Jennifer Radden

Because other cultures classify mental disorders very differently from ours, it behooves us to inquire into the philosophical and cultural sources of our own guiding nosological categories. This paper is a philosophical exploration into the historical and theoretical bases of the late nineteenth-century, Kraepelinian division between disorders of mood or affect, and schizophrenia, in which our present day nosological categories are rooted. By tracing the early nosologists’ divisions into eighteenth-century and Kantian faculty psychology, and following the fate of faculty psychology through the nineteenth century, we discover genealogical elements of our taxonomy likely to affect clinical diagnosis and understanding.

In lieu of an abstract, here is a brief excerpt of the content:Commentary on “Psychopathy, Other-Regarding Moral Beliefs, and Responsibility”Jennifer Radden (bio)Fields’s line of reasoning may be summarized, though to do so is to lose much that is nice, and important, in the details. He begins by distinguishing the kind of disorder we are dealing with. Psychopathy is a personality disorder: an unchanging, trait-based condition, not a mental disease or illness. Then he asks why we might judge the presence of psychopathy to vitiate moral and legal responsibility, and answers that psychopathy must reflect some kind of disability. It has been hypothesized (by Duff) that this disability concerns moral understanding, but Fields offers an alternative account. Rather than lacking moral understanding, he argues, the psychopath is disabled in that he cannot form other-regarding moral beliefs. A very convincing argument is then made to persuade us that such a disability would—or should—constitute an excuse.Much of this reasoning is unassailable, and Fields’s careful and systematic approach is impressive. Yet I am left with a lingering concern. He has not convinced me that the psychopath is incapable of forming instead of merely disinclined to form the required sort of moral beliefs. And rather than furthering or supporting his incapacity explanation, Cleckley’s example of Milt undermines it.Maybe the example of Milt’s callousness is the place to start, although whether this is as strong an example as Fields and Cleckley seem to think of psychopathy, is questionable. It is a rather underdescribed example, certainly. We are told that this is the unvarying pattern of Milt’s behavior. Indeed, it has to be to fit the clinical definition of psychopathy as a trait-based character disorder rather than a short-lived “out of character” response. And yet Milt has reached driving age and his mother is still naive enough to expect he’ll pick her up! We need to know more. If mother hasn’t grasped Milt’s dispositional traits yet, why not? Perhaps these traits are not so unvarying and entrenched after all. Or mother is colluding, or denying? Perhaps the understanding between mother and son contained meanings not apparent in the bald clinical description provided by Cleckley. There may be more to this story than meets the eye.So I’m not sure that the example successfully illustrates the clinical definition of psychopathy. But let’s say it does. If we accept the story as we are told it, there remains a gap in the reasoning. That Milt lacks the capacity to form such (other regarding) beliefs, and to harbor guilt feelings as Fields asserts, would explain his irresponsible [End Page 287] behavior—why he “so easily gives way to whims, even though he knows that to do so is to leave his mother... stranded”(p. 33).An incapacity to form other-regarding beliefs may explain this behavior, true. But so equally might being someone given to whims. After all Milt might just have the personality trait, also long established and unchanging, that he gives in to whims more often than most. This is what people sometimes mean when they attribute impulsiveness. And impulsiveness is not only a rather common trait; as it happens it is also one associated with this particular disorder (among others).Fields recognizes the type of explanation which refers to the presence of an unthought out impulse to act, a whim explanation. But he fails to give this kind of explanation its due, using it only selectively and arbitrarily. If, as Field establishes, it is more coherent to think that Milt’s initial offer to his mother was a matter of whim—rather than evidence of the other-regarding belief that one ought to concern oneself with the welfare of one’s parents—then there is no reason to suppose that his failure to follow through and pick her up was not also a whim. This second whim represents an equally satisfactory (simple, plausible, explanatory, not ad hoc ) explanation: Milt might have come to pick up his mum but he whimfully chose not to.And this is a separate and distinct explanation from the one Fields proposes in terms of incapacity. A whim is not (immediate) evidence of incapacity...

