Tuesday, 19 October 2021

Facts and Values in Mortality Data during the Pandemic

Today's post is by Maria Cristina Amoretti and Elisabetta Lalumera. This is their second of two blog posts on applied philosophy of science and conceptual analysis in the time of COVID-19.


Amoretti and Lalumera


As philosophers, one of our interests is the interplay of facts and values in medical sciences. We think that debunking the myth of science as purely factual is a contribution that philosophers can usefully bring to society. We also think that science can be nevertheless objective and trustworthy, but not in virtue of being purely factual – as many philosophers have argued recently. In a recent paper, we focused on mortality statistics during the pandemic. 

Mortality data have been very salient throughout the pandemic, both at the personal level, by influencing our emotional uptake of the situation, and at the level of society, as government’s decisions are based on epidemiological models, which, in their turn, are fed by mortality data. When is someone’s death due to COVID-19 or, more specifically, when does COVID-19 qualify as the underlying cause of death? For an answer, we analyzed the rules for the certification of death issued by the World Health Organization (WHO).




These rules, supplemented by instructions contained in the Reference Guide of the International Classification of Diseases (ICD) (WHO 2018), are adopted in most countries, so that the death certificate has the same format. According to these rules, the death certificate should contain all conditions the doctor considers causally and etiologically relevant to the person’s death, but one single underlying cause of death must be specified. It is defined as “the disease or injury that initiated the train of morbid events leading directly to death, or the circumstances of the accident or violence which produced the fatal injury” (WHO 2018, 2.17.1).

This definition underpins a mechanistic conception of causality. However, the guiding principle that should inform the selection of one single underlying cause is explicitly the possibility of prevention of deaths to the benefit of public health (WHO 2018, 2.19.2). Thus, we argued, a prudential or normative principle is used to select from among the causes pertinent to someone’s death. We also noted that the same prudential principle figures in the rules for certifying deaths due to HIV-AIDS, for analogous public health reasons, namely, to prevent the highest number of deaths.

In conclusion, a statement on a death certificate, identifying COVID-19 as the underlying cause of death, may be considered a non-purely descriptive predicate, as grounded on both factual (causal chains and the patient’s medical conditions before and at the time of death) and non-factual reasons (the importance of prevention of more deaths). We think that many arguments can be brought to defend such non-factual reasons. However, it is important to disentangle them from facts. Whereas facts can only be described, reasons can be argued for.

Tuesday, 12 October 2021

The Concept of Disease in the Pandemic

Today's post is by Maria Cristina Amoretti and Elisabetta Lalumera. They discuss the concept of disease in the time of COVID-19 which they also write about in a recent article in Theoretical Medicine and Bioethics. This is the first of two blog posts on applied philosophy of science and conceptual analysis in the time of COVID-19.

Maria Cristina Amoretti is Associate Professor at the University of Genoa, Department of Antiquity, Philosophy and History (DAFIST) and Vice-Director of PhilHeaD-Philosophy of Health and Disease Research Center. Elisabetta Lalumera is Assistant Professor at the University of Bologna, Department of Life Quality Studies (QUVI), and member of PhilHeaD.


Amoretti and Lalumera


During the pandemic, medical and non-medical interventions of institutions and governments became central to our lives. Sometimes we felt overwhelmed with worry and anxiety, conditions that do not favour philosophical reflection. In our paper we tried to put worry and anxiety in brackets, and critically engage with the question: What concept of disease is implicit in the interventions that institutions and governments are enforcing during the pandemic?


For doing so, we started with imagining an ideally accurate diagnostic test for COVID-19, with respect to which four classes of people can be identified: people who are positive and symptomatic (PS), positive and asymptomatic (PA), negative (N), and untested (U). Our aim was showing how different philosophical accounts of disease, amongst those discussed in the recent philosophical debate, would better describe the four classes of people. Or, alternatively, which concept of disease is implicit in certain patterns of disease and sickness judgements, like those experienced during the pandemic.


We therefore analyzed different versions of function-requiring and harm-requiring accounts of disease. Of all these, the only disease concept that, unlike the others, allows a positive sickness judgement, not only for the PS group, but also for both the PA and the U groups is the social (risk of) harm account, which equates disease with a condition associated with harm, or increased risk of harm, either to the subject or to someone other than the subject.


We then argued that the concept of disease as social (risk of) harm is the one that can be seen as implicit in many institutional interventions during the COVID-19 pandemic. Many countries have imposed strong lockdowns and quarantines for their whole population in order to suppress or mitigate the outbreak of the virus. Sickness exemptions and benefits were extended, including paid sick leave, tax credits, etc. These privileges also coincided with the imposition of social obligations and of limitations of individual freedom. What is important to our point, however, is that anyone, the U group included, was considered sick and, as an extension, diseased.




Our final point in the paper was that the concept of disease as social (risk) of harm should be adopted in emergency cases only and abandoned when the emergency is over. We gave three reasons for this conceptual revision claim. First, under the social (risk of) harm account, a condition that is harmful or potentially harmful for society is a disease irrespectively of its physiological basis. Therefore, perceived risky social deviances, such as homosexuality and drapetomania, or behavioural proclivities, such as heavy drinking, could come to be regarded as diseases. 

Second, in endorsing the social (risk of) harm account, the subjective and phenomenological aspects of disease would be overshadowed, as asymptomatic people would count as diseased simply because they represent a risk to society. Third, given that the social (risk of) harm account would classify not only the PS group but also the PA and U groups as diseased, the number of diseased people would dramatically increase, creating a problem of overdiagnosis and medicalization.

Tuesday, 5 October 2021

Isn't Everyone A Little OCD?

In today's post, Lucienne Spencer (University of Bristol) discusses the wrongful depathologization of serious mental conditions. The post is based on a paper co-authored with Havi Carel and published open access in Philosophy of Medicine.

Lucienne Spencer

The Mental Health Foundation states that ‘people with mental health problems are amongst the least likely of any group with a long-term health condition or disability to find work, be in a steady, long-term relationship, live in decent housing [or] be socially included in mainstream society’. Given the global decline in mental health following the coronavirus pandemic, addressing the marginalisation of people with psychiatric illness has never been more urgent. According to the literature, this marginalisation is grounded in sanist attitudes that portray people with psychiatric illness as ‘dangerous and frightening’, ‘incompetent to participate in “normal” activities’ and ‘morally repugnant’. 


Comic by Michael Seymour Blake
(Instagram @michaelseymourblake)

 
While some psychiatric illnesses are solely grounded in such stigmatisation (such as schizophrenia and other forms of psychosis), we argue that other psychiatric conditions may also be vulnerable to trivialisation. Have you ever heard someone say, ‘that football match last night gave me PTSD’ or ‘I can’t handle social situations, I’m so Autistic’ or even ‘I love having my kitchen organised- I’m slightly OCD’? 

