- cits, similar internal states may be more fusion was more likely to induce a sponded to a definite world structure or less incapacitating across people de- panic attack in patients with panic and the DSM-III and III-R constructs pending on their respective vulnerabili- disorder than in both normal controls were fictions. Indeed, deleting the ties and strengths. For instance, two and patients with other psychiatric references to panic in generalized people may be experiencing a mild de- disorders anxiety disorder may be a distortion. pressive reaction during bereavement. As Kendler reports, as new valida- The value of the new DSM-IV con- The first may have good social support, tors were selected to further test the struct for generalized anxiety disorder an engaging job, and an internalized distinction, the results grew murkier. is that it better coheres with a number sense of worth. The second may be For instance other drugs known to of scientific and therapeutic goals. isolated, working an unsatisfying job induce panic attacks are not so specif- A very different sort of problem is that is of much lower status than he pre- ic. Administration of carbon dioxide raised by Valerie Hardcastle’s claim fers, and unable to regulate esteem au- induces more panic attacks in people that science should define disorders. I tonomously. It is at least possible that with panic disorder than all other would like to clarify my position here. the first person manages the mood dis- comparison groups, but it also induces Once we demarcate disorders such as turbance, whereas for the second person a high number of panic attacks in major depressive disorder and panic it becomes unmanageable and judged to those with generalized anxiety disor- disorder, we should seek to scientifi- be a disorder. der and premenstrual dysphoric disor- cally understand the mechanisms that der. With respect to pharmacological produce and sustain those phenomena, Scott Waterman dissection, the newer classes of anti- seek to map their rates of occurrence depressant such as SSRIs and SNRIs

48 Volume 24, Number 1 2017

Scott Waterman was one of those They are not mythical illnesses in the In his commentary Doug focuses on bright students attracted to the new Szaszian sense. the interaction between the essentialist biological psychiatry and its mission Should we try to prevent schizo- bias, the metaphysics of natural kinds, of making psychiatry more scientifi- phrenia and bipolar disorder from and misplaced literalism. In doing so he cally rigorous. He spent his career in occurring if we could? I would say raises a question about the proper object a medical school overseeing the edu- we should. That intervention ques- of treatment. A cardiologist treats mitral cation of aspiring physicians. For tion, however, becomes more difficult value prolapse as a technical problem. many of those years he did not believe to answer once the spectrum concept A dentist treats a dying tooth as a tech- that the DSM was a useful tool for is introduced. A spectrum refers to nical problem. They are each able to education, and eventually came to various graded manifestations of a achieve technically amazing things be- believe the same thing about some shared genetic vulnerability. For in- cause of how much they have learned aspects of the current iteration of the stance, schizotypal personality is on about the heart and the tooth. For the biomedical model itself. the schizophrenic spectrum and cyclo- most part, one mitral value is like other In the book I proposed a radial thymic personality is (probably) on mitral valves and one instance of infect- structure for the domain of psychiatric the bipolar spectrum. It is arguable ed pulp is like other instances. By analo- disorder. In this radial structure, psy- that these personality styles could be gy, it could be argued that psychiatrists chotic disorders occupy the center of considered normal variations rather should treat the clinical entities of major the domain. As you move away from than disorders and left alone – even if depressive disorder and PTSD as tech- the center and toward the boundary they involve transient distortions in nical problems, but being able to do so with normality, putative psychiatric reality testing. I suspect, however, will depend on learning more about the phenomena get less disorder-like. that there would be a good deal of brain, or about cognitive-affective psy- The concern voiced at the end of consensus about considering sus- chology. Scott’s review of the book, originally tained psychotic episodes to be disor- Given the success of the technical published by Metapsychology Online dered states and preventing them. approach elsewhere, I do not see how it Reviews, is that to treat psychotic Interestingly, I am also inclined, can be avoided in psychiatry. The clini- states such as schizophrenia and bipo- like Scott to be cautious about apply- cal entity perspective (whether con- lar disorder as diseases is to shove ing the disease label, especially if strued as a natural or practical kind) can them into a procrustean bed that, in disease is conceptualized in an essen- help us see things about major depres- practice, encourages adopting an over- tialist manner. Rather than there be- sive disorder or PTSD that we did not ly narrow view of these phenomena. ing a universal disease nature that is see before. The problem with the tech- For instance, antipsychotic medication equally present in all things called nical approach is that it has not worked nearly always produces unpleasant diseases, the concept of disease refers as well as expected. It is now in vogue side effects, and for some patients the to a family of different states. If the to blame this failure on the invalid cate- side effects are more prominent than concept of disease has a radial struc- gories of the DSM. If we had a better the therapeutic effects. These clinical ture, I might place infectious disease nosology, the thinking goes, the tech- features tend to be minimized in the such as tuberculosis near the center. nical success enjoyed elsewhere in med- biomedical disease model. Also near the center would be genetic icine would accrue to psychiatry. I largely agree with Scott. Given diseases such as Huntington’s disease I am less sure. Much of medicine that a cure seems to be out of the and autoimmune diseases such as type probably involves more guess work and question for now, an alternative goal I diabetes. I would think allergies, trial-and-error than common sense es- is to help people live as meaningfully poisoning, and heat stroke would be sentialist ideas about disease would lead and freely as possible. It turns out further way from the center, as would us to expect, and psychiatry is not dif- that with effort, some people can learn psychosis. Hypertension and hyper- ferent from many other specialties in to live with symptoms adaptively ra- cholesterolemia would be nearer to this respect. But Doug points us in an- ther than having them medically sup- the fuzzy boundary with normality, as other direction – toward the view that pressed. This rehabilitation approach would a grief-related depressive reac- the problem may not be the invalid cate- is similar to the kinds of services of- tions and some personality disorder gories of the DSM, but the complexity fered to people with traumatic brain diagnoses. of psychiatric distress and impairment injuries, – another ailment where cure themselves. is currently not possible. Doug Porter One has to be careful that talk about I am still inclined, however, to place the “complexity” of the psychiatric do- psychosis near the center of the psy- Doug Porter also entered psychiatry main is not a excuse for an obscu- chiatric domain, including schizophre- in the heady days of the biomedical rantism that is resistant to change and nia, major depressive disorder with revolution and has spent his career progress. Yet, it remains true that psy- psychotic features, and bipolar I disor- working with patients suffering from chiatry has almost never turned out to der (i. e. manic depressive illness). major mental illness. As someone be as tractable as expected. Florid psychotic states clearly repre- who works with such patients, he un- There are two aspects to this com- sent developmentally unexpected de- derstands the value of medica- plexity. The first closely tracks my no- clines in function, their onset can be tion. Yet he has also become disen- tion of nominalism in which our general experienced as an affliction, and in chanted with many assumptions of the concepts are inadequate to many partic- psychosis people are readily afforded biomedical model, and especially of ulars of experience. The partialness of the privileges of the sick role – includ- its narrow vision regarding the scope concepts is one reason that entertaining ing a diminishment of responsibility. of psychiatric practice. multiple perspectives can be helpful.

