Marga Reimer

In a recent paper Herman Cappelen and Ernie Lepore challenge an assumption that they rightly claim is pervasive among contemporary philosophers of language. According to this assumption (MA), an adequate semantic theory T for a language L should assign p as the semantic content of a sentence S in L if and only if in uttering S a speaker says that p. I claim that the arguments of Cappelen and Lepore are based upon an uncharitable interpretation of MA. If ‘saying’ is understood in a roughly Gricean sense, MA emerges as an eminently plausible assumption.

Patients with psychosis often have poor insight into their illness. Poor insight into illness is, at least among patients with psychosis, a good predictor of treatment non-adherence. This is no mystery, for as Xavier Amador asks, "Who would want to take medicine for an illness they did not believe they had?" What is curious is that some patients with psychosis do adhere to treatment despite a lack of insight. Why do these patients adhere to treatment, given that they do not believe they are ill to begin with? In this paper, I attempt to answer this question. I do so by first considering cases of non-psychotic patients who adhere to treatment despite a lack of insight. I point out that these sorts of cases are commonplace, and attempt to explain why they arise. The explanation is given in terms of anticipated treatment benefits. However, these benefits are not conceptualized by the patient in terms of pathology. The patient does not, in other words, think of such benefits in terms of illness, symptoms, treatment, and so forth. I then argue that the proposed explanation can be extended to account for why psychotic patients without insight sometimes adhere to treatment. I conclude by drawing out some of the practical implications of the proposed view. I first argue, on practical as well as ethical grounds, that improving insight for purposes of treatment adherence is misguided. I then suggest that such adherence might be increased simply by explaining treatment benefits in language that does not presuppose that the patient is, in any sense, "ill," "diseased," "sick," "unwell," and so on.

In lieu of an abstract, here is a brief excerpt of the content:Reflections on InsightDilemmas, Paradoxes, and PuzzlesMarga Reimer (bio)Keywordsinsight, psychosis, treatment adherence, medical model, autonomy, open placebos, rationalityThe Practitioner's DilemmaThe psychiatrist aware of the potential intractability of what Jennifer Radden calls "insightlessness," faces a dilemma. Should she encourage her patient to embrace a medical model of his "troubles," a model whose adoption is likely to motivate treatment adherence? She might then be trying to do the impossible; she might also alienate her patient in the process. Should she instead encourage her insightless patient to embrace his own non-medical model, according to which treatment adherence makes no medical sense whatsoever? She might then see herself as encouraging a kind of uninformed consent: Her insightless patient might be taking powerful, potentially harmful, medication for reasons (such as sound sleep and "peace of mind") that would never medically justify adherence.In my original paper, I suggested that the way out of this dilemma might be to embrace the latter option, while characterizing the very real (and medically based) benefits of treatment adherence in non-medical terms. I now realize that my proposed resolution reflects an oversimplified understanding of what might be called the "practitioner's dilemma." As Michaela Amering (2010) makes clear, the situation for those with mental illness is improving dramatically. With "recovery orientation" as the "guiding principle of mental health policy," the emphasis is on "health promotion, individual strengths, and resilience." The question becomes: Can the practitioner encourage her insightless patient to partake in this "recovery" movement if she does not simultaneously encourage him to embrace a medicalized understanding of his "troubles"?Not obviously. For although a "recovery" model might eschew notions like illness1 and disease, pathology and dysfunction, and even schizophrenia, it will inevitably involve some medical notions. The patient who partakes in the "recovery movement" described by Amering, would seem to have no choice but to accept a model that is essentially medical. Consider the language used by Amering in characterizing that movement. She talks of mental health problems, therapeutic relations, patient self-determination, diagnosis and, of course, recovery. The concepts underlying such language are intrinsic to the patient-oriented movement Amering describes. The question becomes:How can the insightless patient rationally partake in such a movement without embracing some version of the medical model of mental illness? [End Page 85]This question suggests the importance of promoting some kind of insight, even if not insight "into psychosis." At the close of these comments, I consider briefly what such "revisionary" insight might involve.Paradoxes of Conditional and Relinquished AutonomyAutonomy among patients with psychosis presupposes the sort of clear-headedness that arguably comes only with treatment adherence. This may provide some justification for the "coercive treatments" that Anthony (2006) finds so offensive. For patients with psychosis, genuine autonomy is conditional, requiring some degree of insight: Recognition that their "troubles" are at least amenable to medical treatment. Once the patient recognizes this, he can choose freely to decline such treatment (regardless of whether that choice is ultimately respected). Call this the "paradox of conditional autonomy." The conditional nature of autonomy is a familiar point in philosophical discussions regarding free will. There is no genuine freedom without the sort of knowledge required for informed choices. What distinguishes the patient with psychosis from persons more generally is that his autonomy is further conditioned: The knowledge required for autonomous decision making arguably requires some degree of treatment adherence.However, the mentally ill patient has the right, as do all patients, to relinquish autonomy. He may opt for deference to, and dependency on, the relevant experts: Mental health care professionals (Campbell 1994). We are led once again to paradox. To respect the patient's autonomy, the mental health care professional must respect his right to forego autonomy in favor of deference and dependency. This paradoxical situation, involving a kind of deferred autonomy, is not unique to psychiatry but applies to medicine across the board. Indeed, it applies to the human service industry more generally where, as McGorry (1992) suggests, there is an implicit assumption that the service user is to defer to the expertise of the service provider.This assumption is rightly challenged. Suppose Justin and...

