Wednesday 27 December 2023

Addressing Autistic Mental Health from the First Person

Today's post is by Themistoklis Pantazakos and Gert-Jan Vanaken. Themistoklis (he/him) is an Assistant Professor in Philosophy of Psychiatry at The American College of Greece and an Honorary Research Fellow at University College London. He works on phenomenological psychiatry, focusing on treatment methods that make sense of the point of view of client users and their communities. 

Gert-Jan (he/him) is a post-doctoral researcher at KU Leuven and the University of Antwerp. He works at the intersections of bioethics, disability studies and clinical autism research. His work focuses on developing neurodiversity-affirming autism care practices. Here, they argue that interventions for autism should address autistic mental health directly, and that a first-person approach is key for adapting psychotherapy to the needs of the autistic population. The full article is here, available open access.


Themistoklis Pantazakos

"[R]ight from the start, from the time someone came up with the word ‘autism’, the condition has been judged from the outside, by its appearances, and not from the inside according to how it is experienced."
 
- Donna Williams (Autism: An Inside Out Approach)


Autistic people face a mental health crisis that is hard to overstate. Compared to the general population, autistics among us are significantly more likely to experience most major psychiatric disorders, two and three times more in the case of anxiety and depressive disorders respectively. Alarmingly, 31% of the premature deaths of autistics is due to suicide compared to 4% in the general population.

Public perception is often that the problem of autistic people is autism itself. This view is shared with the dominant, medical approach to autism, which conceptualizes it as a set of neurological and psychological dysfunctions within the individual. Correspondingly, interventions for autism most often aim at making the person less autistic. Particularly so, behavioral interventions, which constitute an overwhelming majority of the interventions publicly funded and undertaken for autism, are purposed to eradicate ‘problematic’, autistic behaviors and establish typical, pro-social ones. 


Gert-Jan Vanaken

First, our paper highlights that this view is not well-supported by the evidence. If autistic ‘symptom’ severity was indeed to blame for the mental health crisis, we would expect to see a positive correlation between the degree of autistic characteristics and mental health problems, which cannot be found at this point. In line with a social model of disability and with claims made by autistic self-advocates, we cite preliminary evidence pointing to a correlation between the wellbeing of autistic individuals and the perceived quality of support and the degree of social acceptance they enjoy. We conclude that what is necessary to address the crisis is not yet more ‘symptom’-targeting interventions and attempted normalization of autistic individuals but approaches that directly aim to improve mental health instead.

Second, we argue that contemporary psychotherapy is ideally posed to fill this lacuna in the autistic mental healthcare landscape if it overcomes a major contradiction. On the one hand, to be neurodiversity-affirming, psychotherapy needs to respect and embrace the ways in which autistic people experience the world, and their different ways of being. On the other hand, psychotherapy is in principle posed to maintain an element of critical disbelief towards what an individual professes to know about themselves. Indeed, the job of therapy is to work against the ‘default mode’, the cognitive and emotional automations of clients, when these automations fail them. Helping clients thus necessitates taking them seriously, not literally.

This impasse, we contend, may be solved by utilizing phenomenology, the philosophical method of inquiring about one’s experience ‘from within’. For medicine in particular, phenomenological approaches emphasize how conditions of interest are lived as unitary experiences, not as disparate biological bodily symptoms. Correspondingly, the focus of phenomenology-based mental health approaches is to make this experience better: to minimize suffering and maximize enjoyment for the involved individual.

Our proposal is not to straightforwardly ask clients what works for them and abide by that. We encourage therapists to maintain the critical attitude that is sine qua non for psychotherapy. What we promote is that the process is occasionally subjected to a phenomenological check: a review of how treatment has impacted the subjective well-being of the client. Therapists should not shy away from trying something new because it does not come easy to the client but, all the same, they should drop the plan if, given enough time, no substantial improvement is noted from a first-person point of view.

On a practical level, we are very sympathetic to the further dissemination of the practice of autistic therapists, who are more naturally posed to know what it is like to be autistic. Correspondingly, we urge non-autistic mental health practitioners to familiarize themselves with phenomenological literature on autism, and researchers to further develop such literature, following the young but strong movement to look at autism ‘from within’.

