Jennifer Radden

The accuracy of anorexia patients’ claims about their own agency (or self-control), are at the center of this discussion. Patients’ typically believe, even boast, that their dietary behavior involves effortful restraint. In recent work Evans has argued that the experiential sense of agency underlying such claims is often not veridical, generating illusory claims to self-control. Empirical findings on AN patients employing implicit measures of the sense of agency—intertemporal reasoning in delay-discounting studies, and a temporal binding approach—seem pertinent to Evans’ hypothesis. But these studies fail to support, and even apparently challenge, the position that such patients’ sense of agency might be inaccurate or illusory, I illustrate. I note epistemic vulnerabilities in Evans’ data, and interpretive ambiguities associated with applying predictive processing models as Evans does. Without additional support, the claim that these assertions are illusion-based is not persuasive, I conclude. And, even if other cognitive and affective symptoms indicate disorder, based on what is presently known, the same cannot yet be concluded of AN claims to self-control.

The brief concluding chapter returns to the questions, first introduced in Chapter 5, of whether, and how, virtue can be taught. The preceding discussions have laid out reasons _why_ virtue should be taught to those who will practice psychiatry. There is a growing body of evidence indicating it is possible to deepen and augment the affective and moral responses making up character traits such as empathy, for example, using a range of pedagogical techniques that harness imaginative capabilities. Alongside the practice skills they learn, the virtues of the good practitioner in psychiatry should and can be habituated and deepened using such techniques, it is argued. As well as to the acquisition of more technical skills, emphasis ought to be placed on character training.

The themes of the previous chapters are brought together in Chapter 7 through the introduction of a series of cases. In contrast to standard depictions of third-person case vignettes, distorted and over-simplified by the heuristic purposes they serve, a new method of case presentation is employed here that attempts to capture the inner world of the practitioner as well as the dynamic ebb and flow of the interchange between patient(s) and practitioner during particular “moments” in the therapeutic session. This demonstrates previous emphasis on the moral psychology and character of the practitioner.

Some tensions inherent in joining the traditional concept of character to that of social roles are outlined in Chapter 6. They are illustrated through a discussion of the moral psychological dangers that attend role morality: inner compartmentalization or lack of integrity, inconstant virtues (honored in one role and neglected in another), and apparently incompatible roles (such as healer and upholder of criminal justice). Some difficulties springing from the way virtues are habituated, are also introduced, including the ethical status of virtues that are merely feigned (as when the practitioner pretends an empathic response to the patient that is not wholehearted or genuine).

The centrality of culture and particularly gender to psychiatry and to the psychiatric project are demonstrated in Chapter 4. (Factors given attention include the cultural associations linking male heterosexuality with mental health, the bias found in diagnostic categories, the differential treatment provided to women, and the implications of practicing psychiatry within traditionally male-oriented cultures.) As one implication of recent identity politics, issues of gender identity represent an inescapable ethical challenge for today's practitioner, and reflect ideas that have received little systematic attention. Moving beyond questions about misogyny, homophobia and homosexuality to explore the ethics of practice with trans-gendered identities, this chapter introduces the elements of a gender sensitive psychiatry.

Some of the virtues called for by the psychiatric setting are enumerated in Chapter 5. Several different kinds of character traits are included here: some are traits as essential in everyday as in professional life but demanded to a greater degree in practice setting than in most other settings. Others, while elsewhere merely prudential or intellectual virtues, become role-constituted virtues for the practitioner in psychiatry. Yet other traits are closely role-constituted virtues, without universally recognized moral value beyond the professional setting. Not intended to be a complete portrait of the character of the virtuous psychiatrist, Chapter 5's discussion rather serves as a template for identifying that character by appeal to particular aspects of the psychiatry setting. The virtues selected for discussion are each analyzed in an effort to demonstrate their link to demands determined by that setting.

Chapter 3 introduces the idea of psychiatric ethics understood as virtue ethics. The authors show why a virtue ethics framework suits the role morality associated with professionalism, and define role-constituted virtues - character qualities called for by the practice setting, that constitute moral reasons for the practitioner. The original contribution of this chapter lies in its explication of the character demands of the psychiatry setting and explanation of why a virtue ethics framework particularly fits psychiatric practice. Within such practice, it is demonstrated, a special part is played by virtues which elude rule-based approaches (here called “unruly virtues”) such as empathy and compassion, and those that are superogatory, such as leadership.

