Mental Health Stigma and Theory of Mind

Wesley Buckwalter is an incoming Presidential Fellow and permanent faculty member at the University of Manchester. In this post, he discusses his paper “Mind-Brain Dichotomy, Mental Disorder, and Theory of Mind” recently published in Erkenntnis.

Stigmatization of mental illness is widespread. Misunderstanding, bias, and discrimination associated with mental health concerns pervade even our closest interpersonal relationships, continue despite educational background or medical training, and create major obstacles to treatment and recovery within our health care system. It is essential to understand this stigma and its origins to prevent these negative outcomes.

As surprising at it may at first sound, some misconceptions about mental health are thought to stem from a centuries-old philosophical theory about the mind. According to this theory, often labeled the “dualist approach” to psychiatry, the mind is essentially distinct in kind from other physical systems.

If it is thought that mental disorders are not brain disorders because the mind is distinct from the physical brain, then this suggests that mental health should be treated very differently than other biological pathologies. Treating these things differently in this way, though, has costs that may perpetuate biases about mental health.

In one set of studies researchers consistently found that others are judged much more blameworthy for behaviors when they follow from mental disorders than physical disorders. For example, researchers found that breaking a promise is judged much less harshly when the excuse involved a physical reason, like complications from a car accident, than a psychological reason, like suffering from serious depression.

Other researchers found that even highly trained medical professionals display similar effects when evaluating clinical vignettes. Patients displaying symptoms perceived as more psychologically determined were regarded as more blameworthy, in greater control of, and more responsible for their behaviors than when symptoms were seen as biologically determined.

Women's Voices in Psychiatry

Today's post was written by clinical psychiatrist, Gianetta Rands.

Women's Voices in Psychiatry was published in June 2018 by Oxford University Press. It is a collection of essays by women psychiatrists working, or who have worked, in the NHS. In addition, medical journalist Abi Rimmer writes on the history of women in British Medicine and Claire Murdoch, National Mental Health director at NHS England, reminisces about training as a registered mental nurse at Friern Hospital in the 1980s.

This anthology has had a momentum of its own from the very start. I was just in the right place, at the right time. With encouragement from Baroness Elaine Murphy, psychiatrist, researcher, senior manager and cross bench peer, and support from several individuals and committees at Oxford University Press this book was on its way.

In 2015, I retired from the NHS and presented an ‘exit seminar’ titled “Career Reflections of a 1970s Feminist” using my experiences of training and working in medicine and psychiatry from 1975 to 2015 to highlight women’s issues in general. Afterwards, I was surprised by comments from current women psychiatry trainees essentially saying that not much had changed over 40 years in terms of their work experiences. This seminar formed the basis of the first chapter of Women’s Voices.

I now work as an independent psychiatrist and my clinical practice focuses on dementias, brain injuries and mental capacity. A long-term preoccupation of mine has been post flight confusion. That is, air passengers being confused after flying. Many colleagues know about this and many of us have seen dozens of cases. It seems to mostly affect older people whose physiological autoregulation mechanisms may not be so good as those of younger people. And, of course, aviation and altitude medicine research is almost exclusively done on fit young men. I continue to rant about this because I think it is a public health scandal.

I have never aspired to write or edit a book but Women’s Voices was an important project and I had the energy, time and contacts needed to commit to it. For me it was essential to record, in real time, women’s experiences as professionals and as patients in mental health services. Too often women have been silenced and the gender publication gap in scientific publications is one example of this. There are many gender differences discussed in these essays. Whilst editing them I was constantly overwhelmed by their quality, integrity, and content, and so inspired by my wonderful colleagues. I can’t imagine that anyone won’t find every word fascinating.

The essays are a range of autobiographies, biographies, case based studies, reviews of clinical literature, and historical descriptions. For example, Fiona Subotsky scrutinizes the archives in her essay “The Entry of Women into Psychiatry”, and Jane Mounty, Anne Cremona and Rosalind Ramsey describe the more recent history of the Women’s Mental Health Special Interest Group.

Rosemary Lethem writes as psychiatrist and patient having suffered with bipolar affective disorder throughout her adult life. Her bravery and stamina are extraordinary and anyone doubting that they can manage their career and their mental illness will be inspired by her experiences and tips.