Wednesday 20 December 2023

Is OCD Epistemically Irrational?

Today’s post is by Pablo Hubacher Haerle on his recent paper “Is OCD Epistemically Irrational?” (Philosophy, Psychiatry and Psychology 2023). Pablo Hubacher Haerle is a PhD student at the University of Cambridge. His thesis is on the epistemology and metaphysics of the mind. He is particularly interested in desire, inquiry and the philosophy of psychiatry.

Pablo Hubacher Haerle

On the mainstream picture of obsessive-compulsive disorder (OCD), people experiencing OCD have intrusive thoughts which lead them to form epistemically irrational beliefs. Consider this classic example: 

Amelia is driving in their car. Suddenly, she hears a weird noise which she can’t identify. She forms the belief that she’s run someone over and spends hours looking for the supposed victim.

But it is true that Amelia must have a belief that she’s run someone over? Following recent advances in the literature (Kampa 2020; Taylor 2021), I consider it much more plausible to construe Amelia’s recurrent thoughts as what if questions. This matters for the assessment of rationality, since the rationality conditions for questions are different from those for beliefs. Imagine that you discover an unknown spoor while hiking in the wild. Here, it seems rationally permitted to ask the question whether this means that a bear is near, even though it would be unreasonable to believe that a bear is, in fact, near. Moreover, given how high the stakes are, it might even be mandated to ask that question. 

This doesn’t mean that questions can never be irrational, though. As Jane Friedman (2019) convincingly argues, sometimes reality is so obvious it would be ridiculous to question it. If you’re directly looking at me, it doesn’t make sense for you to ask where I am. But even if you were to think that people like Amelia are irrational because they’re inquiring into questions whose answers are just completely obvious, there are other instances of OCD where the grounds for a charge of epistemic irrationality are much weaker. Consider this case, adapted from a clinical case study (Bhatia and Kaur 2015; Williams and Wetterneck 2019):

For four years, Joseph has had uncontrolled repetitive thoughts about being gay. He is constantly distressed about this. He constantly has doubts about his sexual orientation.

Joseph suffers from the condition of sexual obsessive-compulsive disorder where the object of endless inquiry is not something in the external world, but instead the patient’s own desires. This complicates the assessment of rationality since now we’re not guaranteed an objective viewpoint on how much evidence for this hypothesis Joseph actually has. He might have repressed desires. Moreover it’s unclear we can trust his own testimony because he might be affected by motivated reasoning as a result of homosexuality still being heavily sanctioned in our societies. Thus, it’s not true that Joseph’s inquiry is irrational in virtue of questioning the completely obvious.  

I conclude that so far we don’t know what’s epistemically irrational about this specific kind of OCD. It might be that OCD isn’t irrational after all, or that its irrationality is merely practical, or that there isn’t one form of irrationality common to all cases of OCD. Personally, I believe that what makes OCD epistemically irrational is the fact that it induces unsuccessful inquiries. But whatever conclusion will be reached in this debate, it’s clear that—in line with research by Lisa Bortolotti (2020) and Sahanika Ratnayake (2021)—also in the case of OCD we cannot distinguish between the pathological and the non-pathological by appeal to epistemic irrationality alone.

Wednesday 13 December 2023

Introspection in the Disordered Mind and the Superintrospectionitis Thesis

This blog post is by Alexandre Billon who presents his argument in a paper recently published in the Journal of Consciousness Studies. This paper is a commentary on Kammerer and Frankish's article on what forms introspection could take.


Alexandre Billon



A couple of authors have suggested that schizophrenia and depersonalization disorder (DD) involve an enhancement of introspective abilities regarding certain important features of our experiences --- call that the Superintrospectionitis Thesis.

The Superintrospectionitis Thesis and Schizophrenia

In the phenomenological tradition, Blankenburg argued that reports of some people with schizophrenia ‘reveal, in a kind of immediacy the conditions of possibility of our existence that otherwise remain concealed’ (Blankenburg, 2001, p. 308). Likewise, Kimura (2001, p. 335) suggested that schizophrenia might render manifest, through introspection, the ‘innate structure of all human beings that happens to be hidden in healthy people owing to some mechanism or other’. More recently Stephenson and Parnas (2018) have compared schizophrenia to an ‘amplified mirror image’ that reveals a ‘differentiation or potential alterity implicit in the dynamic nature of subjectivity’.