In this paper, I explore the implications of adopting one model of self rather than another in respect to one particular feature of our mental life. The need to explain synchronic unity in normal subjectivity, and also to explain the apparent and puzzling absence of synchronic unity in certain symptoms of severe mental disorder, I show, becomes more pressing with one particular model. But in the process of developing that explanation we learn something about subjectivity and perhaps also something about brain functioning

Spanning 24 centuries, this anthology collects over thirty selections of important Western writing about melancholy and its related conditions by philosophers, doctors, religious and literary figures, and modern psychologists. Truly interdisciplinary, it is the first such anthology. As it traces Western attitudes, it reveals a conversation across centuries and continents as the authors interpret, respond, and build on each other's work. Editor Jennifer Radden provides an extensive, in-depth introduction that draws links and parallels between the selections, and reveals the ambiguous relationship between these historical accounts of melancholy and today's psychiatric views on depression. This important new collection is also beautifully illustrated with depictions of melancholy from Western fine art.

Psychiatric ethics spans several overlapping domains, including the guidelines for ethical research in psychiatry, the professional ethics required in the practice of psychiatry, and a broader set of moral and ethical problems and dilemmas distinctive to, or at least magnified by, the mental health care setting. Reviewed here are selected issues arising in the last two domains, some seemingly inevitable components of mental disorder and its cultural history and others resultant from recent changes and discoveries. Even as science explains and demystifies mental disorder, it is concluded, new ethical problems will continue to arise in psychiatry and certain recalcitrant problems will likely persist.

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 10.1 (2003) 63-66 [Access article in PDF] The Pragmatics of Psychiatry and the Psychiatry of Cross-Cultural Suffering Jennifer Radden I AM IN SUBSTANTIAL AGREEMENT with many of the conclusions David Brendel draws in his thoughtful discussion. Misleading language aside, I particularly applaud his use of my plea for ontological descriptivism to support clinical practice, which respects, as he puts it, the subjectively "melancholic" person living behind the objectively "depressed" clinical presentation.Brendel offers two main critiques of my discussion about the relationship between today's depression and melancholia of past eras. First, he asserts that I neglect the relevance of causal reasoning in my preference for a descriptivist over a causal ontology. Second, arguing that pragmatic considerations ought to be, as he says, front and center when philosophers and psychiatrists "grapple with the complexities of psychiatric explanation," (Brendel 2003, 54) he questions what he sees as my too ready dismissal of pragmatism in this discussion. Allegiance to pragmatism seems to me to sit strangely with support for a causal ontology, as I shall try to demonstrate. But first let me comment on these two sides of Brendel's commentary.The case of Van Gogh's alleged melancholia is particularly well chosen because there has been continuing debate about Van Gogh's condition, including scholarly work attributing it to an inherited metabolic disorder (Arnold 1992). Brendel's suggestion that a causal ontology might allow us to use historical evidence to throw light on the relation between depression and melancholia is an interesting and fruitful one that I had overlooked. Brendel also holds hope for drug cartography as a means of determining the causes of mental disorders. I admit to the initial plausibility of the approach to classification employed by drug cartography, of course. Diagnostic maps must be evaluated according to their effectiveness for the purposes they serve, and cannot—or should not—be seen as mere descriptions of natural phenomena. And maps based on psychopharmacological effects will serve one of the most important purposes we can have in relation to mental disorders: their successful treatment. Nonetheless, as I indicated in my essay, there are conceptual limitations to drug cartography. That several different syndromes respond to the same drug is suggestive, but it does not tell us anything definitive about structural similarities or differences between those different disorders. Nor, from the fact that a condition is alleviated by drugs, does it follow that a particular brain state was the initiating cause of that condition.My dismissal of a pragmatic approach in the foregoing discussion may have been overly hasty. [End Page 63] But in trying to make good this omission, I find myself struck by the complexity of the task. There appear to be at least five different places where a pragmatic response might be called for: (1) in deciding what to say about the relationship between depression and melancholia; (2) in determining the structure of any given psychiatric classification; (3) in choosing between what I have called descriptivist and causal ontologies; (4) in electing a course or method of treatment in the clinical context; and (5) in evaluating psychiatric explanations.With regard to (1), I have sketched in a note one pragmatic consideration in favor of equating melancholia and depression: by so doing, we might reinvest depressive states with some of the glamorous associations from the past and so diminish the stigma and provide some compensation and consolation for the suffering attaching to depression. Pragmatic reasoning may be perfectly appropriate here. I beg to point out that pragmatic considerations let me neglect it.With regard to (2), I recognize that psychiatric classifications are not so much identifications of natural kinds as responses to our various purposes; indeed, this point is offered as one drawback of adopting a causal analysis, because there is little reason to expect our purposes, which are a product of culture, to correspond to natural arrangements, which are not.With regard to (3), if there were overriding pragmatic considerations that favored accepting one or the other of these ontologies, then perhaps this would be...