When we make light of psychiatric illnesses in this way, we risk reducing a serious condition to a mere personality trait. Consequently, people with these kinds of psychiatric illnesses are more likely to be met with scepticism regarding the severity of their illness; characterised as ‘just like everyone else’, yet labelled as ‘difficult’, ‘manipulative’, or ‘attention-seeking’. Therefore, while these conditions are still subject to systematic stigmatisation, they can also be trivialised. We call this simultaneous operation of stigmatisation and trivialisation of a psychiatric illness ‘wrongful depathologisation’.

Our new article uses OCD as a case study to focus on one distinct harm that may emerge from wrongful depathologisation: epistemic injustice. First, if a condition like OCD is not perceived to be as complex or debilitating as the patient claims, testimony that goes beyond the palatable aspects of the condition is not taken seriously. This would constitute a case of testimonial injustice. 


Havi Carel

Second, wilful hermeneutical ignorance may occur if a diagnostic term, like that of ‘OCD’, is misappropriated by those who do not have the condition. Rather than using the term to refer to a serious psychiatric illness, ‘OCD’ is frequently used to describe an inclination towards tidiness and organisation. Through this misappropriation, the true meaning of the term ‘OCD’ is suppressed and loses its hermeneutical power.

We hope that the concept ‘wrongful depathologisation’ may open a space for new ways of understanding other marginalised experiences that are simultaneously stigmatised and trivialised. For example, cases of rape, sexual assault and domestic abuse, where the individual is vulnerable to stigmatisation and victim-blaming, yet their experiences may be trivialised due to cultural attitudes that normalise sexual and domestic violence. As a new contribution to the literature, we hope that the concept of wrongful depathologisation may bring to light further cases of epistemic injustice driven by the paradoxical twining of stigmatisation and trivialisation.

Friday, 1 October 2021

Belief and Evidence: An Interview with Carolina Flores

Today's post is part of a series on the AHRC funded project Deluded by Experience, ran by PI Ema Sullivan-Bissett and Co-I Paul Noordhof. In this post Harriet Stuart (Research Assistant for Deluded by Experience) interviews Carolina Flores about their research interests and most recent work. Carolina is a graduate student in Philosophy at Rutgers, New Brunswick, specialising in philosophy of mind, epistemology, and social philosophy.


Carolina Flores



HS: Your PhD work seeks to address questions around belief and interactions with evidence, how did you first become interested in these ideas?

CF: My interest in these questions has a theoretical and a political source. The theoretical source was my interest, as an undergraduate, in Davidson’s idea that to have beliefs is to be rational. Though I was intrigued by this view, it was also clear to me that it is in tension with the fact that we are frequently irrational, sometimes deeply so (as in the case of delusions). In my undergraduate thesis, I attempted to address this tension in a way friendly to Davidson’s view.

Irrationality and evidence-resistance turned out to be timely topics for political reasons. I finished my undergraduate thesis the year of the Brexit referendum and Trump’s election. As a response to these events, mainstream media propagated an irrationalist narrative which blamed them on ordinary people’s stupidity and irrationality. This political context made me even more interested in understanding belief and interactions with evidence in general, and in particular in pushing back against the narrative that people are epistemically irredeemable—as I attempt to do in my dissertation.

HS: In a paper you currently have under review, you introduce the notion of epistemic styles, could you briefly introduce the notion and explain why you think this notion is beneficial in your research?


CF: I introduce the notion of epistemic styles to help explain why people interact with evidence in different ways. Epistemic styles are ways of interacting with evidence that express a unified set of epistemic values, preferences, and other epistemic parameters. My idea is that differences in what evidence one finds persuasive, how many explanations for evidence one considers, how actively one seeks out evidence, etc. can often be explained in terms of the adoption of different epistemic styles.

There are two main advantages to appealing to epistemic styles. First, it does justice to the role both of situational factors (mood, social norms, etc.) and of agency in how we interact with evidence. In my account, people flexibly take up different epistemic styles in response to situational factors, where their style then governs their interactions with evidence. In this way, appeal to epistemic styles captures the positive aspects of both virtue-based approaches, which seek to explain our epistemic behavior in terms of deep, stable character traits, and situationism, which emphasizes the influence of trivial situational factors.


Second, appealing to epistemic styles can make others’ interactions with evidence intelligible at the personal level. Thinking in terms of epistemic styles can move us from being puzzled at others’ interactions with evidence, or finding them deeply irrational, to understanding how they interact with evidence in the light of the epistemic values, preferences, etc. that they have taken up.

HS: In your recent paper ‘Delusional evidence-responsiveness’, you argue that delusions are evidence-responsive but that patients can rarely be successful in exercising their capacity to respond to evidence. Can you briefly introduce this idea and talk about how this claim relates to your notion of epistemic styles?

CF: The central idea in this paper is that delusions do not erase the patient’s rational capacities. Patients with delusions have the capacity to respond to evidence bearing on their delusions. If they were to successfully exercise their capacities, they would rationally revise. Unfortunately, unusual perceptual experiences, cognitive biases, and the desire to avoid painful beliefs interfere with these capacities. For this reason, it is very hard for patients to abandon their delusions.


This view is independent of my discussion of epistemic styles. I don’t think delusional patients necessarily take up a distinctive delusional epistemic style when interacting with evidence. That said, there is interesting research in psychiatry that suggests that delusions in schizophrenia are underwritten by a distinctive epistemic style—a view I am developing in a new paper.

HS: Your project draws from many disciplines including philosophy and psychology, what are the advantages and disadvantages of interdisciplinary work? How have you overcome any difficulties?

CF: I love getting to learn from many disciplines! It helps me cultivate a sense of wonder at how much there is to learn and discover. I also think that it has improved my work, by making it sensitive to how actual humans interact with evidence and maintain their beliefs.

One downside of this approach is that it is often overwhelming to realize how much there is to learn. I also worry about not doing justice to scholarship in other fields. To combat this, I try to get very clear on what empirical resources a project requires and then go on a focused deep dive. And I strive to continually expand my general knowledge of other disciplines.

HS: What do you hope to see as the outcomes of your work?

CF: At a theoretical level, I hope to make progress in (1) understanding the nature of belief and (2) developing a clear framework in which to understand how people interact with evidence—one which does justice both to cognitive science and to our rational agency. I hope that this will be useful in understanding delusions, conspiracist beliefs, prejudice, ideologies, political beliefs, and so on. I also hope that this work finds practical application in helping us devise better strategies for changing minds and for rationally engaging across deep disagreement.

