Jodie Louise Russell

Recent work on the phenomenon of self-illness ambiguity has sought to not only understand how tensions arise between one’s experience of self and one’s disorder experiences, but also how best to resolve said ambiguities to relieve the suffering of the person in question (Sadler, Psychiatry: Interpersonal and Biological Processes, 70(2), 113–129, 2007; Dings & Glas, Philosophy, Psychiatry, & Psychology, 27(4), 333–347, 2020; Dings & de Bruin, American Journal of Bioethics, 22(6), 58–60, 2022; Jeppsson, Philosophical Explorations, 25(3), 294–313, 2022). While the involvement of other people has been emphasised as important in regulating the self and thus will play a part in self-illness ambiguity, the impact of this social dimension has not been sufficiently explored. The goal of this paper is to provide an account of how social norms may be implicated in the enactment of the ‘self’ and experiences of self-illness ambiguity. To do this, I will provide a plausible account of what it means to have a coherent or understandable self, drawing on the mind-shaping view of social cognition (McGeer, Folk Psychology Re-Assessed, 137–156, 2007; Mameli, Biology & Philosophy, 16(5), 595–626, 2001; Zawidzki, Philosophical Explorations, 11(3), 193–210, 2008; Zawidzki, Mindshaping: A new framework for understanding human social cognition. Cambridge, MA: MIT Press, 2013; Zawidzki, Mindshaping and self-interpretation. In J. Kiverstein (Ed.), The Routledge Handbook of Philosophy of the Social Mind, 495–513. London & New York: Routledge, 2016). Mind-shaping suggests that we are successful in social coordination tasks because we are able to negotiate and follow shared norms that facilitate understanding. These norms indicate and shape what kinds of people we understand ourselves to be, as well as how others understand us, which we might refer to as the ‘self’. Given that disorder experiences can be transformative, fundamentally changing how the world is meaningful for someone, we may therefore expect that disorder experiences can transform norms of the self that may undermine seamless social coordination. Following this, I argue that individuals with self-illness ambiguity face unique challenges when it comes to navigating social problems that other individuals with disorder experiences may not face. This is because, as I argue, some discourses around mental disorder are deemed more or less _valuable_ strategies for conceptualising the relationship between self and disorder. Since self-illness ambiguity doesn’t ‘fit’ into these discourses, individuals with self-illness ambiguity may feel isolated not just from their wider community but also from mental disorder communities themselves. I suggest, then, that individuals with self-illness ambiguity might experience an acute form of alienation that is yet to be discussed in the literature.

In recent years, autopoietic enactivism has been used to address persistent conceptual problems in psychiatry, such as the problem of demarcating disorder, that other models thus far have failed to overcome. There appear to be three main enactive accounts of psychopathology with subtle, although not incompatible, differences: Maiesecharacterizes disorder as distinct disruptions in autonomy and agency; Nielsen characterizes disorder as behaviors that relevantly conflict with the functional norms of an individual; De Haan emphasizes patterns of disordered sense-making, that are transformed through the existential dimension. Given that these accounts are intended to provide not only an ontologically richer account of psychopathology but also reduce the stigma experienced by individuals with mental disorders by accounting for lived experience, a critical analysis of these approaches is needed. I will provide a problematization of enactive accounts of mental disorder, showing that this particular framework does not, as it stands, necessarily reduce the harm and suffering experienced by individuals with mental disorder because of its ontological openness; enactivism leaves much to be interpreted and applied by the clinician (or patient) such that practical and ethical problems in its use arise.

In this thesis I develop an account of how processes of social understanding are implicated in experiences of mental disorder, critiquing the lack of examination of this phenomena along the way. First, I demonstrate how disorder concepts, as developed and deployed by psychiatric institutions, have the effect of shaping the cognition of individuals with psychopathology through setting expectations. Such expectation-setting can be harmful in some cases, I argue, and can perpetuate epistemic injustices. Having developed this view, I criticise enactive accounts of mental disorder for failing to consider how such terms like ‘dysfunction’ are open to interpretation and can come embedded with normative expectations. Enactive accounts consequently run the risk of perpetuating injustices in their account of the sociality of mental disorder. Similar concerns arise when we consider the attachment of enactivism to the medical model, I argue. But by adapting enactivism to consider other experiences of disorder, such as those described as ‘madness’, enactive psychiatry may genuinely provide ethical groundwork for a better conception of disordered experience. Then, I consider a further concern with a distinctly medicalised conception of mental disorder from the perspective of self-illness ambiguity, arguing that self-illness ambiguities appear to form a special class of ambiguities due to their proximity to disorder concepts which mark them as appropriate targets for therapeutic treatment. However, I argue further that we should be critical of the idea that self-illness ambiguities necessitate disambiguation, as, in cases where self and illness are demarcated, individuals may still experience distress because simply having a mental disorder can be socially alienating. The medicalised focus in self-illness ambiguity, and the explicit need from the medical perspective to disambiguate it, might then exacerbate the distress someone experiences in mental disorder. Moreover, drawing on Mad Studies, I suggest that one might not need a coherent self-narrative to live well. Because of this, one may not need to adopt a medicalised view of the self in the case of selfillness ambiguity. In order to support this analysis, I provide a phenomenological account of language and argue that the very thoughts implicated in mental disorder shape the individual’s perception of the world due to the way that language foregrounds particular aspects of our world. This demands a critical examination of the language adopted and used by both clinicians and disordered individuals. I thus conclude with some thoughts on how to approach research and developing understanding of mental disorder given that we, as people, are always implicated in this process and therefore socialisation of some kind will always be taking place.

I argue that psychiatric researchers, clinicians, and the wider public actively regulate the minds of individuals with mental disorder through the prescriptive processes of mind-shaping (see Andrews in South J Philos 53:50–67, 2015a; Andrews in Philos Explor 18(2):282–296, 2015b; McGeer, in: Folk psychology re-assessed, Springer, Berlin, 2007; McGeer in Philos Explor 18:259–281, 2015; Mameli in Biol Philos 16(5):595–626, 2001; Zawidzki in Philos Explor 11(3):193–210, 2008; Zawidzki, in: Kiverstein (ed) The Routledge Handbook of Philosophy of the Social Mind, Taylor and Francis Group, London, 2016). Consequently, all those with a vested interest in the language of mental disorder should take a critical and dialogical approach in how concepts of psychopathology are developed, disseminated and used. Mind-shaping describes how our folk-psychological categorizations actively regulate the behaviour of those categorized. This is done through setting certain norms, which can be achieved through the application of folk-psychological concepts. I argue that psychiatry has embedded norms and goals in its activities that are non-epistemic in nature and these are not only bound up in disorder concepts, but also in the social roles that clinicians, researchers and patients play. In this way, psychiatry uses folk-psychological type tools for the social understanding of individuals with mental disorder, and the application of these tools also helps it meet these non-epistemic goals. Given this, I characterise psychiatry as partaking in mind-shaping. When we characterise psychiatry as mind-shaping, we are then able to explain occurrences of looping effects between disorder categories and individuals categorized (Haslam in J Psychopathol 22(1):4–9, 2016) and provide a theoretical basis for the occurrence of hermeneutical injustice in the field of mental health.