The Superintrospectionitis Thesis and Depersonalization Disorder

The term ‘depersonalization’ comes from the works of the Swiss diarist Amiel who arguably suffered from it but was quite ambivalent with regard to it. He sometimes described it as an awful psychological disorder, sometimes as a metaphysical blessing and a confirmation of Schopenhauer’s Buddhist views on the unreality of self (Amiel, 1894). This ambivalence about DD is still common. 

Even though DD is usually dysphoric and the strange experiences of people with DD are usually considered misleading, the popular writer Suzanne Segal, aided by her Buddhist teachers, has argued that her DD was the first step of a spiritually enlightening journey (Segal, 1996). She has been followed by some philosophers who saw in DD a confirmation of Buddhist views on the unreality of the self (see  manuscript by Chadha, "Depersonalization and the sense of self") and has led many patients to question the deep meaning of DD (as witnessed by frequent discussions of DD forums).

I consider and reject various arguments for the Superintrospectionitis Thesis (coming from the phenomenological and Buddhist traditions and from evolutionary psychiatry) and I provide a simple, tentative argument against it, the “fine-tuning argument”.

The Fine-Tuning Argument

Suppose you open a radio receiver, choose one wire randomly, and disconnect it, or connect it to a different slot. Suppose that, as a result, you cannot listen to CDs on your stereo anymore. You might still be able to listen to your favorite radio stations. Maybe not. But the chances that it might now better receive the range of radio waves it used to receive, or that it might receive a new range of radio waves, seem extremely meager. The reason why is that a stereo is a fine-tuned system, that is, a system optimized to fulfill a certain set of functions, and whose functioning is extremely sensitive to a set of parameters. 

Accordingly, if you modify these parameters, you are likely to end up with something that cannot properly fulfil some of its functions, and extremely unlikely to obtain something that fulfils some of its functions better. Now, our minds are likewise fine-tuned: they are optimized to fulfil a certain set of functions, including introspection. On the most plausible accounts, schizophrenia, and DD are mental disorders, a mental disorder involves a (harmful) dysfunction of the mind (Wakefield, 1992), and it is extremely unlikely that a dysfunction of a fine-tuned system might make it better at fulfilling some of its (other) functions such as introspection.

The Fine-Tuning Argument does not forbid that some people with mental disorders might become better at introspection after some time, by a form of overcompensation or hyperspecialization (compare with auditory overcompensation to early blindness). Unfortunately, advocates of the Superintrospectionitis Thesis all claim that the earliest symptoms of schizophrenia (in fact the prodromes) and depersonalization disorder reveal a form of introspective enhancement. So overcompensation and hyperspecialization are excluded here.

(For interest, Kammerer and Frankish respond to this commentary here). 

Wednesday 6 December 2023

Silence

This post is by Dan Degerman, Leverhulme Early Career Research Fellow at the University of Bristol, soon to join the new project EPIC (Epistemic Injustice in Healthcare), funded by a Wellcome Discovery Award. (A version of this post appeared on the EPIC blog on 15th September 2023.)


Some members of team EPIC: Matthew Broome, Ian Kidd,
Dan Degerman, Havi Carel, Kathleen Murphy-Hollies, and Fred Cooper.


Silence is an important phenomenon in mental health. But while philosophers have had much to say about the social silencing of people with psychiatric diagnoses, other ways in which silence can feature in psychopathology have been underexplored. In a recent workshop at the University of Bristol, generously funded by the Leverhulme Trust, we sought to begin to address this neglect by exploring the different faces of silence in psychopathology.

Ian Kidd opened the workshop with a talk that explored painful silences common in bereavement grief. In particular, he focused on four silences, each characterised by a loss of communicative possibilities that follows the death of a loved one. This included, for example, silence as the loss of the distinctive communicative style of the deceased and silence as the permanent absence of narrative closure. For the person subject to these silences, they are painful for three reasons, Ian explained. Firstly, these silences cannot be filled. Secondly, they involve the awareness that the ways of being in the world the relationship with the deceased made possible are now impossible. Thirdly, they involve the awareness that one can no longer be the same person that one was with the deceased.