49 Volume 24, Number 1 2017

The second aspect is that the goals concept in which illness is understood we adopt can influence which aspects out there and symptoms signal their through the lens of some theory of dis- of phenomena we weight more heavi- presence, but signification also in- order. Particularly when the infor- ly. As Doug points out, the ultimate volves an act of interpretation. When mation gained from a disease model goal of psychiatry is to reduce the we particularize something such as does not heal, an understanding of ill- suffering and impairment related to anhedonia, we are isolating one aspect ness can contribute to better patient psychiatric distress. The goal of re- of what is ‘ontologically abundant.’ care. ducing suffering tends to give individ- To say that anhedonia signals major Not only is psychopathology broader ual features of a case more importance depressive disorder is to notice a rela- than classification and nosology, as the than they would receive in the clinical tionship between one thing and anoth- humanist Kleinman notes, human expe- entity approach. For things like grief- er, but that is not the only possible rience is broader than psychopathology. related depression and PTSD, for in- relationship that we can notice. This I would add broader than does not mean stance, the individual content of the makes noticing an interpretation. independent of. Our understanding of person’s thought (this lost loved one, As I understand him, Mel says that psychopathology without classification this traumatic event) become part of anhedonia can be interpreted to sym- would be more narrow and shallower, the treatment. bolize many different things. I would and likewise our understanding of hu- Should psychiatric disorders be argue that a kind concept such as ma- man experience without psychopatholo- studied as clinical entities or is the jor depressive disorder is also an ab- gy would more narrow, and shallower. clinical entity view an illusion be- straction from what is ontologically In the next section I will say more about cause the nature of psychiatric disor- abundant, and what it “symbolizes” is the relationship between classification ders cannot be separated from the partly also a function of interpreta- and psychopathology. context of the individual psyche, the tion. society, and the culture in which they For example, when we say anhe- Psychiatric Classification is not the appear. I would say that clinical enti- donia signals depression, does that Same as Psychopathology, but it is a ties are not illusions. For example, by mean that it signals an affliction – Substantive Part of it. observing many cases of an epidemic something forced upon me and be- and discerning a common clinical yond my control, or could it signal a In my response to Robin Gaier, I stat- entity, Sydenham learned something kind of self-expression – an act of ed that diagnosis, classification and that the individual-centered Galenists giving up or withdrawing? Indeed, working with patients are somewhat never saw. In psychiatry, however, to both interpretations might provide us distinct activities, but all benefit from an absolutely separate disorders from with important information. In this understanding of psychopathology. their context is to misunderstand respect, Mel’s claims about the onto- Although Grant Gillet’s and Héctor them. As Doug’s commentary indi- logical status of symptoms recalls Pelegrina Cetran’s commentaries could cates, they are not isolated from what Locke’s workmanship of the human have fit into both of the previous sec- else is going on around the person. understanding, and even more so Nel- tions, as each takes a more critical son Goodman’s metaphysical notion stance, I have grouped them separately. Melvin Woody of worldmaking. In titling the book A Metaphysics of I have often written about our nam- PSYCHOPATHOLOGY, I opened my- Melvin Woody’s introduction of ing practices, but Mel helpfully shows self to scrutiny. Both Gillet and Pelegri- semiotic considerations takes us into that names are also interpretations. na Cetran argue that my account is inad- deeper waters. From a classification Just as phenomena are not constituted equate and offer their own substantive standpoint, symptoms are usually con- by names and concepts, phenomena views on the nature of psychopathology. sidered fallible indicators of some are not constituted by interpretations. The philosophy in A Metaphysics of underlying pathological process. In In the book, I do not discuss this us- Psychopathology was drawn from the clinical psychology’s construct validi- ing the language of semiotics, but my history and and ty tradition, underlying pathological claim that the notions of natural kind, largely applied to psychiatric classifica- processes are modeled as latent varia- practical kind, historical kind and tion. Focusing on psychiatric classifica- bles. In the causal network tradition normative concept are cognitive re- tion as I did imposes constraints. Clas- discussed by Neil Pickering, disorders sources can be used to reveal different sification systems such as the ICD and are produced and maintained by caus- information about the phenomena of the DSM should not be used as text- al relationships between symptoms. psychiatric disorder is making a simi- books of psychopathology. The ICD has Rather than observable indicators of lar point. no aspirations to be a textbook. The underlying processes, symptoms are Mel also calls attention to how dis- DSM, however, offers more than a list- considered to be parts of disorders. orders are not the only things that ing of diagnostic criteria. It includes In addition to issues about whole symptoms indicate, and to think of sections on development and course, and parts, the latent variable versus symptoms only as signifying disor- risk and prognostic feature, and cultural- causal network distinction raises ques- ders is to view them (and disorders) related diagnostic issues, making it text- tion about the nature of properties. It too narrowly. His thinking here has book-like. is probably obvious that I would not been inspired by Arthur Kleinman’s Classification, however, is only part view properties as universals. distinction between illness and dis- of psychopathology. An understanding Mel’s comments orient us in differ- ease. By illness, Kleinman means the of various theoretical perspectives on ent direction, toward symptoms as variety of ways we experience and disorder constructs is another. These, signifiers. A key idea here is that we understand medically-relevant human perspectives can be found in both the tend to think that disorders are entities suffering. Disease is a professional professional and scientific literature. A