Thursday, 30 September 2021

The Impossibility of Imagining Pain

In today's post Paul Noordhof discusses the possibility of imagining pain, summarising a paper, Explaining impossible and possible imaginings of pain, that appears open access in a forum dedicated to responses to Jennifer Radden's article, Imagined and Delusional Pain, in Rivista internazionale di Filosofia e Psicologia. Noordhof's paper is an output of the AHRC Project Deluded by Experience, led by Ema Sullivan-Bissett at the University of Birmingham. 


Paul Noordhof


One form of imagining has a content that is like our sensory experiences and bodily sensations. For example, if I’m asked how many windows the front of my mother’s house has, I might answer by imagining the house as if I am looking at it. Equally, we can imagine our hand being warmed by a close-by fire. In a recent paper, inspired and responding to a paper by Jennifer Radden entitled ‘Imagined and Delusional Pain’, I considered the question of whether it is possible to imagine a pain in the same way. People vary in their answer to this question but it seems particularly difficult to imagine the hurtfulness of pain (which may be a good thing). Radden concludes that it is impossible. If so, the question is why? and what implications may this have for understanding some kinds of mental disorder?

I don’t follow Radden all the way. I argue that it is possible to imagine pains indirectly by imagining circumstances in which they arise but agree with her that it is, generally, impossible to imagine pains directly. This is because, I claim, the representation of something as hurtful is due to our disposition to respond aversively to it and this disposition is undermined by our act of imagining. In a typical philosophical inversion, my suggestion is that we experiencing something as hurting because we are disposed to respond aversively to it rather than are disposed to respond aversively to it because it is hurting. Our act of imagining something undermines the disposition in question in a way that bears comparison to the way we find it hard to tickle ourselves. Our control over the content of our imaginings removes the sense of something happening to us and the anxiety we might feel as a result both of which are characteristic of pain.

Radden’s investigation into the impossibility of imagining pain had the aim of establishing that subjects could not be depressed from imaginary pains or be deluded about the pains from which they suffered. My more moderate position allows for the following possibilities. First, a subject imagines pains as a result of imagining circumstances in which they would naturally occur. Second, either involuntarily or due to weakness of will, a subject may imagine threats to their body which, because of their anxiety, involve the disposition to respond aversively and so they imagine the hurt of the pain that would result. Think of the child crying that you are hurting them brushing their hair when your brush hasn’t even touched their hair yet.

Subjects suffering from monothematic delusions arrive at beliefs that try to make sense of their anomalous experiences. Active imaginings do not support beliefs in the same way since the subject is aware that they are responsible for the content of their imaginings. However, where control over their imaginings break down from weakness of will or involuntary imaginings, subjects are more susceptible to form beliefs in response to their content. This may include depression over the pain one experiences and delusions about the state of one’s health.

Wednesday, 29 September 2021

The First Deluded by Experience Workshop Report

In today's post Harriet Stuart (MRes student in Philosophy at the University of Birmingham) reports on the Deluded by Experience workshop on delusion formation, held online on 12th and 13th July 2021. This was the first workshop of the AHRC funded Project Deluded by Experience and was organised by Ema Sullivan-Bissett and Paul Noordhof.


Poster of the event


Day one started with Kengo Miyazono who presented ‘Salience and Affordance in Schizophrenia’. Kengo proposed a revision of the Aberrant Salience Hypothesis (Kapur, 2003). He claimed that “salience” can be analysed in terms of affordance; an object X is “salient” if and only if X “affords” attention. The altered experience in schizophrenia involves some aberrant salience which is caused by relatively strengthened attentional affordances owing to damage to top-down suppression mechanisms.


Kengo Miyazono


Then Sam Wilkinson presented ‘Agent Representations as Generative Models: The case of Delusional Misidentification’. Sam suggested that delusional misidentification can be explained by errors in the management of mental files whereby mental files are a metaphor for singular (agent) representations. Management of files is to be thought of as a generative model whereby hypotheses are hierarchically arranged and selected based on how well they minimise prediction error.


Sam Wilkinson


Closing day one was Carolina Flores, speaking on ‘The Intelligibility of Schizophrenia’. Carolina introduced her notion of epistemic styles: a unified way of interacting with evidence that express (aspects of) a set of epistemic parameters. The central claim was that the cognitive biases implicated in delusion formation in schizophrenia constitute a distinctive epistemic style. Everyone ordinarily adopts an epistemic style but subjects with schizophrenia can set up their parameters in one specific, extreme way. However, this is not qualitatively different from everyday reasoning. Importantly, the view suggests that intelligibility and rationality should be separated.


Carolina Flores


Day two started with Paul Noordhof and Ema Sullivan-Bissett with their talk ‘The Everyday Irrationality of Monothematic Delusions’. Ema argued that the examination of non-clinical paranormal beliefs and monothematic delusions shows no significant difference that would warrant positing a second irrationality (in addition to the anomalous experience) to explain the latter. Paul went on to claim that monothematic delusions can display features of everyday motivated irrationalities like wishful thinking/weak self-deception and strong self-deception, supporting their claim that delusions are closer to everyday irrationalities than typically thought.


Ema Sullivan-Bissett


Next up was Clara Humpston presenting ‘Isolated by Oneself: Solipsistic Delusions in Schizophrenia’. Clara argued that self-disturbance characterised by paradoxical states of thought is the central background to ‘ontologically impossible’ experiences, which sometimes lead to solipsistic delusions, in schizophrenia. Solipsistic delusions retain the centrality of the self during grave self-disturbance; it is the delusion that ‘adopts’ the patient rather than the other way around, what Clara called ‘autophagy of the self’ or ‘self-eating-self’.


Clara Humpston


Lastly, Dan Williams spoke on ‘Computational Psychiatry and the Social Focus of Delusions’. Dan argued that insights from a predictive coding account and a social account of delusions were possible to integrate without positing the social element as an extra, clinically significant factor. He claimed that the domain-specific content of delusions result from the interaction of a global information-processing dysfunction with various social factors, therefore explaining why delusions tend to cluster around a small number of themes.


Dan Williams


Tuesday, 28 September 2021

Anomalous Experience in the Explanation of Monothematic Delusions

This week we feature the AHRC Project Deluded by Experience, led by Ema Sullivan-Bissett, who is a Reader in Philosophy at the University of Birmingham. In today's post she overviews the first of the Project’s outputs, co-authored with Paul Noordhof (Co-I): ‘The Clinical Significance of Anomalous Experience in the Explanation of Monothematic Delusions’, recently published in Synthese (open access). 