This chapter places psychiatric ethics within professional and biomedical ethics more generally, and introduces the “role morality” notion: that some ethical imperatives derive from particular social roles. Some differences between psychiatry and other medical practices are illustrated through three issues: questions of patient autonomy, rules governing the ‘boundaries’ around the therapeutic relationship, and concerns over psychiatric diagnostic categories. Building on previous work in biomedical ethics, the authors adopt the methodology employed in the American Psychiatric Association's _Annotations with Particular Application to Psychiatry_ (2001), which identifies the ethical implications of particular features distinctive to the practice of psychiatry. When practiced with severely ill patients, it is asserted, psychiatry makes extra ethical demands on practitioners.

Chapter 2 puts forward a systematic and developed rationale for the view introduced previously that psychiatry requires its own ethics. Few aspects of psychiatric practice are medically unique, yet taken together a set of elements differentiates psychiatry as a unique healing practice. These elements include patient vulnerability, attitudes towards psychiatric symptoms, stigma and controversy over mental disorder in our culture, and the nature of the therapeutic project in psychiatry. These are analyzed, together with more recent factors influencing practice, in particular, managed care delivery systems, and the advent of consumer movements made up of mental health service users.

In this chapter we outline ethical issues raised by the application of public health approaches to the field of mental health. We first set out some of the basics of public health ethics that are particularly relevant to mental health, with special attention to the ongoing debate over the traditional presumption of non-infringement, increased recognition of the social determinants of health, and the concept of prevention. Then we turn to the moral particularities of mental health, focusing on questions concerning coercion and treatment pressure, personal identity and sociocultural factors (including stigma), and unresolved conceptual and methodological issues in psychiatry that complicate its extension into the domain of public health.

Mental disorder (earlier entitled “illness” or “disease”) is ascribed to deviations from normal thoughts, reasoning, feelings, attitudes, and actions that are considered socially or personally dysfunctional and apt for treatment. Schizophrenia, depression, and bipolar disorder are core examples. The concept of mental disorder plays a role in many domains, including medicine, social sciences such as psychology and anthropology, and the humanities, including literature and philosophy. Philosophical discussions are the primary focus of the present entry, which differs from the entry on Philosophy of Psychiatry in noting several different approaches—not only those of the philosophy of science and mind, but also those arising from phenomenology and social theory. Mental disorder is a widely contested concept and there are longstanding debates on whether disorders are biological or social in nature. Even uncontroversial disorders, such as those listed above, were not always regarded as disorders in the past (Porter 2002). Moreover, the status of mental disorder has frequently indicated ethical, as much as other deficiency (Irwin 2013). Such reminders direct our attention to contemporary medical psychiatry’s sometimes uncompromisingly neurobiological, and avowedly value-free “medical model”, with its incumbent analogies and assumptions, and to the general question of how the taxa of psychiatric classifications are to be viewed as objects of natural science. This model has received intensive philosophical scrutiny, including arguments that deny these conditions are deficiencies at all. Along with issues arising from cognitive psychology and the neurosciences, such foundational matters make up much of the following entry. Because of their focus on issues central to the philosophy of mind and ethics (e.g., the mind-body problem, moral responsibility, agency and identity), analyses of mental disorder have extensive implications for those fields. As clinical phenomena, they also reflect an inescapable, everyday, social reality, giving theoretical inquiries additionally urgent practical, moral, and legal implications.

This chapter argues that despite the recent, welcome interest in autobiographical writing about depression, its use for research purposes presents an epistemological challenge because the extent to which these descriptions illuminate the true nature of depressive experience cannot be discerned. Contextualized within the genre of autobiography as well as the subgenre of illness memoir, the depression memoir exhibits ambiguities, it is shown, imposed by the constraints of its genre, and by the nature of autobiographical memory. Sources of ambiguity distinctive to depression memoirs are next introduced, some tied to cultural meanings, others to the status of depressive states as constituted by moods. Finally, some empirical corroboration for these claims is cited, in findings indicating that depression affects autobiographical memory and writing style. The indeterminacy identified here is not a reason to dismiss depression memoirs, it is concluded, so much as to employ caution in drawing inferences from them.