50 Volume 24, Number 1 2017

familiarity with the history of psycho- general cultural factors. For instance, pathology is also important. Ideally in the discourse of the soul are not what are his views regarding being a one’s understanding of psychopathol- mere epiphenomena, but real features man, his views about marriage, or his ogy should be augmented with per- of psychiatric disorder as experienced ideas about and religion? spectives from the study of normal by persons rather than as described in Another relevant domain is that of psychology, social work and sociolo- diagnostic manuals. personality. For a diagnosis of hysteria, gy, anthropology, political and social I agree with Grant that psychia- we might expect such a person to be criticism, history, and philosophy. As trists, psychologists, and other mental extroverted and attention seeking, high- important as anything, is working with health processional should interact ly impressionistic, distractible, and lack- patients. with individuals, not just tokens of a ing in factual knowledge. He might be Although classification is only a disorder, but I do not agree that the suggestible and emotionally expressive, part of psychopathology, it is a neces- imperfect community model is too although his emotions may have a per- sary and substantive part. As a result, sparse to be relevant to achieving this formative aspect and be rather shallow. the wide variety of commitments that humanist perspective. Just the oppo- To the extent that any of these fea- are adopted for classification such as site is the case. tures apply to this case, they could be the causal versus descriptive, essen- As Grant’s perspective seems to be relevant to working with this patient tialist versus non-essentialist, and nat- partly based on his training in neurol- because the developmental, cultural and uralist versus normativist perspectives ogy, let me describe my own training personality domains are important indi- have direct influences on our stand- history. In some psychology pro- viduating factors. At the very least they ards for “relevant,” “real,” and “valid” grams, clinical training begins with taking account of them can contribute to psychiatric disorder constructs. In my administering structured interviews to the establishment of a decent working responses to Gillet and Pelegrina Ce- establish a diagnosis. In other pro- alliance. All these factors are real, and tran, I hope to illustrate the kind of grams, it begins by learning to treat a they make this person more than a token substantive contribution that classifi- condition such as depression using an of conversion disorder. That is not all cation theory can make to psycho- empirically-supported treatment man- there is, and more could be added, but pathology. ual. The emphasis is on disorders. neither is it sparse. My training in all-purpose psycho- The imperfect community model re- Grant Gillet therapy was quite different. For the fers to the notion that the class of psy- first couple of years I was taught to chiatric disorders hangs together, but The first part of Grant Gillet’s com- attend to the developmental challeng- not because of a shared essence. The mentary is partly a reconstruction, es typical of a client’s age and/or life notion of networks embedded in net- from the perspective of a different stage. Development can be divided works augments this by emphasizing philosophical paradigm, of various into career, social, and personal devel- that the nature of disorders cannot be assertions I made in the book. For opment – each considered as a distinct solely located in fixed internal proper- instance, he offers a neurological and domain. We were also taught to at- ties. The multi-domain approach that I ethological account of the nominalist tend to gender, race, and cultural fac- learned in my psychotherapy training view of concepts as partial representa- tors. was one of the frameworks that in- tions that both reveal and conceal phe- In supervision, the focus was not on formed my thinking about the domain of nomena. His Rule Maker claim is con- establishing a diagnosis but on the psychiatric disorder. sistent with my emphasis on how de- process occurring between therapist The imperfect community model, pendent we are on authorities in form- and client. Whatever the merits or however, was proposed for mostly phil- ing beliefs. Asserting that a touch of demerits of this approach, one merit osophical purposes with respect to psy- the real can intrude and thus compel was that I was not taught to initially chiatric classification. In the book, I the Rule Makers to modify their be- view a client as a token of a disorder. introduced the imperfect community liefs is compatible with my thinking When disorder constructs were intro- model by referring back to my notion of about mind-independence. Finally, duced, they were partly seen as being instrumental nominalism from an earlier his notion that scientific concepts pre- embedded in these other domains. chapter. The problem with general kind sent the world in ways suited our in- This was a pluralistic model in which concepts is that important particularities terests and practices has a strong prag- taking account of different domains are dropped out, and if the concept be- matic flavor to it. could reveal unique information about comes reified or is taken too literally, it However, Grant is critical of the the person. can distort the phenomenon. However, imperfect community model as a theo- Let us combine this developmental we also learn about things by grouping ry about the nature of psychopatholo- perspective with the notion of symp- them together under kind concepts and gy. Using an example of a young man toms embedded in networks by look- seeing what they have in common, so with conversion disorder, he says that ing at Grant’s example of conversion kind concepts can be useful instruments. we can explain the conversion symp- disorder. Grant’s patient is a male Darwinian non-essentialists view a toms as a pattern of brain activity, but with a highly dominant spouse, and species as population of individuals that only by talking to this person, and he is having an affair. He is likely in vary. This notion that “variation is what learning about his history and his per- his early 40s. Asking about what de- is there” can also be applied to kind sonal situation can we begin to under- velopmental tasks is he facing with concepts such as hysteria, depression, stand the reasons for this patterning. respect to the domains of career de- and schizophrenia, often under the aus- He poetically calls this later perspec- velopment, social development, and pices of family resemblance models tive the discourse of the soul. The personal development might be re- and/or radial categories. Depression and implication is that what we attend to vealing. The same with respect to schizophrenia are analogous to species