There are chapters about Perinatal Psychiatry (Jacqui Humphreys), The Role of Women in Intellectual Difficulties (Angela Hassiotis and Rupal Dave), Women in Forensic services (Jail Birds by Annie Bartlett), and a contemplation about whether or not women only mental health units are needed (Aoife Singh).

For the more psychodynamic essays, Jo O’Reilly considers the need for psychotherapist support in mental health units and proposes a model of the “Maternal Lap” with its changing concavities. An important update of our understanding of child sex abuse and complex trauma is presented by Joanne Stubley, Maria Eyres and Victoria Barker. Sandra Evans and Jane Garner write on “Old Age, Women, and Dynamic Psychotherapy” firmly refuting the belief that psychotherapy is only for the young.

There are chapters about Dementia and how to reduce its risks (Joanne Rodda), about difficult, life-and-death clinical decisions that have involved the Court of Protection (Clementine Maddock), and about the evolution of services - Claire Hilton’s biography of Barbara Robb, and Amanda Thomsell interviewing Nori Graham about Old Age Psychiatry and working with the Alzheimers Society UK and International.

A collection of essays by psychiatrists would not be complete without descriptions of our training (Philippa Greenfield and Georgina Fozard), and our experiences as trainers of psychiatrists (Hannah Fosker and Ann Boyle); but this time it’s women’s views. In addition, inspiring reflections from the Royal College of Psychiatrists President, Wendy Burn, and recent past president, Sue Bailey, give insights into their roads to success.

These essays are interspersed with short ‘profiles’ of pioneering colleagues such as Helen Boyle, Fiona Caldicott, Dora Black, Helen Green Allison, Eluned Woodford-Williams, and nurses Lisbeth Hockey and Annie Altschul. Poems by GP poet Emily Wills create pauses for reflection about women as doctors, as patients, and many aspects of women in general.

Sweeping vs. Creeping Reductionism in Addiction Research

Şerife Tekin is an Assistant Professor of Philosophy at the University of Texas at San Antonio. Her research program in philosophy of science and mind aims to enhance psychiatric epistemology by developing methods for supplementing the existing scientific literature with a philosophical study of the first-person accounts of those with mental illness. 

She draws on the scientific literature on mental illness, philosophical literature on the self, and the ethics literature on what contributes to human flourishing to facilitate the expansion of psychiatric knowledge that will ultimately yield to effective treatments of mental illness. Here she discusses her article, “Brain Mechanisms and the Disease Model of Addiction: Is it the Whole Story of the Addicted Self? A Philosophical-Skeptical Perspective,” which recently appeared in the Routledge Handbook of Philosophy and Science of Addiction.

In my chapter in this anthology, which brings together cutting-edge work on the scientific and clinical research on addiction and various philosophical puzzles pertaining to addiction, I take issue with the disease model of addiction that construes addiction merely as a problem of the “broken brain.” I defend that self or person models of addiction are more resourceful for enhancing research on the mechanisms of addiction and developing effective interventions.

A common debate among scientists and philosophers is whether human sciences, such as psychology and psychiatry, involve phenomena distinct from those targeted in the physical sciences. According to reductionism, target phenomena in human sciences are only prima facie distinct from those in the physical sciences, lending themselves to explanation or even replacement by phenomena in the physical and chemical sciences.

Reductionism exists on a spectrum (Schaffner 2013). On the one extreme, human phenomena “are nothing but aggregates of physicochemical entities,” a view labeled “sweeping reductionism” (Schaffner 2013: 1003). For “sweeping” reductionists, “there is a theory of everything” and “there is nothing but those basic elements—for example, a very powerful biological theory that explains all of psychology and psychiatry” (ibid). 

How We Understand Others

Today’s post was written by Shannon Spaulding, Assistant Professor of Philosophy at Oklahoma State University. Her general philosophical interests are in the philosophy of mind, philosophical psychology, and the philosophy of science. 

The principal goal of her research is to construct a philosophically and empirically plausible account of social cognition. She also has research interests in imagination, pretense, and action theory. Here she introduces her new book, “How We Understand Others: Philosophy and Social Cognition”.