Subjects with monothematic delusions often undergo some highly anomalous experiences. For example, in Capgras delusion, the strange experience has been understood as one of absence of something expected, the subject has reduced affective response to familiar faces traceable to ventromedial prefrontal damage (Tranel, Damasio, and Damasio 1995, Coltheart 2007), or right lateral temporal lesions and dorsolateral prefrontal damage (Wilkinson 2015, Corlett 2019). Empiricists about delusion formation take it that these experiences play an explanatory role in the formation and maintenance of delusions. One-factor theorists claim that they are the only clinical abnormality involved. Two-factor theorists insist on an additional clinical contribution at the level of belief formation or evaluation.

 

In our paper we defend a one-factor account according to which monothematic delusions are a normal response to anomalous experiences. Part of the motivation for two-factor accounts is the apparent existence of people with the relevant anomalous experience but without the delusion. A second abnormality is posited to explain why only some folk move from the experience to the delusion, and others do not. However, we argue that it is a mistake to understand the one-factor account as saying that the sole causes of delusions are anomalous experiences. Rather, anomalous experiences are the only causal contribution which have the feature of being abnormal  The one-factor account does not predict—as is often claimed—that all people with the relevant experience will form the associated delusion.


Ema Sullivan-Bissett


We critically evaluate the case for several proposed second factors of bias, deficit, and performance error theories of delusion. We argue against them on the grounds that they cannot play the envisaged explanatory role or that they lack complete coverage. We are open to the possibility of particular cases involving the proposed second factors, but argue that it would be a mistake to take what is going on in a particular case to provide insight into the nature of monothematic delusion as a distinctive kind of mental disorder.

 

We next turn to the development of our one-factor position, and consider two ways of understanding ‘normal response’. The first way is to challenge the idea that there is just one rational way to respond to anomalous experience, and that even if there is, reasonable differences over what that one way is would both explain variation in subjects’ responses and also make those responses reasonable (even if incorrect).

The second way is to allow that a subject’s response to their experience is not rational, but it nevertheless falls within the normal range of responses, concerning which we would not suppose that there is anything clinically amiss. On this second way of developing the view, the variation between those subjects who form, or persist in, delusional beliefs, and those who do not, is due to individual differences in intellectual style and character at work in normal belief formation. Once we recognize that talk of ‘normal response’ is consistent with a range of other contributions to belief formation or retention, it is utterly unsurprising that people come to different beliefs upon the same kind of experience. 


Paul Noordhof



We turn to epistemic responsibility, and frame thinking about a second factor as involving mental processes that are (1) significantly more resistant to rational correction than we would expect in general from the population given (2) the presence in that population of the kind of experiences subjects with delusions undergo. (1) draws attention to normal irrationalities and epistemic responsibility for them; those whose irrationality is abnormal are not simply epistemically irresponsible but are outside the realm of epistemic responsibility. (2) is key: if some experiences hinder our capacities to appropriately respond to reasons, we need to adjust our expectations of rational responsiveness to those experiences.

 

Our claim that subjects with delusions are, at worst, only normally irrational, is the claim that their epistemic irresponsibility in the face of anomalous experience results in delusions. The difference between these subjects and e.g. vexatious litigants or conspiracy theorists is the disturbing character of their experiences. That is not to say that subjects with delusions can thus always be reasoned out of their belief, but this feature is characteristic of a whole range of normal range beliefs.

We finish by considering two objections. The first is that neurological damage often found in people with monothematic delusions establishes the two-factor theorist’s second abnormality. We argue that such damage does not establish a clinical abnormality of the relevant kind. Even if there were relevant consequences, these may be no more than shifting a subject from one kind of normal range response to another.

The second objection is that some monothematic delusions don’t have obviously identifiable anomalous experiences, and so there must be a cognitive deficit relating to interpreting ordinary experiences in special ways. In response we briefly suggest two ways a one-factor account might be developed to explain these cases, in terms of motivational frameworks or an extension to the notion of experience.

We conclude that arguments in favour of two-factor accounts do not work. The second factor has proven elusive and may turn out to be neither abnormal nor unified. The one-factor approach on the other hand provides a plausible and unified treatment of monothematic delusion. Unless and until there is theoretical reason from the study of delusions to posit a second factor, the one-factor account should be treated as the default hypothesis.

Monday, 27 September 2021

Deluded by Experience: An interview with Ema Sullivan-Bissett



This week we feature the project Deluded by Experience, led by Ema Sullivan-Bissett, who is a Reader in Philosophy at the University of Birmingham. The project will last 30 months (January 2021–June 2023) and is funded by the Arts and Humanities Research Council, with Ema as PI and Paul Noordhof as Co-I. You can follow the Project on twitter @del_by_ex

In today's blog, I ask Ema about the project.

LB: What is Deluded by Experience about? 

ESB: Deluded by Experience is focused on three main areas. The first is monothematic delusion formation. Philosophers, psychologists, and cognitive neuroscientists have argued that subjects with monothematic delusions have anomalous experiences in which delusions are rooted. However, few take anomalous experience to be the only clinically relevant factor. This is the one-factor approach. The current orthodoxy has it that a second clinical factor (cognitive deficit, bias, or performance error) is present which explains why not all people with anomalous experiences have delusions. This is the two-factor approach. 

Our leading hypothesis is that we need not go searching for a second factor. Rather, the explanation for different responses to anomalous experiences derives from individual differences between subjects in the normal range, not some distinctive cognitive failing symptomatic of delusions. We have begun to make our case for this in the Project’s first output, ‘The Clinical Significance of Anomalous Experience in the Explanation of Monothematic Delusions’ (forthcoming in Synthese). 

The second area of interest is the nature of anomalous experience, and implications for philosophical accounts of experience. We distinguish between those experiences involving positive hallucinatory content (e.g. experiencing a second head, as in delusional bicephaly) and those involving an unexpected lack (e.g. lack of affective response characteristic of Capgras). We are interested in whether different philosophical approaches to experience can equally accommodate these two kinds of experience, and the role they play in delusion formation. 

In particular, some currently fashionable relational theories of experience deny that hallucinations have the character that they need to have in order to play the envisaged role in accounts of delusion formation. We are keen to think about whether such relational theories ought to be abandoned, or whether their retention can provide further insight into how anomalous experiences should be understood in accounts of delusion formation.

The third area of interest is the relationship between belief states and truth, often thought to explain several features of belief (e.g. doxastic transparency, involuntarism, and its standard of correctness). We’re interested in whether these features are as much features of monothematic delusions, our current thinking is that they usually are. If that’s right, we want to think about whether certain accounts of monothematic delusion formation, or of the nature of perceptual experience, can sit alongside popular approaches to the truth link (specifically the normative and aim-based teleological accounts). 