51 Volume 24, Number 1 2017

in biological classifications. The im- psychiatry is older than many successful perfect community model moves up together advocates of network theory sciences such as molecular genetics and from the species level to a genus level with experts in dynamical systems robotics. by applying this radial structure to the theory. My ideas about depressive There is currently widespread dissat- domain of psychiatric disorder itself. episodes that are locked-in being isfaction with psychiatry, but rather than The domain was built by an expansion more disorder-like was inspired by the it being a feature of psychiatry as a of its boundaries to include symptom dynamical system theory of critical young discipline, it is a feature of failed clusters that resembled what was al- tipping points and alternative stable expectations contingent upon the inher- ready in the domain in a variety of states. ent complexity of psychopathology. ways, but there is no one way in We are social creatures from the Pelegrina Cetran refers to this complexi- which they are all alike. The psychi- moment of birth. In addition, both ty himself in noting that psychopatholo- atric domain is itself embedded in communitarian and postmodernist gy is a multi-disciplinary endeavor. other domains – personal, interperson- critiques suggest that the isolated What about Pelegrina Cetran’s notion al, cultural – setting up the possibility knower is a myth. Although I am of essences as dynamic processes shap- for significant individual variation. wary of the anti-modern, illiberal ing the structural identity of entities. I By taking this notion of “variation commitments of postmodernism, am constrained in how much I can say is what is there” and making it a part some of its ideas are informative. For because it is hard to get a sense of how of the general concept of psychiatric instance, many of our cognitive his ideas would work in practice. The disorder, the resources for resisting achievements occur through a process intricate mélange of systems theory, reification and misplaced literalism of imitation and borrowing, including enactivism, development psychology, become an inherent part of the con- what we might even consider our phenomenology and more that consti- cept itself. That was the goal anyway. “original ideas.” tutes his metaphysical framework is I too would question an ontology of difficult to decipher from only reading a Héctor Pelegrina Cetran substances, nevertheless, an ontology 5000-word essay. of individuals seems valuable to me. According his “essential activism,” Pelegrina Cetran’s perspective rep- In part, my views may reflect the em- the nature of psychiatric disorder is a resents the kind of theoretically rich phasis on individual differences that destruction or threat of destruction of understanding of psychopathology is paradigmatic of American psychol- the identity of a living entity, based on a ogy. Although we are social crea- that is less common today, especially dis-appropriate structure of behavior, in the U.S. Responding to his com- tures, our relationships are not literal- on a misuse of the information provided ly symbiotic and separation from oth- mentary is more challenging because in normal behavior. From an empiricist he brings very different metaphysical ers is something we all have to nego- perspective that is a quite lofty abstrac- tiate. Even if our ideas come about as commitments to the material than I tion. a kind of imitation, once they become do, and he also comes to a different The same is true for in major depres- internalized they become ours. We conclusion about essences. sion the predominate feature is the con- can also imitate those who reject tra- We agree that the various essential- viction that one’s personal life is threat- dition, and in doing so learn that the isms associated with Plato and Aristo- ened by the inaccessibility of resources freedom to choose to be different is tle distort our understanding of psy- or possibilities for realizing them in this hard to exercise because it can in- chopathology. I argue that this is due world and the pathological element in crease separation. Such considera- to a cognitive bias that we all share. the manic phase is the biographic con- tions readily suggest an ontology of In Pelegrina Cetran’s view, the im- sequences of his unmeasured and in- individuals. portant problem is not a disposition to appropriate behavior with respect to his Turning to the topic of essentialism, expect that the world is pre-organized world and with respect to the own re- my and Pelegrina Cetran’s different into a collection of natural kinds that sources. metaphysical commitments are partly share an identity-determining nature; The shared idea in these definitions is correlated with discrepant views rather the metaphysics of kinds- that symptoms are part of a person- about what might be called psychia- entities-substances is itself problemat- environment system and cannot be un- try’s “identity issue.” Pelegrina Ce- ic because it is the framework in derstood in isolation. Persons are also tran claims that psychiatry is a young, which an illegitimate subject versus agents in this model who are continually even immature discipline. On my object split and reductive mechanistic constructing themselves and their identi- reading, his essential activism ex- accounts emerge. From his perspec- ties in congruence with the environ- presses a view about what a more tive, modern philosophers of both the ment. Psychopathology, he suggests, is mature psychiatry would look like. empiricist and idealist sort continue to a process of . I am not sure, however, that the adhere to this ontology of substances. Disorders may be deconstructive in “young discipline” interpretation of From a pragmatist standpoint I his sense, but a lot of challenges create psychiatry is historically accurate. readily admit that his alternative – a disharmony without being psychiatric The birth of contemporary medical process ontology or a general systems disorders. Why deconstructive process- specialization occurred in the 19th ontology, can be informative, as can es (as essences) are specifically identity- century. In France, an early form of ecological models of psychology. The determining for psychiatric disorders psychiatry (alienism) was one of the network model that I discussed in needs more explaining. Without such first specialties to appear. The estab- chapter 8 is compatible with a systems an explanation, the claim that disease is lishment of University-based medi- theory approach. Some of my deconstructive and health is presumably cine in Germany was even more im- thoughts expressed in the book were constructive works like an ad hoc meta- portant. As a science, the discipline of developed at a workshop bringing physical augmentation that depends on