In lieu of an abstract, here is a brief excerpt of the content:Diagnostic WannabesJennifer Radden, PhD (bio)Saunders explores challenges for the clinician faced with self-styled sufferers from attention deficit hyperactivity disorder, post-traumatic stress disorder, bipolar disorder, autism spectrum disorder (ASD), and fibromyalgia. The diagnostic system was not meant to be used as “a scaffold for identity,” she points out. Yet wannabe patients now step into the clinic wielding self-proclaimed diagnoses as social identities. Saunders explains the context where such phenomena arise, and offers guidelines for clinicians addressing this new reality. To do so, she enlists Rashed’s innovative normative approach to the so-called boundary problem of assigning, and providing justification for, the contested line between normal and disordered. The boundary problem itself seems to rise to prominence during our current era of increasingly dimensional thinking, it is worth noting, with psychiatric diagnoses taken to refer to points on a continuum, rather than to discrete categorical disease entities.On the likely sources of these ‘diagnostic’ social identities, as well as reasons why certain diagnoses attach to them more commonly than others, Saunders points to social trends (including what she asserts to be a “post-stigma” cultural environment), the failure of efforts to identify neurobiological markers for psychiatric disorder, the ubiquity of social media, the algorithms themselves, and the hyperconnected existence of contemporary times. Such narratives also offer the comforts of a sense of belonging and explanations for perceived inadequacies, she rightly observes.Despite today’s virtual and other inducements, the problem introduced here is not an entirely new one. The first part of the seventeenth century in Europe saw an apparent “epidemic” of what was known as “melancholy,” a condition associated with the spleen, whose symptoms loosely resembled those of today’s depression and anxiety. Much of this suffering was undeniably real, but much was a fashionable, identity-conferring pose. “Every distemper of the body now is complicated with spleen,” the poet John Donne ironically observes in a letter dated 1622, “and when we were young men we scarce ever heard of the spleen. In our declinations now, every accident is accompanied with heavy clouds of melancholy”1 (Gosse, 2019). By then, the Melancholic Man (or homo melancholicus), with his surfeit of spleen, was an unmistakable character type—or social identity, as we would now say. Recognized and saluted in centuries-long literary and illustrative traditions, the type was an anchoring element of the humoral medicine which, despite the gradual emergence of more empirical science, had endured since Galenic times.Melancholy’s closest descendants, affective depressive and anxiety disorders, are today less evident among the troubling identities Saunders discusses—somewhat preempted, she points out, by more cognitively-based diagnoses such as ASD. [End Page 279] This is itself an ironic reminder of the vagaries of cultural attitudes, cautioning us to remember the broader context where these particular social identities are selected for emulation and adoption.The lure of the melancholy man’s2 social identity is well understood: already normalized, within the humoral system in which excess black bile afflicted roughly one in four people, it had been valorized for centuries—arguably by Aristotelian writing (in the dubious ‘Problems’), during the Renaissance by Ficino, and Shakespeare—even by Freud in his 1916 ‘Mourning and Melancholia.’ Through most of Western history, the positive attributes and benefits of the dark moods of melancholy have needed no further explaining or justifying. They glow with glamorous associations.Applying Rashed’s conditions for appropriately acknowledging and recognizing the fit of a person’s chosen social identity, Saunders‘ guidance for clinicians clarifies boundary matters. And it illustrates how to understand, regulate and communicate the appropriate norms in ways that can dissuade those whose personal growth and mental health are not served by claiming such identities.With at least some of the popular social identities Saunders describes, I think we can helpfully continue the comparison with the homo melancholicus. For the ‘neurodiversity’ rhetoric of our own times contains forces promoting both the normalization and the valorization of syndromes such as ASD. Pointing to analogies with differences of gender, ethnicity and culture, neurodiversity theorizing argues for a respect for, and appreciation of, difference. Mental or cognitive variations are equally natural and valuable, it is...

Feelings associated with grief are regularly described as painful, but in what respect are they to be understood as pain? The acute pain of easily located tissue damage has long been the paradigm of pain in scientific and philosophical analysis, a dominance serving to obscure features the pain of grief might share not only with chronic pain but with some depressive suffering. Two examples of such commonalities are explored (ways pain feelings are experienced as in and of the body; and are often recessed to the background of consciousness). These features are introduced to illustrate how a preliminary search for additional pain paradigms might proceed, and in so doing to offer some support for the proposal that pain endured as part of grieving may be real pain, not merely 'pain'.