One line we’d like to develop concerns whether the relationist about experience, in denying that positive anomalous experiences have particular features, might be forced into a much less popular approach to the belief-truth link grounded in biology (defended in my 201720182020). Finally, although we are broadly persuaded by doxasticism about delusion, we are also interested in whether there are sub-doxastic states (thoughts, imaginings, etc.) which might better characterize some components of the mental lives of subjects with delusions.


Ema Sullivan-Bissett


LB: How did you become interested in delusions?

ESB: Kind of accidentally actually! I wrote my PhD on the relationship between belief and truth, and one of the philosophers on my yearly advisory panel asked me if I’d read anything about delusion. I hadn’t (and I didn’t know what the term even meant). I think I started with your excellent book Delusions and Other Irrational Beliefs, and then I was lucky enough to work as a postdoc on the Epistemic Innocence Project, and then on Project PERFECT, with the latter position focusing on delusion. 

I continued working with Paul during this time (whilst finishing my PhD but also thereafter). I remember a conversation with him that convinced me that there was considerably more potential in the one-factor approach than the debate would suggest. We decided that one important part of our continuing collaborative work would be developing this further.

LB: The project primarily focuses on monothematic delusions such as Capgras, but you think that your research can also be informed by other “rationally resistant”, beliefs. How?

ESB: I’ll just take one stream of this – the relationship between anomalous experiences and strange beliefs. What’s really striking is that a key motivation for two-factor theories is the fact that not all people with anomalous experiences develop delusions, and so the thought goes that we can explain why some subjects develop delusions off the back of anomalous experiences while others do not by appeal to a special irrationality afflicting the former. But our view is that that just fails to recognise the huge tolerance in the normal range of human belief formation and evaluation practices based on experience. 

There are all sorts of beliefs based on strange experiences, where the set of folk with the latter outnumber the set of folk with the former. Beliefs in the paranormal are one example. Researchers interested in their genesis have not sought to identify clinically significant irrationality even whilst recognising that experiences reported by believers are also had by non-believers. That such experiences can prompt different beliefs is of course what one would expect from those experiences interacting with the huge variety of cognitive styles found among healthy subjects (I say similar things about alien abduction beliefs in my 2020). In general, one way in which non-clinical rationally resistant beliefs can inform our work is that reflection on such cases will help demonstrate that the appeal to clinically significant irrationality to explain delusion is unmotivated.

LB: Your project partner is Headway Birmingham & Sollihull. What plans do you have for this collaboration?

ESB: Headway is a national charity working with people affected by brain injury, whose goal is a better understanding of brain injury and how it impacts lives. Our Project shares this goal. Specifically, it seeks to identify a new framework for thinking about people with monothematic delusions, something often brought about following brain injury. In general we’re interested in whether our approach – which does away with any claim about people with delusions being especially irrational – might have implications for clinical practice and the stigmatization of people with delusions. 

If we’re right, the therapeutic process should not expect clinical irrationality, but should rather recognise people with delusions as on a continuum with the normal population with respect to reasoning, and under the strain of responding to highly anomalous and often distressing experiences. 

We plan to run two workshops with Headway Birmingam & Sollihull in May 2022 and 2023, with the participation of service users, practitioners, and academics. These workshops will involve discussing with participants the significance of strange experiences, and considering implications for destigmatization and therapeutic treatment. Our hope is that these events might enhance practitioner understanding of delusion formation amongst service users, and facilitate developing strategies within their own practice or organization.

Tuesday, 21 September 2021

Being Familiar with What One Wants

Today's post is by Uku Tooming (Hokkaido University) on his new paper “Being Familiar with What One Wants” (2020, Pacific Philosophical Quarterly).

Uku Tooming

In my paper, “Being Familiar with What One Wants”, I argue that there are two kinds of self-ascription of desire. First, there are easy cases where a sincere self-ascription seems to be immediately expressive of self-knowledge. For example, if I believe that I want to eat ice cream then, given the person I am, my self-ascription is true and there is no room for doubt. Second, there are hard cases which lack this kind of immediacy and where one could have easily been wrong about one’s self-ascription. For example, when I believe that I want to have a child then, given the person I am, this self-ascription is not immediately expressive of self-knowledge and can be put under question.

How to explain the difference between easy and hard cases? In particular, what makes a self-ascription of a desire an easy case? Since in the philosophical literature on self-knowledge of desire this question has not been asked, there are no clear guidelines how to answer it. Whichever proposed method of coming to know what one wants we consider it is not sensitive to the difference between easy and hard cases. This is not so much a criticism of any existing theory, but an indication that there is more work to be done.

In my paper, I propose a solution to this problem. My explanation of the difference between easy and hard cases proceeds from the assumption that our self-ascriptions in easy cases are safe self-ascriptions, i.e., they could not have easily been false. For our self-ascriptions of desire to be safe, they must track the constraints under which our desires are formed. What are those constraints? I take it that the generation of a desire is due to the updating of prior reward values of one’s options and these prior values were based on the agents’ past experiences. A self-ascription of desire thus tracks those constraints and is thereby safe only if it properly sensitive to those past experiences.

What does it take for a self-ascription of a desire for x to be properly sensitive to the relevant past experiences? My proposal is that there should be some previous experience with a rewarding option that was similar to x. For instance, I can be sure that I have a desire to eat ice cream because I have had comparable experiences before, and this ensures that I have the self-ascribed desire that is shaped by my actual learning history, and thereby excluding the close possibility of being wrong about my self-ascription. On the other hand, I am not in a position to exclude the possibility that it is false that I want to have a child because I have not experienced as rewarding anything that is relevantly similar to the experience of having a child. It is therefore a close possibility that I have a learning history which did not give rise to a desire to have a child.

The difference between easy and hard cases can thus be defined in terms of familiarity: in easy cases, the agent has experienced some content that is relevantly similar to x; in hard cases, she has not. 

Tuesday, 14 September 2021

Epistemic Uses of Imagination

Today's post is by Christopher Badura (Ruhr-Universit├Ąt Bochum) and Amy Kind (Claremont McKenna College) on the new collection on the epistemic role of imagination Epistemic Uses of Imagination (Routledge, 2021). 



In recent years, philosophical interest in the epistemic role of imagination has blossomed.  Although there are a number of philosophers who remain skeptical, there is now considerable agreement that imagination has an important role to play in the epistemic domain.  But when it comes to the question of how best to articulate that role, or to the related question of what explains the ability of imagination to play that role, there is considerably less agreement.  These are the kinds of issues explored in the 15 contributions to our recently released volume, Epistemic Uses of Imagination (Routledge).