52 Volume 24, Number 1 2017

the abnormal versus normal distinc- were important factors in rejecting Cart- tion already having been made. ries in geography, atomic physics, and wright’s “slave by nature” notion, just As I noted in the opening section of so on. Coherence does look to agree- as personal experience and narratives my responses, metaphysical minimal- ment, but not the kind of agreement about lesbian and gay people have re- ists worry about people ‘s tendency to based on group consensus and con- cently played a role in changing atti- adopt about abstract concepts a feel- formity. tudes about sexual orientation. ing of certainty that is only appropri- Furthermore, correspondence Jim also made some interesting and ate to the particulars of daily life. with the facts by itself did not lead to important points about my notion that if Inappropriate conviction was one of the rejection of the Drapetomania we cannot acquire any information the things for which the psychoana- construct. Even if it had been widely about a supposed matter of fact, then we lysts were criticized. Their certainty accepted, Drapetomania could not cannot treat it as a fact. Hence, if we about the universal Oedipus complex survive the abolition of slavery. Abo- cannot obtain any information about is a good example of misplaced con- litionism was argued for both on reli- what Arthur Conan Doyle ate for break- viction. One could agree that some- gious grounds and in conformity with fast on a specific day in 1903, then for thing looking like Oedipal dynamics the liberal aspirations of the Enlight- practical purposes, it is not a factual might occur without making the Oedi- enment and the Declaration of the matter. pus Complex into a human universal. Rights of Man. One likely reason that Jim’s counter example refers to the In the same way, an impairment of our slavery was abolished was because it taking of his morning pills. Jim is sup- active attempt to self-actualize in har- was not coherent with some versions posed to take his pills in the morning, mony with our ecology might be a of Christian morality or with Enlight- but he finds that by the time night ar- particular feature of psychiatric disor- enment values. So, Jim correctly pre- rives, he cannot always remember if he der that we can usefully notice, but I dicted that I would say that rejecting took the pills. Whether he did take would not inflate it into a universal, Drapetomania was contingent on a them, Jim says, is still a matter of fact. nor anoint it an essence. specific set of coherence relations He cannot make a valid factual assertion coming to be seen as more important. about whether he took his pills, but it is (An 11th hour) Response to Jim The force of these coherence con- a matter of fact nevertheless. Phillips’ Editor’s Column) siderations (as opposed to facts) may With some caution, I agree, but do not partly explain some of Cartwright’s believe that this example is analogous to Jim Phillips’ claim that corre- own arguments in his infamous essay. the Conan Doyle example. First, con- spondence and coherence are inextri- With respect to the religious grounds, sider defining facts according to what cably entwined is largely consistent Cartwright offered a biblical justifica- philosophers call a God’s eye point of with the general ideas I have been tion for black people being slaves by view. From a God’s eye point of view, attempting to articulate. My argument nature. With respect to the Enlighten- what Conan Doyle ate for breakfast over against correspondence to the facts as ment political values, Cartwright ar- 100 years ago, whether a star is current- a universal standard of truth was not gued that his claim that black people ly exploding more than 15 billion light meant to replace it with another uni- are not suited to freedom and self-rule years away, and the temperature in New versal standard such as coherence is proven by the social dissolution that Haven, Connecticut on July 4, 2055 are with what else we accept to be true. It ensued when former slaves (inspired all presumably matters of fact. I don’t was an argument against taking corre- by the Declaration of the Rights of see how that perspective on facts can be spondence to be the sole standard. Man) took control of the French colo- practically relevant to us. Let me note, however, that my no- ny of Saint-Domingue (later renamed For us, to call something a fact is to tion of coherence and Jim’s appear to Haiti). I surmise he made these assert that we are compelled to accept differ. Jim combines coherence with claims because he realized that the that particular claim about the world no consensus – claiming that if a commu- most damaging arguments against his matter what we want to believe. That is nity of psychiatrists agreed that slaves views were based on considerations of why facts are important in contrast to who repeatedly tried to escape slavery coherence. fantasies and wishes. Is whether Jim were disordered, that consensus could I also acknowledge the important took his morning pills a fact in this re- be shattered by facts showing that the role that facts can play in breaking up spect – independently of the metaphys- consensus was not true. coherent networks of beliefs. Various ics of a God’s eye perspective? Indeed, In contrast, my notion of coherence philosophers (Duhem, Quine, Putnam, it is because we can acquire information refers to coherence with what else is Longino, Lakatos, etc.,) have shown about whether he took the pills and it accepted to be true. Some people that isolated facts bear a complicated may be practically important that we do might say coherence with what else is relationship to networks of abstract so. known to be true. Coherence does not beliefs, and in agreement with them, I For instance, if Jim gets to the end of refer to agreement within a communi- do not hold that facts inevitably speak the month and still has 20 pills out of ty – which can be epistemically flim- for themselves. All the same, net- his original 30, then we have infor- sy. More rigorous than consensus works of principles and their associat- mation about his taking of the pills. He within a group, coherence includes ed “facts” can be dogmatically held has not been taking them regularly. He agreement with other facts, but seeing and experiences that are anomalous could even track the number of pills in facts depends on background assump- with such networks can play im- the bottle throughout the month, which tions, theories, other facts, etc. For portant roles. Fact-based experiences, is what the pill box does on a daily ba- instance, the theory of evolution is testimony, and narratives regarding sis. coherent with the facts of the fossil Black slaves as persons (having emo- More importantly we can also ask record, but those facts belong to theo- tions, talents, values, and aspirations,) what the pills were for – and it may