A question that has long interested me is how we understand others – that is, what are the cognitive processes that underlie successful social understanding and interaction – and what happens when we misunderstand others. In philosophy and the cognitive sciences, the orthodox view is that understanding and interacting with others is partly underwritten by mindreading, the capacity to make sense of intentional behavior in terms of mental states. 

On this view, successful social interaction often involves understanding what others are thinking and what they are trying to achieve. In our ordinary social interactions, we attribute beliefs, desires, emotions, and intentions to people to make sense of their behavior, and on the basis of that we predict what they are likely to do next. 

In this book, I argue that mindreading is an important tool in our folk psychological toolkit. But, I argue, mindreading is not as simple, uniform, or accurate as the orthodox view portrays it to be. The philosophical literature on mindreading suggests that neurotypical adult humans rarely make mindreading mistakes, that competent mindreaders all pretty much agree on the mentalistic explanations and predictions we infer, and all there really is to mindreading is attributing a belief, desire, or intention and explaining and predicting behavior. 

I challenge each of these ideas. I argue that individuals differ with respect to informational input to mindreading, their goals in mindreading, the kind of mindreading strategies they adopt, and the kind of mindreading output they produce. My claim is not simply that individuals use their mindreading judgments differently. That much is uncontroversial. 

Rather, my claim is that the input, processing, and output of mindreading all vary along many dimensions, which makes constructing an empirically adequate account of mindreading significantly more challenging than typically recognized. The overarching theme of the book is that mindreading is much more complex, messy, interesting, and relevant to other debates than philosophers have acknowledged. 

There are two particularly important dimensions of complexity for mindreading: the input and output of mindreading. Philosophical accounts of mindreading for the most part do not discuss the input into mindreading mechanisms. Discussions of mindreading rarely concern how social categorization (rapidly, spontaneously classifying individuals by their age, race, gender, and other categories), stereotypes, social biases, and situational context influence how we interpret social behavior. 

These aspects of social interaction filter the available information that serves as input to mindreading and thus directly influence the mental representations mindreaders end up attributing. Thus, realistic and accurate accounts of mindreading must explain how these aspects of social interaction shape both the input and output of mindreading judgments. 

Most contemporary mindreading theories presuppose that our primary goal in mindreading is to attribute beliefs in order to accurately explain behavior. Although this is the case in certain conditions, this presupposition is wrongheaded in two ways. First, mindreading is not limited to belief-based explanations. Existing mindreading theories often narrowly focus on how we attribute beliefs to others. 

Although there is good reason to think that belief attribution is a significant cognitive achievement, and there’s an interesting history of how belief attribution came to dominate philosophical discussion of social cognition, the result of this fixation on belief is that philosophical discussions neglect other important aspects of social interaction, such as attributing various kinds of mental states in order to influence others (mindshaping), to enforce social and moral norms (regulative folk psychology), to confirm our worldview, protect in-group members, and, in cases of competition or threat, vilify an outgroup member. 

The Subjective Structure of Thought Insertion

Pablo López-Silva is a Reader in Philosophical Psychology at the Faculty of Medicine of the Universidad de Valparaíso in Chile. He is the leading researcher of the FONDECYT project ‘The Agentive Architecture of Human Thought’ granted by the National Commission for Scientific and Technological Research (CONICYT) of the Government of Chile. 

His current research focuses on cognitive phenomenology, attributions of mental agency, and delusions. In this post, he summarizes his new paper titled ‘Mapping the Psychotic Mind’ recently published in the Psychiatric Quarterly.

Thought insertion – TI henceforth – is regarded as one of the most complex symptoms of psychosis. People suffering from TI report that external human and non-human agents have inserted thoughts or ideas into their minds. Over the last years, the enigmatic nature of TI reports has become target of a number of phenomenological, empirical, and conceptual debates. In fact, TI has been used as a good excuse to debate about the nature of delusions, the nature of psychiatric reports, the nature of the self, self-consciousness, the adaptive role of beliefs, the principle of immunity to error through misidentification, among many other issues.

However, three problems underlie these discussions.