The theoretical implications of equating the melancholic states of past eras with today's depression are explored. These include the presuppositions of the descriptive psychiatry so influential in twentieth century classification, which attempts to identify and describe mental disorders without reference to underlying causes. It also includes claims made about different forms of masked, and non-Western depression, and the new "drug cartography" assigning psychiatric categories based on psychopharmacological effect. An evaluation of the relative merits of descriptivist and causal ontologies, together with an assessment of the similarities and differences between melancholia and depression, suggest the conclusion that these two conditions are misleadingly equated.

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 10.4 (2003) 357-359 [Access article in PDF] Learning From Disunity Jennifer Radden In describing his four cases, Lloyd Wells (2003) throws out a challenge. He asks his readers to recognize similarities between their own more ordinary self-identity and the discontinuous narrative and seeming absence of a steady authorial subject resulting from disorders such as depression, schizophrenia, and Multiple Personality Disorder (MPD). In light of these cases, he implies, the unity of the self we have unreflectively assumed until now to be universal requires reconsideration. Psychopathology seems to force a sharpening, clarification, and closer conceptualization of our philosophical theories of self-identity.While acknowledging that philosophical categories and theories of narrative identity can help us to assess the ravages wrought by mental disorder, James Phillips (2003) is also respectful of the contribution of psychopathology to theorizing about identity: he ends his thoughtful discussion of Wells' cases by looking not at how philosophy can enlighten us about psychopathology but at how cases such as these can illuminate philosophical categories. Speculating on the tragic absence of narrative identity in schizophrenia and advanced Alzheimer's disease, Phillips concludes that, as he puts it, psychopathology "reconfigures the contours of our notion of narrative identity and requires a looser, minimized, nonsubstantial notion of the narrative self" and argues for a self that "transcends the limits and loss of narrative identity" (2003, 326).I also support the approach, shared by Wells and Phillips, that allows psychopathology to clarify and illuminate philosophical concepts and categories. Here, in a handful of footnotes to their insights, I want to point out ways that cases from psychopathology reveal distinguishable elements or aspects of self-identity often confused because, in the normal case, they form an unquestioned and apparently indissoluble unity. One of these is the difference between synchronic and diachronic subjective unity. Another is the difference between the elements of authorship and temporality in conceptions of narrative identity. And last is the difference between what I shall call constitutional identity and self-identity. Synchronic and Diachronic Identity The difference between synchronic and diachronic identity, elements so seamlessly blurred in more ordinary subjectivity, is nicely illustrated by Wells' cases. Mary's dissociative states leave her with interruptions in her diachronic identity: the memory of her experiences is fragmented and incoherent. Yet at any given moment, her synchronic unity is unimpaired. She recognizes and can describe the oneness of her experiences and their boundaries; she is aware which are her experiences and which are not. For all her scatteredness and dissociation, as Phillips puts it in describing Mary's case: "there is a strong and [End Page 357] articulate narrator... the fact remains that this I is there" (2003, 318).In contrast, the shy and self-conscious adolescent Edward seems to suffer not from diachronic but from synchronic disunity. (And if anything, as Melvin Woody [2003] points out, Edward's "narrative" seems to fuel the comparisons which so distress him about his uncomfortable and distressing subjective experiences.) Edward struggles to "delineate what's inside my mind and what's outside it... " When he thinks about what he sees as a firm boundary around the self in others which is not well demarcated in his own case, he remarks "... I completely lose any sense of myself" (p. 330).Thought insertion or "made" feelings in psychosis provide similar instances of such fracturing of their sufferer's synchronic identity (it is perhaps such experiences that Edward alludes to here; Wells' quotations are too sparse for us to tell). Just as Edward complains of losing any sense of himself, so other sufferers from these alarming conditions complain of losing a sense of the self's boundaries, of possession and mind control, and of being the unwelcome host to alien thoughts, feelings, and intentions.In normal experience diachronic and synchronic unity—my oneness across time and at a time—form a seamless whole. These cases, where one or the other is compromised, vividly remind us that these two forms of unity must be distinguished. Narrative Identity Phillips (2003) explicates an analysis of narrative identity which comprises entwined but distinguishable features: a narrating...