In lieu of an abstract, here is a brief excerpt of the content:Understanding First: Exploring Its Scope and Testing Its LimitsMarga Reimer, PhD (bio)I thoroughly enjoyed reading and reflecting on this provocative, engagingly written, and persuasively argued paper. My commentary focuses on the authors’ “understanding first” principle. I begin by exploring that principle’s scope by appeal to aesthetic analogues to the moral cases of Pete and Jacob; I then explore its limits by appeal to cases involving agents struggling with maladaptive traits that are more self-destructive than antisocial.According to the authors, when attempting to eliminate or reduce a maladaptive trait, it is important that the agent begin with a non-moralizing understanding of that trait’s “root cause.” In this way, the agent avoids some of the epistemically distorting and otherwise counterproductive effects associated with an approach that begins with a moralizing assessment of the problematic trait. They can then proceed with a reason-based “dispensation” of that trait.The cases of Pete and Jacob make these points vivid and lend them considerable credence. Moreover, the authors’ “understanding first principle” arguably exemplifies a more general, and no less plausible, principle concerning the remediation of virtually any problem. Who would deny that an objective, non-normative, understanding of a problem’s “root cause” might be useful in addressing that problem? Who would deny that normativizing a problem before understanding its origin might prevent a deeper understanding of that problem and therewith its maximally effective “treatment”?One way to showcase the intuitiveness of the authors’ “understanding first” principle would be to explore the applicability of an analogous principle to problems beyond those involving “moral matters.” Problems involving aesthetics might prove particularly illuminating in this regard insofar as aesthetics, like morality, is inherently normative and yet it lies beyond the scope of morality proper. If an “understanding first” principle can be shown to be applicable to certain types of aesthetic problems, then the authors’ already strong case for the applicability of such a principle to certain types of moral problems would be further strengthened.In the cases of Pete and Jacob, the problems are unambiguously moral: the patently antisocial behaviors of these two individuals are paradigmatically “bad” and their premature assessment as [End Page 205] such can be epistemically distorting and otherwise counterproductive. Consider now analogous cases involving aesthetic problems. Pete and Lucie are getting ready for the holidays and are expecting family from out of town. But there are a couple of problems. Pete notices an “ugly” stain on the living room carpet and Lucie notices a subtle but decidedly “nasty” odor permeating the entire house. Neither Pete nor Lucie know where the stain came from, nor where the odor is coming from. But both the stain and the odor are “pretty gross” and so they need to “get rid of” them before family arrive. There’s no time for investigative work into “root causes.”Pete scrubs the stain until the portion of carpet beneath it is threadbare; Lucie buys three different deodorizers, all of which eliminate the odor but only temporarily. Had Pete and Lucie understood the root causes of the “ugly” stain and “nasty” smell, their treatments might have been different—and, importantly, more effective. The stain turned out to be caused by red wine, easily treatable without leaving a noticeable “bald spot.” The lingering odor was from an easily fixable plumbing problem, albeit one requiring more extensive (and costly) work.Pete and Lucie’s aesthetic evaluations (“ugly,” “nasty”), coupled with a lack of understanding of “root causes,” have predictable results: their control over some “pretty gross” problems is significantly diminished. Similarly, with respect to moral evaluations of maladaptive traits (“bad,” “wrong”) coupled with a lack of understanding of “root causes.” As the authors show, such evaluations can be epistemically distorting and otherwise counterproductive with the result that the agent’s control over the problematic trait is significantly reduced.Further aesthetic analogues are easy to develop and potentially even more revealing. Imagine that Pete and Lucie, who are expecting family later in the week, are experiencing symptoms, both respiratory and gastrointestinal, that are “kind of yucky.” As with the maladaptive traits of Pete and Jacob, the problematic traits in this case are literally “in” the agent (vs...