Ian Kidd


The second speaker, Richard Stupart, drew on accounts of investigative journalists working in South Sudan to shed light on some of the mental dangers of being silent. He argued that journalists are at a heightened risk of moral injury, referring to the negative psychological impact a person experiences when they are unable to respond to a situation in what they consider a morally appropriate way. Journalists in conflict and crisis situations are particularly vulnerable to such injury because they often find themselves subject to structural pressures that may prevent them from communicating their knowledge about morally charged stories.

Richard Stupart


Inner speech in mental disorders was the subject of the next talk by Sam Wilkinson. He defended what he called a strong dialogical account of inner speech, which entails that all inner speech is directed at a recipient, namely, ourselves. This account also suggests, among other things, that inner speech plays a central role in shaping our identity. Sam then outlined some ways this account can help clarify the implications of inner speech and its absence in different mental disorders. For example, the strong dialogical account indicates that negative inner speech in anxiety and depression is not just an epiphenomenon of pre-existing a person’s feelings but that it can create a downward spiral of those feelings.

 

Sam Wilkinson


The fourth talk by Anna Bortolan examined experiences of silence in social anxiety. Drawing on some distinctions proposed in a recent paper on silence in mood disorders, Anna showed that these capture experiences described by people with social anxiety as well. She then went beyond that account to argue that a further two experiences of silence can be discerned in accounts of social anxiety. The first is characterised by a perceived inability to fill certain silences when one wants to do so, and the second is accompanied by a diminished sense of agency over how silences are filled.


Anna Bortolan


Finally, in my talk, I argued for the importance of attending to first-person experiences of silence in psychopathology through a case study drawn from accounts of depression. Using a phenomenological framework inspired by the work of Merleau-Ponty, I described an experience common in first-person accounts of depression that I termed empty silence. This is an unpleasant experience that involves a solicitation to speak and a breakdown in a person’s habitual relationship with words, which confronts them with their own outward and inner silence. I proceeded to argue that if lived repeatedly, it may give rise to bodily doubt in one’s ability to speak.

Dan Degerman


If you are interested in learning more about the talks, presentation materials from most of them can be found here. The talks were followed by wonderful discussions with the interdisciplinary audience that was in attendance in the room and online, and I want to extend heartfelt thanks to all those who participated.

The workshop was the capstone event for my Leverhulme Early Career Fellowship. However, it also served as an informal launch event for the EPIC project, with many of its team members in attendance, including Ian Kidd, Havi Carel, Matthew Broome, Fred Cooper, Kathleen Murphy-Hollies, and myself. The conversations and explorations that began during this workshop on silence and psychopathology will continue as part of the EPIC project, and if you are interested in contributing or participating in some way, please do get in touch.


Wednesday 29 November 2023

Remembering requires no reliability

This post is by Changsheng Lai (Shanghai Jiao Tong University).

 

Changsheng Lai


You believe that you locked the door before you left your house, but do you really remember that? Your belief about the past episode might be true, but in what sense is the past episode genuinely remembered rather than being just accurately imagined or veridical confabulated? A popular view, which I refer to as ‘mnemic reliabilism’, suggests that the process of remembering is distinguished by its reliability condition. That is, successful remembering must be produced by a reliable memory process. 

Prominent champions of this view include the simulationist Kourken Michaelian (Michaelian 2016) and the causalist Markus Werning (Werning 2020). Besides, you might also find mnemic reliabilism attractive if you are sympathetic to both the orthodox view that ‘remembering entails knowing’ and the idea that ‘knowledge requires reliability’.