53 Volume 24, Number 1 2017

matter quite a bit whether Jim takes we conceive the object of our concep- sent in all members of the species (put them. If they are blood pressure pills tion to have. Then, our conception of there by God or by nature). In contrast, and he finds that his blood pressure is these effects is the whole of our con- for Darwin a species is a population of spiking by 8PM, that blood pressure ception of the object. individuals that varies, with no one fea- reading is providing information about For instance, to say that something ture or set of features that that all mem- whether the pills were taken. The is hard is to say, if you scrape it with bers must share. The properties may measure of his blood pressure may a sharp object, it will not scratch; if also change over time. A real species offer more valid information about you throw it through a window, the category can be thought of as a collec- taking the pills than his memory. For window will break, and so on. These tion of individuals that form a homeo- us, this information is accessible and practical effects are important aspects static property cluster in Richard Boyd’s relevant, and thereby factual in the of the meaning of hardness, but they sense or a real kind in ’s way that matters. That was not the are not the whole meaning. For exam- sense. case with the Conan Doyle example. ple, we can discover a new practical Verbal disputes seem inevitable once Let me also say that mattering to us effect such as if you bombard it with we introduce abstract terms like species, does not make something a fact – to radiation, it will not be damaged. Ac- essence, and nature. However, the dif- believe that would be to confuse fact cording to the strict operationalist, the ference between the Platonic concept of with interest and preference. There are meaning of hardness has changed species the Darwinian concept involves many more facts than we will ever with the inclusion of this new test. more than a matter of how we use assert, and most of them are not rele- According to Meehl it has not words. It would take quite a bit of men- vant. Facts about blood pressure are changed significantly – the old obser- tal gymnastics to argue that both the relevant. vations and the surplus meaning are Platonic and the Darwinian concepts of In Jim’s first commentary he took much the same. species are correct. issue with my statements that the truth Theoretical terms, theories, and One of the most important considera- of any claim is an inference supported statements are all different things, but tions in adjudicating between the two is by evidence; that Truth it is not an any claim that one of them is true is that the Darwinian concept of species entity in the world; and that truth is typically going to depend on more readily coheres with and follows from not a property possessed by true state- than observation itself. I do not advo- the genetics of sexual reproduction, and ments. In the book, I was attempting cate for a dichotomy between strict the paleontological and biogeographical to explain why declaring that a claim operationalism (or verificationism) evidence. The Platonic concept preced- “is true!” is not an argument for be- versus a transcendent, noumenal truth ed our understanding of this evidence lieving it. As Jim repeats his concern as Jim seems to suggest, nor would I and, historically, made it harder for us here, I must be missing some point he occupy either end of a dimension with to see paleontological and biogeograph- is making. observation and transcendental truth ical facts. Before trying to address that point, as it end points. Platonic and empiricist commitments let me clarify, that contrary to what Jim’s final point is that people use also have consequences that are more Jim suggests, I do not assert that the words in many ways, and that our than linguistic and each offers range of meaning of a true statement is fully uses of metaphysical terms such as advantages and disadvantages. One ad- specified by the evidence for that real, true, and objective may invoke vantage of a universal human nature th statement. Being a child of late 20 essentialist standards or may invoke shared by all members of our species in psychology and influenced by Paul nominalist and non-essentialist stand- the Platonic sense is it supports the no- Meehl’s notion of construct validity, I ards I agree that the words are used in tion of shared human rights. This is an would not advocate for such a strong different ways and some people may attractive feature. Darwinian models operationalist (or verificationist) per- be more Platonic and others more have a more mixed record here, despite spective on meaning. Meehl’s notion empiricist in how they use words such only being proposed after the Enlighten- of construct validity referred to the as real, true, and objective. This lin- ment. However, if combined with a meaning of theoretical terms such as guistic observation is one common theory of rights, the Darwinian model’s depression (and was largely inspired insight behind the deflationist view emphasis on the continuity of species by ’s notion of partial that many metaphysical disputes are tends to broaden the theory to include definitions). Briefly, Meehl said that often verbal disputes. animal rights to some degree. the meaning of theoretical terms such However, I have typically adopted One advantage of Darwinian non- as depression cannot be fully specified realist commitments about metaphysi- essentialism is that differences are seen by their observational consequences. cal claims involving the nominalist as variations, not deviations from an They have surplus meaning by being and non-essentialist features of empir- essential type. This supports tolerance implicitly defined by other theoretical icism. Consider biological species. in a different way than the Platonic con- terms – for depression that would in- Metaphysical disputes about whether cept does. Seeing difference rather than clude psychosis and psychiatric disor- the species category is a real category deviation is a better kind of tolerance, der. in nature are largely arguments about but complicated because accepting dif- On such Meehlian grounds, I also what one means by “real category,” ference does not mean you tolerate eve- regard the pragmatist theory of mean- but some actual species concepts en- rything no matter what. Tolerance is ing to be incomplete. The most often tail more than how words are used. only meaningful in the context of norms quoted definition of that theory is One way of being a real category is and standards because what we from Charles Peirce. for a biological species to share a “tolerate” is always a violation of some Consider what effects, that might fixed essence that is completely pre- norm. conceivably have practical bearings,