The idea for the volume was born in Bochum during summer 2019 when we co-organized a conference on Fiction, Imagination, and Epistemology at Ruhr University.  When we thought about what united the bulk of the talks, we realized that, in one way or another, they were concerned with explicating how imagination can contribute to justification, knowledge, and/or understanding. The talks took up this task in various epistemic contexts – some of them focused on the way that imagination functions in the modal domain, some on the relationship between imagination and reasoning, some on the role (or roles) that imagination plays in thought experimentation, and some on how imagination can help us to understand ourselves and others. 

In this way, we were guided towards an organizing principle for the volume: we would aim to achieve a greater understanding of imagination’s epistemic import by concentrating in particular on these four different epistemic uses of imagination.  We brought a few additional contributors on board to round out the volume, secured a contract from Routledge, and we were on our way.

And then – COVID-19 happened.  Could we still meet our original deadline for volume submission in the midst of a global pandemic?  Was it even reasonable of us to ask our contributors to try?  We decided to push on and, somehow, we were all able to do what it took.  We’re so incredibly grateful to our 14 authors for their Herculean efforts throughout this all.  Somehow, they managed to submit their drafts in a timely fashion, to give one another excellent feedback on those drafts, to revise (and, in many cases, to re-revise), to respond to copy-editor queries, to check page proofs – and to do it all with remarkable grace.



As we note in our introduction to the volume, there are several key themes running throughout the book.  We’ll here briefly mention three themes that we discuss.

Imaginative Constraints

One notion that has featured prominently in recent discussions of imagination’s epistemic usefulness is that of constraint.  Given that imagination, unlike perception, is not world-sensitive, it is generally agreed that imagination must be in some way constrained in order to be epistemically useful.  Imaginative projects typically start from some initial content that then unfolds to some further content.  Constraints play a role in both of these aspects of the project.  Not only must the initial content be appropriately constrained, but so too must the unfolding process.  Throughout the volume, authors attend to these issues – some attending to constraints of the first sort, some to constraints of the second sort, and some on both.

Imaginative Skill

The better that an imaginer is at setting appropriate constraints on their imagination, the more likely they are to succeed in putting imagination to epistemic use. This fact brings us to a second theme that runs throughout the volume, namely that imagination is best thought of within a framework that treats it as a skill.  Setting and obeying constraints are activities that one can be better or worse at, and imagining is correspondingly an activity that one can be better or worse at. This feature – that is, the fact that people differ with respect to how good they are at it – is one of the paradigmatic features of activities that are skills.  Though the contributions in the volume are not always explicit about their treatment of imagination as a skill, we think it is implicit in many of the contributions across all four parts of the book.

Imaginative Justification

Most (though not all) of our contributors are optimists about imagination’s epistemic usefulness and, more specifically, optimistic that imagination can provide an imaginer with justification.  But an important question remains. How does such justification work? This brings us to the third theme that runs throughout the volume, namely, an attempt to provide an explanation of what we might call imaginative justification. Although many of the contributions to this volume take up this theme, they do not all provide the same sort of answer.

As reflected by the orientation of the chapters in our volume, the philosophical discussion of the epistemic usefulness of imagination has at this point largely moved beyond the question of whether imagination can play an epistemic role to the question of how it can play that epistemic role.  In our view, any answer to this question will likely have to reckon with the issues arising out of these three themes that we’ve just discussed. By doing so, the chapters in this volume help address the role of imagination in epistemic contexts and thereby contribute to the development of an epistemology of imagination.  Of course, there is still considerable work to be done. 

The epistemology of imagination has not progressed to a stage at which it can be compared to the epistemology of perception or the epistemology of testimony. But it is our hope that this volume contributes to that progress and, in particular, that these chapters will advance our understanding of many of the critical issues surrounding the epistemic work that imagination can accomplish.  For our part, we’re very pleased with how the volume came out, and we hope that it will prove useful not only to folks already interested in imagination but also to others who work in epistemology, aesthetics, cognitive science, and on other related questions.

Further information about the book, including a complete table of contents, is available here.  We look forward to hearing what readers think of it.


Tuesday, 7 September 2021

Disturbances of Shared Intentionality in Schizophrenia and Autism

Today's post is by Alessandro Salice (University College Cork) and Mads Gram Henriksen (University of Copenhagen) on their new paper “Disturbances of Shared Intentionality in Schizophrenia and Autism” (published in 2021 in Frontiers in Psychiatry).


Alessandro Salice

In the past decades, shared intentionality (i.e., the capacity to share mental states like beliefs, intentions or emotions) has attracted intense attention in several disciplines. These include various theoretical disciplines (e.g., philosophy and game theory), empirical sciences of the mind (e.g., developmental psychology, social psychology, and cognitive sciences), and social sciences (e.g., anthropology, economics, and sociology). By now, the idea that shared intentionality pervasively characterizes human psychology and, therefore, human forms of social life has become fairly uncontroversial in the literature. 

However, the large body of insights secured by this burgeoning line of research has, so far, remained largely neglected in psychiatry. In particular, the relevance of shared intentionality and its potential to enrich our understanding of mental disorders such as schizophrenia and infantile autism have not yet been fully appreciated. 

While relevant literature does recognize that problems of sociality are part and parcel of the two syndromes, these problems are usually considered sequela of social cognitive deficits, and no references to shared intentionality are made. Moreover, with the extension of the diagnostic boundaries of the autism spectrum and the contemporary autism research that typically focuses on persons without intellectual disability, knowledge of the qualitatively different problems of sociality in autism and schizophrenia are gradually disappearing. 

Against this background, our recent paper ‘Disturbances of Shared Intentionality in Schizophrenia and Autism’ (Frontiers in Psychiatry, 2021) pursues two main goals (by amplifying and enhancing some theses already presented in Salice & Henriksen 2015). 

On the one hand, it aims at filling the aforementioned gap in psychiatric literature by specifically focusing on how shared intentionality breaks down in schizophrenia and infantile autism. Specifying the nature of these social difficulties–and especially how they differ from each other in the two syndromes–may potentially help resolve the growing differential-diagnostic confusion between schizophrenia and autism spectrum disorder in clinical psychiatry. On the other, by illuminating how shared intentionality is disrupted in the two syndromes, the article also intends to shed light on the pre-conditions of shared intentionality when it is functioning normally or unproblematically.

To achieve these goals, we develop an empirically informed, conceptual account of two main forms of shared intentionality: joint intentionality and we-intentionality. Joint intentionality crucially relies on the agents’ mentalizing abilities such as mindreading and the ability to factor in (or “to be moved” by) their partner’s intentions in deliberation and action planning. 

By contrast, we-intentionality relies on the agents’ capacity to understand themselves as group members and to adopt the group’s perspective (on the nature of these two processes, see this other entry). Armed with this account, we then move our attention to the social difficulties in schizophrenia and in the severe end of the autism spectrum disorder (infantile autism), respectively.