In my recent paper entitled ‘Remembering requires no reliability’, I argue against mnemic reliabilism. I demonstrate that there are cases where past events can be successfully remembered despite the unreliability of the corresponding memory processes. Roughly, my cases can be divided into two types:

The first type of cases focuses on patients with neurodegenerative diseases such as Alzheimer’s disease (AD). There is ample empirical evidence to show that AD severely undermines the reliability of patients’ episodic memory by causing frequent memory distortions. However, AD does not deprive patients of the capability of remembering, at least occasionally, some past events. After all, discussions about ‘true memories’ or ‘remembering’ in AD patients are ubiquitous in the psychological literature. It is also untenable to claim that AD patients cannot successfully remember any past event just because they cannot remember many past events reliably.

The second type of cases illustrates how healthy subjects can remember the past unreliably. Empirical studies have discovered many factors that can render our memory processes unreliable. For instance, divided attention (during the stage of encoding or retrieval) has proven to be able to result in more inaccurate memories than accurate ones (Perez Mata et al. 2002). Likewise, high mental stress during post-encoding consolidation also tends to impair memory performance and increase false memories (Pardilla-Delgado et al. 2016). 

Memory processes involving those reliability-affecting factors tend to end up with false memories; however, they can still sometimes end up with true memories. For example, in Pardilla-Delgado and colleagues’ (2015) DRM-style experiments, while stressed participants remembered more false than true words, there was still a 29% chance that presented words could be accurately remembered. Therefore, an overall unreliable memory process can nevertheless lead to successful remembering.

The upshot is, any satisfactory analysis of remembering should avoid including the reliability condition. Moreover, if successful remembering can still provide defeasible justification for our memory beliefs without requiring reliability, then a reliabilist account of (memory) justification is also questionable. Finally, if reliability-affecting factors are prevalent enough in daily life, then perhaps we ought to reexamine the received view seeing memory as a reliable epistemic source.

Wednesday 22 November 2023

Reichenau Summer School: Dealing with Uncertainty

In today's post I report on the Summer School in Reichenau  which I had the pleasure to attend on 25th and 26th August 2023. The theme was Belief, meaning, knowledge: how we deal with uncertainty. Delusions was a topic often discussed in the presentations, from philosophical, phenomenological, and clinical perspectives. Organisers of the event were Johannes Rusch, Daniel Nischk, Dorothea Debus, and Thomas Müller.


Rathaus Reichenau (front)

Rathaus Reichenau (courtyard)


The first speaker was Rico Gutschmidt (Konstanz) with a presentation on Mysticism and Delusions. Fundamental uncertainties are limitations of knowledge and experience and three questions arise: (1) Where do we come from? (2) Why there is anything at all rather than nothing? (3) Who are we? Although such questions are not easy to answer or possible to answer they can evoke transformative experiences. Philosophical experiences such as struggling with these questions can be transformative because they change the type of people we are. They change our attitude towards life. They contribute to the mystery of existence.

Mystical experiences are an extreme form of transformative experiences. They can be induced by substances and meditation and can include a feeling of unity with everything and the loss of the self. People feel like they understand a deeper level of reality that is often ineffable -- cannot be put into words. Such experiences can be both positive and negative, they are often overwhelming. Gutschmidt argued that mystical experiences can be reinterpreted as experiences of the unboundedness of existence.

In a recent study led by Gutschmidt and Nischk several participants were interviewed and their interviews analysed in interpretive phenomenological analysis: it was found that some delusions are very similar to mystical experiences (loss of the self etc.). So these types of delusions can also be interpreted as experiences of the mysteries of existence. In this sense, delusions are not pathological and involve a revelation of a deeper reality (enlightenment); the sense that one is outside time and space and past, present, and future are fused together; and ineffability. Patients describe delusions as meaningful experiences.

The second speaker was Uwe Herwig (Konstanz and Zurich) who presented about Psychedelics: Phenomenology and Psychotherapy. As the talk was in German, I will offer only a very brief summary of its contents. Herwig started with an introduction on psychedelics. Often psychedelic phenomena occur in ritualistic settings. Psychedelics are a group of substances that modify the qualitative nature of the experience. The words "psyche" and "delos" mean "opening the soul". A typical psychedelic substance is Psyllocybin and an atypical one is Ketamine.