This is a comprehensive resource of original essays by leading thinkers exploring the newly emerging inter-disciplinary field of the philosophy of psychiatry. The contributors aim to define this exciting field and to highlight the philosophical assumptions and issues that underlie psychiatric theory and practice, the category of mental disorder, and rationales for its social, clinical and legal treatment. As a branch of medicine and a healing practice, psychiatry relies on presuppositions that are deeply and unavoidably philosophical. Conceptions of rationality, personhood and autonomy frame our understanding and treatment of mental disorder. Philosophical questions of evidence, reality, truth, science, and values give meaning to each of the social institutions and practices concerned with mental health care. The psyche, the mind and its relation to the body, subjectivity and consciousness, personal identity and character, thought, will, memory, and emotions are equally the stuff of traditional philosophical inquiry and of the psychiatric enterprise. A new research field--the philosophy of psychiatry--began to form during the last two decades of the twentieth century. Prompted by a growing recognition that philosophical ideas underlie many aspects of clinical practice, psychiatric theorizing and research, mental health policy, and the economics and politics of mental health care, academic philosophers, practitioners, and philosophically trained psychiatrists have begun a series of vital, cross-disciplinary exchanges. This volume provides a sampling of the research yield of those exchanges. Leading thinkers in this area, including clinicians, philosophers, psychologists, and interdisciplinary teams, provide original discussions that are not only expository and critical, but also a reflection of their authors' distinctive and often powerful and imaginative viewpoints and theories. All the discussions break new theoretical ground. As befits such an interdisciplinary effort, they are methodologically eclectic, and varied and divergent in their assumptions and conclusions; together, they comprise a significant new exploration, definition, and mapping of the philosophical aspects of psychiatric theory and practice

Data indicate the ubiquity and rapid increase of depression wherever war, want and social upheaval are found. The goal of this paper is to clarify such claims and draw conceptual distinctions separating the depressive states that are pathological from those that are normal and normative responses to misfortune. I do so by appeal to early modern writing on melancholy by Robert Burton, where the inchoate and boundless nature of melancholy symptoms are emphasized; universal suffering is separated from the disease states known as melancholy or melancholia, and normal temperamental variation is placed in contrast to such disease states. In Burton's time these distinctions and characterizations could be secured by the anchoring tenets of humoral theory. Without such anchoring, and in light of the findings and assumptions of today's biological diagnostic psychiatry, we must re-visit each of them. My goals here are to show the need for analytic foundations when claims are made about depression such as those cited above, and to draw attention to some contemporary attempts that may help provide those foundations, particularly, attempts to define disorder or disease. With adjustments, one of these (Cooper 2002) is shown to take us some way toward that goal

In Moody Minds Distempered philosopher Jennifer Radden assembles several decades of her research on melancholy and depression. The chapters are ordered into three categories: those about intellectual and medical history of melancholy and depression; those that emphasize aspects of the moral, psychological and medical features of these concepts; and finally, those that explore the sad and apprehensive mood states long associated with melancholy and depressive subjectivity. A newly written introduction maps the conceptual landscape, and draws out the analytic and thematic interconnections between the chapters. Radden emphasizes and develops several new themes: the implications, theoretical phenomenological and moral, of recognizing melancholy and depressive states as mood states; questions of method, as they affect how we understand and characterize claims about melancholy and depression; and the persistence and force of cultural tropes linking such states to brilliance, creativity, and sagacity. Insights from literature and the history of medicine, psychology, and psychiatry are woven together with those from the more recent disciplines of feminist theory and cultural studies. This is interdisciplinary writing at its best-part analytic philosophy, and part history of ideas.