Mads Gram Henriksen

When approaching the topic of sociality in schizophrenia, one is likely to encounter a staggering puzzle. On the one hand, patients with schizophrenia often report continuous difficulties in establishing and maintaining social relations with others, and frequently these difficulties are a source of loneliness and isolation. On the other hand, patients may simultaneously report that they enjoy and often participate in various forms of social interactions. 

We explain this apparent incongruity in social behavior by arguing that, in schizophrenia, we-intentionality appears to be disrupted, while joint intentionality remains unaffected. The main – although perhaps not exclusive – sources of problems of we-intentionality in schizophrenia are identified in trait-like, non-psychotic, anomalous self-experiences (also called ‘self-disorders’), which empirical studies consistently have found to hyper-aggregate in schizophrenia spectrum disorders but not in other mental disorders or healthy controls. 

In short, our claim is that the enduring presence of anomalous self-experiences may affect these patients’ capacity to understand themselves as group members (in the specific sense at stake in group identification) and, by extension, their ability to engage in we-intentionality.

When it comes to infantile autism, aberrant social behaviour has been considered as a hallmark of the syndrome since it was first described by Kanner and Asperger in the 1940s. We hypothesize that this pervasive aberrance in social behaviour can be cashed out in terms of difficulties that impact both joint and we-intentionality. 

In relation to joint intentionality, we argue that characteristic impairments in the intuitive understanding of other persons make it difficult to track and consider their intentions and to factor them in in action planning and conduct. Put another way, persons with severe autism are often not ‘moved’ by others’ intentions, which directly impacts their capacity to form participatory intentions and, thus, to engage in joint intentionality. 

The root of these difficulties is, in our view, best described by Hobson, who argues that persons with autism have a decreased propensity to identify-with others: they rarely are emotionally drawn or ‘moved’ to assume the others’ bodily expressed psychological attitude and, eventually, to acquire it as a potential attitude for themselves. 

We claim that this decreased ability to understand others’ attitudes plays a crucial role in inhibiting we-intentionality, too. More specifically, we suggest that the very same difficulties that persons with infantile autism encounter in adopting another individual’s perspective may affect the adoption of a group’s perspective.

In conclusion, the picture emerging from our article is that joint intentionality and we-intentionality are complex abilities that rests on various psychological pre-conditions. Consequently, alterations in these pre-conditions may have important consequences for the subject’s sociality and reverberate in the ways in which the subject interacts with others. 

While, evidently, there is currently no available experimental design to test our account or empirical evidence to validate or falsify it, we hope that our paper illustrates that research on shared intentionality can shed a new, refreshing light on some complex issues of relevance in psychiatry and clinical psychology.

Tuesday, 31 August 2021

Discounting Responsibility as Epistemic Injustice

This post is by Kelly Saunders. Kelly did an undergrad degree three decades ago. She completed a Bachelor of General Studies at Simon Fraser University in greater Vancouver. Philosophy was by far her favourite. After her degree she worked at a few jobs, including as a mental health worker, before ultimately deciding to open a small business. 

During all the years of running her business, she never quite lost the feeling of wishing she had pursued philosophy to a greater extent. When she came to a "fork in the road" a year ago, she discovered the M.A. in Philosophy of Religion and Ethics at Birmingham. Her hope is to use her M.A. to work as a philosophical counsellor.





When it comes to the issue of responsibility and psychopathology, Hanna Pickard's contributions are immensely valuable for the subject of addiction. She helpfully differentiates between responsibility and blameworthiness in addiction. That is, she maintains that while it may be unhelpful, and morally questionable to blame an addict for their behaviour, the opposite is the case when it comes to responsibility. This distinction paves the way for a practically, as well as morally constructive means to approach addiction, and offers actual hopefulness for the addict.

Clinical practice in addictions and the rehab industry, as well as societal opinion, in large part operate on and accept an approach that eliminates all responsibility from the addicted individual. Addiction practice and philosophy generally follows a predominantly biological model, wherein agential choice is by-passed. Alcoholics Anonymous is a very well known example of this. The first tenet of their program is to admit that "we were powerless over alcohol." Interestingly, although statistics are not easily obtainable, a 2014 book about the efficacy of 12-step programs such as A. A., reports a 5 to 10% "success rate". Another in-depth article debunking myths surrounding the success of A. A.'s approach, can be found in this 2014 article in The Atlantic.

Along with Pickard, I suggest that denying agency to the addict is wrong-headed. At bottom, we have available to us our agency - the possibility to say yes, or the possibility to say no. Exercising this agency may be difficult, but it is not impossible. It is a grave disservice to struggling addicts to further the narrative that it is impossible. I see such treatment of addiction as representing a form of what Miranda Fricker has referred to as "epistemic injustice". 

Epistemic injustice can manifest as testimonial injustice (unwillingness to accept the addict at their word, as a "knower"), or as hermeneutic injustice (an inability or unwillingness to understand or interpret the addict's experience - this can occur in both the addict as knower, and the clinician as "hearer"). When hermeneutic injustice results in the addict being poorly understood, this contributes to the oversimplified view that an addict cannot change. This results in a loss of opportunity for the addict to understand her addiction in a way that recognizes her agency.

When the addict is a priori attributed a lack of agency, this "controls" their personal narrative in a way that is unjust. Arguably, what prevents the addict from making changes is lack of awareness of responsibility, and the accompanying lack of awareness of actual ability to exercise options. It is not so much the addiction being in control of the addict's behaviour, but rather a belief that addiction controls their behaviour that is maintaining the status quo.

With her clear-eyed approach to addictions and responsibility, Pickard nicely swims against the tide of common assumptions that addicts have no responsibility for their addictions. By returning agency to the addict, Pickard does the addict a great service, and helps to work against epistemic injustice.

Tuesday, 24 August 2021

Does our metaphysics determine our definition of mental illness?

This post is by Laura Roklicer. Laura is an MA student in Philosophy of Mind and Cognitive Science at the University of Birmingham, alongside which she is attending the Expansions of Quantum Theory Towards Consciousness course organized by ECR-Institute (Berlin) and hosted by the Dev Sanskriti University (Haridvar). She holds a First-Class Honours bachelor’s degree in Psychology and in Media Production, and she is looking to pursue a PhD next year through which she hopes to continue exploring the mind.



Laura Roklicer


How the world actually is beyond our apparent understanding matters greatly in defining our views on many important topics. If consciousness were seen as a mere illusion, a great trick played by an unintentional Nature, then we would all be deluded in thinking that we’re thinking. Similarly, if the whole of existence were a single, unified mind, we would again be deluded in thinking we exist apart from each other, in our own private heads on our own two shoulders, and with our own palette of experiences. 