54 Volume 24, Number 1 2017

Concluding thoughts Dr. Kroll and I are now working (Continued from page 1, Editor) with members of the APA general erations of coherence to inform Hopefully, I have explained myself assembly on an action paper to re- what it means to be a fact. If and elaborated on what I wrote in the quest that the Goldwater Rule be so, the correspondence theory book without needlessly repeating ide- reconsidered for a variety of reasons. depends, in part, on the prag- as. Some of what I elaborated on here Disappointingly, the APA ethics matic and coherence theories. was itself a rethinking. This rethinking committee reinforced the Goldwater has been informative to me and maybe Rule last week with little further con- I would argue, in contrast, that to others as well. sideration of the reasons for or coherence actually depends on cor- Like with much in philosophy, my against it. The opinion states that 1. respondence. Human history is overlong responses raise a question Psychiatrists are ethically prohibited replete with examples of this. Take, for instance, the diagnosis of about whether such effort is worth it, or from evaluating individuals without th what contribution it makes. Some permission or other authorization Drapetomania in the 19 century. clues about my answer to that im- (such as a court order), 2. Psychiatric Psychiatrists concluded, in a coher- portant question can be found in my diagnosis without a full history and ent consensus, that run-away slaves repetition of nominalist themes. Essen- examination “compromises both the suffered from Drapetomania. It was tialist thinking is easy to come by and integrity of the psychiatrist and of the later determined that that coherent- difficult to leave behind. Learning to profession itself,” and 3. Public diag- ist conclusion was false. Thus co- adopt a more non-essentialist (or nomi- nosis of a person a psychiatrist has herence succumbed to correspond- nalist) perspective can widen the scope never examined may stigmatize per- ence. The coherentist might now of what we notice. Doing so takes prac- sons with mental illness, and make respond, no, with more evidence tice. My responses illustrate how I established patients wonder about the the false conherentist conclusion practice it, and perhaps some readers quality and confidentiality of their was replaced by a correct coherent- might be encouraged to practice it as own treatment. This opinion is prof- ist conclusion. Now we come back well. fered with only superficial considera- to Peter’s question, but in reverse. tion of the arguments made against He says, “how do we know if what *** the Rule in the setting of last year’s our statement corresponds to is election, and it gives no substantive indeed a fact?” But we can also attention to its claim that expressing ask: how do we ever know if our (Continued from page 1, President) current coherence conclusion is any and conscientiously communicated professional concerns about public better that Drapetomania? I could to the public, the Goldwater Rule is figures creates or promotes stigma now say that correspondence is itself morally problematic. against persons with mental disorders always lurking in the background Since our paper came out, there generally. Dr. Kroll and I, with our to judge coherence. Or, what I real- have been articles and editorials APA colleagues, hope that by contin- ly think, that correspondence and about the Goldwater Rule in the uing to do good philosophy we can coherence are inextricably en- New York Times, Washington Post, get the APA to do so, too. twined. CNN, Associated Press, Huffington In his response to Cooper and Post, fivethirtyone.com, Vice News References Thornton, Peter discusses their Tonight, Vanity Fair, Slate, Forbes, objections to his apparent anti- Psychology Today, and Rolling 1. American Psychiatric Associa- realism, and specifically to his Stone, among other popular publica- tion. “Principles of Medical Ethics statement that “what Arthur Conan tions. The psychiatric trade papers with Annotations Especially for Psy- Doyle ate and drank on a particular regularly address the propriety and chiatry,” 2006 edition. day in 1903 was once a matter of scope of the Goldwater Rule. Citi- 2. Ginsburg v Goldwater, 396 fact, but is now not a fact because zen Therapists Against Trumpism U.S. 1049 (1970) the information is not accessible to published online Manifesto arguing 3. Annual Meeting, Association us…If we cannot access any infor- that Trump’s public behaviors and for the Advancement of Philosophy mation about what Doyle ate on attitudes “is antithetical to the ex- in Psychiatry, Washington, DC. May, that day, we cannot make factual amined life and healthy relation- 2008. “APA’s Goldwater Rule: The assertions about that either. That is ships that psychotherapy helps peo- Ethics of Speaking Publicly about what I meant.” ple achieve.” Three psychiatrists Public Figures.” Let’s switch the scene. My short- wrote a letter to President Obama in 4. Annual Meeting, American term memory is lousy, and conse- December 2016 explaining why Psychiatric Association,Washington, quently at the end of the day I often Trump is psychologically unfit to DC. “APA’s Goldwater Rule: Ethics couldn’t remember whether I took serve as president. A change.org of Speaking Publicly about Public my morning pills. I fixed that prob- petition intended for the US Senate Figures.” lem a couple years ago by buying a minority leader claimed that Trump 5. Kroll, J. and Pouncey, C. “The pill box. At the end of, say, Mon- is mentally ill and should be im- Ethics of APA’s Goldwater Rule.” day, the Monday compartment was peached under the 25th amendment. JAAPL 44(2), June 2016, 226-35. either empty or still contained the Two psychiatrists wrote to the New Monday pills. Before the fix, I had York Times that “We believe that Claire Pouncey, M.D. Ph.D. no way of determining whether I the grave emotional instability indi- had taken the pills or not; with the cated by Mr. Trump’s speech and *** pill box, I could answer the ques- actions makes him incapable of serving safely as president.” 55 Volume 24, Number 1 2017 tion. About my situation before the pill tary I focus on how these words are used, we will have to determine box I think Peter would say: on Mon- used (and thus the reference to Witt- what the speaker means in using day morning it was a matter of fact that genstein). In the book Peter empha- them. you did or did not take the pills; but by sizes that words like truth and objec- In this discussion, I may be Monday evening you were no longer tivity, from an empiricist perspective, making much of nothing. I am as able to make a “factual assertion” only have meaning when they imply, nominalist and anti-essentialist as about whether you did or did not take ‘supported by evidence’. Otherwise Peter, but I am arguing that con- the pills. And that means that on Mon- they appeal to some kind of essential- cepts such as truth and reality day evening the issue of your pill- ist, transcendent standard that ignores may be Platonic, essentialist, and taking on Monday morning is no long- evidence. If the discussion involves transcendent to experience, or er a fact. something like creationism, it’s obvi- they may not. I am arguing in a This does strike me as an unusual ous that creationists are invoking Wittgensteinian manner that the view on what makes something a fact. I some standard (e.g. religious belief in meaning of words is in their use, would of course want to state it more the Bible) other than scientific evi- and that in their use these con- simply: it was a factual matter whether dence. In many other areas this prin- cepts cover a range from the es- I took the pills on Monday morning, ciple is less clear and depends on sentialist to the nominalist. and I will never know whether I did or how the respective words are used – not. and that their use can veer from the JP So far I have been talking about facts essentialist to the nominalist. If I say, and evidence, correspondence and co- for instance, that the DSM represents *** herence in Peter’s discussion of Rego, an objective picture of psychopathol- and the nature of fact in the discussion ogy, I might be invoking an essential- of Thornton and Cooper. In Peter’s ist standard that implies that the discussion of my own commentary, DSM categories are based on essen- one of the issues is the status of truth, tial features, or I might be merely objectivity, the real, etc., and where saying that the categories are based they stand with respect to evidence. on the best available evidence. In Around this issue Peter notes a com- probably every case in which words monality in the commentaries of Rego, such as true, objective, and real are Thornton, and myself. In my commen-