Uwe Herwig presenting on psychedelics

Then Herwig provided a brief history of the use of psychedelic drugs in clinical contexts. First therapeutic use of psychedelics occurred in the fifties, mainly for anxiety and depression. New applications have been introduced since 2020, for post-traumatic stress disorder and substance dependency as well as anxiety and depression, with various measures of success. The study by Hendricks et al. (2015), showing that psychedelic use is associated with reduced psychological distress and suicidality, was discussed in some detail, as well as more recent studies. In the last part of the talk, Herwig explored the psychophenomenology and neurobiology of psychedelic treatments, arguing that such treatments work and clinicians need to be prepared to offer them.

On the second day, Philipp Sterzer (Basel) presented a paper on the Functionality of Delusions. He started defining psychosis and its symptoms (delusions and hallucinations) and described the Bayesian approach to explaining psychosis. The key is abnormality in inferential mechanisms: what we perceive is always an active process of inference where we predict what things are like given what we already know. If we fail in our prediction, then there is a prediction error, and that's usually a bad thing. But via prediction errors, we can update our beliefs. Inference is to minimise prediction errors.  

When we have psychotic symptoms, our priors are not precise and the new experience is very salient. So, the story goes, in psychosis we are more guided by the actual stimulus and tend to ignore priors. What does the evidence say? People with delusions are more resistant to visual illusions and their priors are weak. However there is also some evidence that people with hallucinations have strong priors. 


Philipp Sterzer and a picture of his book, 
Die Illusion der Vernunft

So it would seem that there are two separate mechanisms:

  • Weak prior -> Aberrant salience demands explanation -> Emergence of delusions (bottom-up)
  • Strong prior -> Sensory signals interpreted in accordance to priors  -> Persistence of delusions and emergence of hallucinations (top-down)

But a more complex hierarchical model solves the apparent paradox:

  • Weak low-level priors -> Aberrant Salience demands explanation -> Emergence of delusions
  • Strong high-level priors -> Sensory signals interpreted in accordance with priors ->  Persistence of delusions and emergence of hallucinations.
Studies on perceptual ambiguity and on perceptual uncertainty conducted in Sterzer's lab show that weak priors can be at the origins of both delusions and hallucinations. Schizophrenia patients use sensory evidence more than controls to disambiguate stimuli. In sum, what we have in psychosis is lower perceptual history biases and higher sensitivity to disambiguating evidence. In this framework, delusions are a compensatory mechanism used to minimise prediction errors. And the people most likely to adopt delusional beliefs are those whose brains create more ambiguity. 

Susanna Burri (Kostanz) was the last speaker of the day and the Summer School, and her talk was on Final (and Other) Goodbyes. She asked what a good dying process looks like: what type of death should we hope for? Two options are the Sudden Exit (e.g., just drop dead) and the Some Advance Notice (e.g., knowing you will die in two weeks).


Susanna Burri discussing good ways to die


Occasions for goodbyes include when we leave people behind (in a valued relationship); when we leave places we are attached to, or other non-persons; when there is no increased physical distance but when there is increased psychological distance (e.g., the relationship changes). A goodbye is about anticipating and acknowledging a loss. Burri offers a definition of saying goodbye:

Goodbye: to say goodbye is to openly acknowledge and reflect on the fact that a valued relationship or set-up is about to come to an end or change significantly.

What is bad about goodbyes: (1) goodbyes are meaningless performances, (2) they are awkward and delay things for those leaving, (3) they detract from the fun and they interrupt the flow for those staying, (4) they are unpleasant because they are an ending. What is good about goodbyes: (1) goodbyes are respectful and helps those left behind to adjust their expectations, and (2) they help people prepare for the ending which will make grief easier later. Preparing for a loss means interpreting it and helps us determine what the value of thing or person you are losing is. As a result, saying goodbye provides orientation: it prevents feeling lonely and drifting. Goodbyes also help showing appreciation for something that was valued.

===

The Summer School was a really great opportunity to interact with people with different backgrounds and enabled participants to discuss all the key themes in detail and in a relaxed and friendly atmosphere.