However, a contemporary framework will have us believe that there is a proper mind, and a less proper mind. That is, that those who see the world – and especially their own minds – differently, are delusional and, more often than not, ill. I want to present a rather controversial view that the ‘mentally ill’ schizophrenics might actually be the sane(r) ones considering a specific type of ontology, but not limited to it.

Schizophrenia is defined in phenomenological terms as a holistic account of a self-disorder rather than by a vast number of unrelated symptoms as it is predominately seen in psychiatry. Thus, an enactivist views it as ipseity disturbance (Ipseity derives from ipse, Latin for “self” or “itself,” Sass, Parnas & Zahavi, 2011, p. 7) characterised by hyper-reflexivity, or the exaggerated reflection on the subject’s own thoughts and experience, and diminished self-affection. The latter means that an individual has lost their ‘self’, and this is interpreted in varying ways.




Some consider this loss of the self to be a delusion in an epistemological sense, claiming that a schizophrenic is not seeing things clearly, confusing their own identity. On the opposite side of the spectrum, Gipps (2020) proposes that this is an ontological matter. What this means is that instead of an individual with schizophrenia wrongly interpreting or not appreciating their self as existing within their ego boundary, they are actually right in saying that their ‘self’ is lost or dissolved. Put simply, an ego boundary is a formal, non-materialist, non-psychological, non-spiritual concept of an axis where Other begins and I end, and when it breaks in an ontological sense, the individual’s self truly ‘disappears’.

"I do not know my boundaries; I am unable to differentiate between inside and outside myself; I feel unsheltered; Parts of the body are outside myself; My brain is outside myself; I feel unprotected; Everything is intruding into me, penetrates me; What others think is transferred into me; What I suffer all others have to bear; I cannot keep my thoughts to myself, everybody can know them; I feel unsheltered and open for every external influence." (Scharfetter’s study in Gipps, 2020, p. 94)

 


However, there is still ‘someone in there’ who feels and thinks, and who observes this perishing individual and judges his interactions with the external world. So, who is this ‘self’ that has taken the place of a diminished person? The answer largely depends on our view of metaphysics, of how the world really is.

One view is Bernardo Kastrup’s (2017) idealist ontology, which postulates That Which Experiences (TWE) as the true nature of existence. TWE is all that exists, a unified whole, or a mind of us all, and we are but dissociated alters of this single entity. As individuated ‘alters’ of TWE, we interact with each other, with the external world, and with ourselves, as belonging to the illusion of separation in which we own an ‘ego’. In this kind of ontology, a person whose ego had dissolved into nature would in fact be breaking the delusion and approaching a higher form of sanity, rather than having it the other way around in a physicalist framework.

I have concluded two things, both of which favour the non-delusional interpretation of schizophrenic’s diminished self. First, a schizophrenic is not delusional about having its self dissolved with the rest of reality, because their ego boundaries are ontologically, rather than epistemologically, broken, and thus the individual’s self in fact diminishes. Second, a schizophrenic’s diminished self-affection is not a product of a delusion in an idealist ontology, in which the whole of reality, our individual minds included, are really just one holistic thing – the unified mind or That Which Experiences. In the latter sense, the schizophrenic is on a ‘journey to a higher form of sanity’ (Laing, 1967), that is on their way to a unified reality that underlies our individuated existences.

Tuesday, 17 August 2021

Problems of Living

Today's post is by Dan Stein (University of Cape Town) who writes about his new book, Problems of Living (Elsevier, 2021).



It seems to me hard to practice psychiatry without asking some key “big questions”, both about the nature of the mind (and mental illness) in particular, and about the nature of life (and mental suffering) in general. More than a decade ago I published a volume, Philosophy of Psychopharmacology, in which I addressed some of the “hard problems” faced by mental health clinicians, with a particular focus on philosophical issues raised or addressed by advances in psychiatric medication. 

This year I’ve published my second volume at the intersection of psychiatry and philosophy, Problems of Living, in which I look at a range of “hard problems” raised by life as a whole, with a particular focus on philosophical issues raised or addressed by advances in the cognitive-affective sciences including psychology and neuroscience.

I view my approach in both of these volumes is “integrative” in a number of ways. First, I often spell out debates in the psychiatric or philosophical literature, and then take a “middle way” that I see as drawing on the best points made by the protagonists in the debate. 

Second, in thinking through the “big questions” and “hard problems”, I draw on a range of disciplines, including not only philosophy, but also psychiatry, psychology, and neuroscience. 

Third, I often juxtapose authors from different times and places; Aristotle, Spinoza, Hume, Dewey, Jaspers, and Lakoff are amongst my favourites, perhaps precisely because each covered so many different areas, bringing together different disciplines, with a wisdom and practical judgment that remains relevant.


Dan Stein
 

I can imagine that a registrar in psychiatry, working in the trenches, and swotting neuroscience for exams, might well shrug his or her shoulders in response to this all, perhaps even rolling their eyes at the disjuncture between intellectual pretension and clinical reality. 

Similarly, an individual suffering from a mental disorder, that perhaps has not responded successfully to modern interventions, may be less interested in conceptual niceties, than in psychiatry making practical progress. 

On the other hand, for a philosopher doing cutting-edge work in metaphysics or epistemology, this volume doesn’t cut the mustard; it lacks the rigour that sophisticated philosophy requires. And for the hard-nosed neuroscientist, the excursions made by the volume into brain research may similarly smack of over-simplification.

But perhaps this is a space worth holding: stepping back far enough from clinical realities to try to contribute to work on the “big questions” and “hard problems”, but not stepping back so far as to lose touch with key concerns for clinicians and patients working and living at the coalface. 

And I’d also like to hold a space that tries to make a contribution, but that doesn’t necessarily offer resolution: the thing about the “big questions” and “hard problems” is that there isn’t necessarily a single best answer, these involve “essentially contested” constructs and issues, which don’t give way to simple solutions, but which entail complexity and wickedness, and which it is therefore crucial to keep discussing.

Philosophy of Psychopharmacology argues that psychiatry is precisely the sort of field that should on the one hand acknowledge its own fallibility, while at the same time try to make a positive difference - even though we have still so much to learn about the brain-mind and its disorders, and even though our interventions are far from ideal. 

Problems in Living argues that any answers to the problems of living can only be partial and tentative, but that we should nevertheless persist in trying to live meaningful lives – even though we have still so much to learn about human nature and the world, and despite life’s apparent absurdity. Taken together they argue that it’s key to find a balance between overly optimistic Panglossian views of psychiatry and of life, and unremittingly pessimistic perspectives, and to keep moving forwards - as best we can - with each.