ASSOCIATION FOR THE ADVANCEMENT OF PHILOSOPHY & PSYCHIATRY (AAPP) MEMBERSHIP APPLICATION

Membership in AAPP is open to all individuals interested in the subject of philosophy and psychiatry by election through the Membership Committee. The Association welcomes Student Members (enrollees in degree-granting programs in colleg- es and universities and physicians enrolled in approved psychiatric training programs and post-graduates in post-doctoral programs). In order to join AAPP please detach this form and mail to: Ms. Alta Anthony, Journal Subscriptions/ Memberships, The Johns Hopkins University Press, P.O. Box 19966, Baltimore, Maryland 21211. You can also join online at https://aapp.press.jhu.edu/membership/join

Annual Dues: $115 Members; $42 Student Members (this includes a year’s subscription to Philosophy, Psychiatry, &Psychology (PPP). Make checks payable to The Johns Hopkins University Press.

Name Qualifications (clinical and/or philosophical)/Speciality/Interests

Address Telephone FAX

Amount Enclosed: Check:______VISA:______Exp.Date:______

56 Volume 24, Number 1 2017

The Association for the Advance- Paul Lieberman, M.D. Philosophy, Psychiatry, & Psychology ment of Philosophy and Psychiatry Christian Perring, Ph.D. was established in 1989 to promote Douglas Porter, M.D. K.W.M. Fulford, D.Phil., MRCPsych. cross-disciplinary research in the Nancy Nyquist Potter, Ph.D. Founding Editor philosophical aspects of psychiatry, Kathryn Tabb, Ph.D. John Z. Sadler, M.D. and to support educational initia- Serife Tekin, Ph.D. Editor in Chief tives and graduate training pro- G. Scott Waterman, M.D. grams. J. Melvin Woody, Ph.D. Bulletin Editor OFFICERS EMERITUS MEMBERS James Phillips, M.D. President Jerome L. Kroll, M.D. 88 Noble Avenue Peter Zachar, Ph.D Jennifer H. Radden, D. Phil. Milford, CT 06460 Louis Sass, Ph.D. Phone (203) 877-0566 Vice-president Fax (203) 877-1404 Christian Perring, Ph.D. INTERNATIONAL ADVISORY E-mail [email protected] Secretary BOARD James Phillips, M.D. K.W.M. Fulford, FRCP, FRCPsych AAPP Web Site Treasurer Gerrit Glass, M.D., Ph.D. John Z. Sadler, M.D. https://philosophyandpsychiatry.org Emilio L. Mordini, M.D. Jean Naudin, M.D. Giovanni Stanghellini, M.D. EXECUTIVE COUNCIL

Robyn Bluhm, Ph.D. Jeffrey D. Bedrick, M.D. Louis C. Charland, Ph.D. Edwin L. Hersch, M.D. Ginger Hoffman, Ph.D. Brent M. Kious, M.D., Ph.D. Aaron Kostko, Ph.D. Jerome L. Kroll, M.D. Robert S. Kruger, Ph.D.

57