In lieu of an abstract, here is a brief excerpt of the content:Insightlessness, the Deflationary TurnJennifer Radden (bio)Keywordsinsightlessness, deflationary turn, Harry Stack Sullivan, open placebos, space of reasonsMarga Reimer argues that treatment compliance in patients who are without any, or complete, insight into psychotic symptoms may be neither particularly abnormal nor entirely unreasonable. In broad sympathy with these conclusions, I wish only to add a couple of ancillary observations and some historical context.Reimer's discussion can be placed alongside other research on aspects of psychosis putting forward what have been called "deflationary" accounts, accounts that depict psychotic symptoms as differing from normal states, traits, and responses in degree rather than kind. Such accounts have been offered about auditory hallucinations or "hearing voices" (Leudar and Thomas 2000; Romme and Escher 1989; Smith 2007), about delusional thinking (Bentall 2003; Bentall et al. 1989; Bracken and Thomas 2005; Hamilton 2007; Kinderman and Bentall 2007), and spiritual experiences (Jackson 1997; Jackson and Fulford 1997); in the introduction of the notion of "benign psychosis" (Jackson 2007), and even in recognition that insight is a complex, dimensional attribute (Amador and David 1998). Harkening back to the middle years of the twentieth century, and associated with Adolph Meyer's influence in the United States, as well as the influence of psychodynamic (and psychoanalytic) ideas, this deflationary turn challenges the neo-Kraepelinian presuppositions of our contemporary biomedical psychiatry. Rather than sharply separating psychotic states and symptoms from normal experience, the deflationary approach emphasizes the continuities and similarities linking them.Reimer proceeds in two separate steps. To the extent that treatment compliance among patients suffering psychotic states occurs in the absence of any or full insight, it is shown, this seems not dissimilar from other more ordinary cases where treatment compliant behavior occurs either without—or without regard for—a recognition that one is ill. (The term insightlessness is here used to indicate the absence of full and complete insight. This recognizes the dimensional and complex nature of insight, which has been shown to involve a range of beliefs over one's disorder, those about its presence, about the need for treatment, and about the social consequences of suffering it.)Had her discussion stopped here, Reimer would have completed the first "deflationary" step. By showing that this sort of insightless treatment compliance also occurs in the absence of mental disorder, she encourages us to see psychotic patients' lack of insight into their disorder as at least akin to more benign and commonplace responses. In doing so, she would have shifted something of the burden of proof within discussions of insight. Those insisting insightlessness is an irresoluble obstacle to positive treatment outcomes would [End Page 81] now be required to explain why this should be so. And those denying the analogy between the insightless compliance of the psychotic patient and more everyday cases such as those Reimer describes, might be called upon to show why these cases were disanalogous.Reimer does not leave matters there. She goes on to establish that none of the instances of insightless treatment compliance that she discusses can be judged to be entirely unreasonable. Treatment compliance without full insight is not only quite normal, it may not even be particularly irrational. As she explains, the patients in each case anticipate benefits from the treatment, even though such benefits are not understood in terms suggestive of pathology. Unfailingly, they conform to a general human tendency: [T]o act in accordance with what we perceive, rightly or wrongly, to be in our best interests.Reimer locates the error in more traditional thinking about lack of insight at the immodest assumption that there is but a single way to accurately characterize the patient's condition—medically. This view, which she attributes to contemporary psychiatry, she finds mistaken—and mistaken, I agree it is. Rather than one, there seem likely to be several accurate ways to frame things. And although the medical framing will best fit the interests and purposes of clinicians, other framings may better suit the interests of their patients.When the possibility of alternative, non-medical perspectives is granted, and our goal is to assess insightless compliance vis à vis rationality norms, a number of considerations gain salience. The insightless patient, Reimer shows, may...