Wednesday 15 November 2023

Philosophy of Psychiatry and Lived Experience (2)

This blog post is by Zsuzsanna Chappell. Zsuzsanna is an independent scholar and research associate at the Centre for the Philosophy of Natural and Social Sciences, London School of Economics. She currently writes on the social philosophy and ethics of mental illness, and the role of researchers with subject-relevant lived experience in the human sciences. Previously, she held academic positions at the London School of Economics and the University of Manchester and is the author of Deliberative Democracy: A Critical Introduction, Palgrave 2012.

Zsuzsanna reports from the third annual Philosophy of Psychiatry and Lived Experience workshop. The workshop was held on 17-18 April 2023, online (hosted by the University of Umeå). The aim of these workshops has been to bring together  philosophers and philosophy-adjacent scholars who self-identify as having lived experience of mental disability / difference, and are also writing on these topics. 


Zsuzsanna Chappell

Our first post described our main activities so far and why we believe there is a need for a workshop specifically for philosophers with subject-relevant lived experience. Last week's post also summarised two of the six papers presented at this year’s workshop. This post will describe the remaining four.


Shay Welch (Spelman College): Am I Safe Enough For You? On Borderline Personality Disorder

Welch offered an erudite phenomenological insight into what it is like to live with borderline personality disorder (BPD). It is a way of being which is full of inconsistencies; of overwhelmingly hatred for oneself while still loving oneself, of over-riding boredom and emptiness accompanied by emotional fullness. Based on her own experiences of erasure and inner death, she drew out the implications of erasing this borderline sense of self, something which is demanded by society and by psychiatry. 

She contrasted BPD and responses to it with addiction, arguing that the demand on BPDers is to erase what it is tobe themselves, rather than to simply let go of a dysfunctional habit or way of life. This kind of self-erasure is a kind of violence not seen in society’s response to all mental disorders,  which for the most part BPDers will finally consent to, even if they will still continue longing for their unmedicated selves. Rather than seeing BPD as an inherent source of vice, she argued that the qualities that come from it, - whether impulsiveness or empathy, - demand a different way of cultivating virtues to a high level which can make BPDers a valuable part of our moral community. This paper is now forthcoming in The Philosophical Forum.


Rachel Handley (Trinity College Dublin): Mental Illness and Transformative Experience

For Handley, their anxiety is a special kind of transformative experience. Rather than changing them from one moment to the next, it transformed them over time. This experience, they argued, would be impossible to understand without taking into account its transformative component. This seems to have an epistemic component as well for them: the sheer outrageous excess of anxiety disorder needs to be experienced to be believed. At the same time, their anxiety was closely tied to their identity: anxiety was part of them. 

They cannot look at their disability and assess it from above, there in no non-anxious Rachel we can compare anxious Rachel to. This complicates the way in which we can understand transformative experience. It is not immediate, there is no easy baseline against which the transformation can be measured, the transformation may even be episodic. Very interestingly, they argue that certain kinds of transformations can even block further transformations, for example when it comes to resistance to a medicated self. 


Rachel Handley


Zsuzsanna Chappell (independent scholar): Shared decision-making in psychiatric diagnosis

Access to the internet and social media have made people more aware of possible diagnoses, while at the same time there is also increased official reliance on self-diagnosis (just think of Covid-19 home tests or the recorded phone messages urging us to check the NHS website before we are connected to the GP receptionist). Medical sociologists (eg Jutel) argue that as a result doctor-patient relationships have changed, have become less unequal in many ways. These changes may be harder to accept in psychiatry, given that patients are often supposed to lack insight. 

Chappell argues that this is problematic as diagnostic labels strongly influence both internal, personal identity and external, social identity, and thus some will be easier to wear than others. This gives us an increased incentive to take into account patients’ ideas of what their problems may be, especially if we believe that psychiatric diagnoses are to some extent social constructs in the way that many other medical diagnoses are not. This is made possible if we take into account the inherent relationality of diagnoses: they will influence the relationships of the patient with themselves, with their clinicians, with friends, family and wider society. 

This preserves psychiatrists’ expertise but in a modified form: the point is not to allow patients to self-diagnose themselves inappropriately, but to give greater scope to shared decision-making when differential diagnoses are available.


David Ellis (Leeds Trinity University): A Phenomenological Investigation of ADHD - Language and Medication

Ellis drew on his personal experience of growing up with with ADHD to map out how language around ADHD and its management, introduced at a young age, inevitably shapes the development of the self. This can leave ADHDers unsure whether their neurodivergence is a disability or whether their medication is “treatment” in any meaningful sense. This touches not only on experiences of authenticity, but also turns the self into a battle ground between the “normal” and the “deviant”. 

Ellis was told that his ADHD was “undesirable”, that taking tablets and learning coping mechanisms would help, to the point that he came to identify his “real” self as the self without ADHD. Yet it also became increasingly obvious to him that managing someone’s ADHD is at least as much for the benefit of doctors and teachers. In the abstract he writes: “Being given medication whilst being told that it will ‘help’ not only caused me to think that the real me is the medicated me, but that the default natural me is akin to an illness in need of treatment, and that one of its symptoms is my inability to recognise my illness and interests. This develops attitudes of self-rejection, where part of me was seen as something that should not be seen.” 

His conclusion from these reflections is that since ADHD is part of the self, it is in fact unhealthy to develop negating, medicalising views towards a part of oneself. This contradicts the language of help which is usually adopted by professionals. Ellis’s talk really brought it home to me how neurodivergent children are positioned as the problem which not only needs to be solved, but which just requires too much effort from everyone to manage. 


David Ellis

================================================

So far, we have limited participation in our workshops to academic philosophers and philosophy-adjacent scholars who self-identify as having lived experience of mental disability / difference. (We never ask for any details or disclosure beyond a basic self-identification.) Presenters are free to give talks which are as personal or as abstract and general a they wish. 

Our group is not a “secret” one, but we have struggled with working out how to advertise it effectively beyond word of mouth. We have also talked about a workshop where we would share our work with “Sane” allies, about the possibility of starting a blog, and are planning a workshop based in an American time zone. 

This blog post is part of our efforts to publicise our work more widely. If you are a philosopher of psychiatry / mental health / neurodiversity with lived experience or if you are an ally who would like to support our project, we would love to hear from you at PhilPsyLivedExp@gmail.com

Wednesday 8 November 2023

Philosophy of Psychiatry and Lived Experience (1)

This blog post is by Zsuzsanna Chappell. Zsuzsanna is an independent scholar and research associate at the Centre for the Philosophy of Natural and Social Sciences, London School of Economics. She currently writes on the social philosophy and ethics of mental illness, and the role of researchers with subject-relevant lived experience in the human sciences. Previously, she held academic positions at the London School of Economics and the University of Manchester and is the author of Deliberative Democracy: A Critical Introduction, Palgrave 2012.

Zsuzsanna reports from the third annual Philosophy of Psychiatry and Lived Experience workshop. The workshop was held on 17-18 April 2023, online (hosted by the University of Umeå). The aim of these workshops has been to bring together  philosophers and philosophy-adjacent scholars who self-identify as having lived experience of mental disability / difference, and are also writing on these topics. 


University of Umeå


Zsuzsanna Chappell (me!), Sofia Jeppsson and Paul Lodge started organising these workshops during the pandemic. We have since been joined by August Gorman and Elliot Porter. All of us are Mad philosophers and we all felt that there was a need for a safe place where philosophers with experiences which are often difficult to talk about and stigmatised could talk freely and provide feedback on each others’ work. The workshop is open to anyone with lived experience, regardless of the concept and identity they prefer to use: madness, neurodiversity, mental illness, and so on. 

Why the need for a workshop just for scholars with subject-relevant lived experience? Sofia Jeppsson writes that talking to each other as Mad / neurodivergent scholars helps us to see how diverse our experiences are. Paul Lodge views it as a form of consciousness raising among Mad scholars, and argues that a  philosophy of psychiatry, where there are relatively few contributions by Mad philosophers, is as if feminist philosophy was dominated by the voices of men. 

I (ZC) argue that it is important to have a space reserved for those of us with lived experience, as it allows us to present ideas with an audience like ourselves in mind, rather than primarily addressing the “Sane” majority and their needs. I hope that these workshops will create space for views and voices which would not otherwise be heard, and encourage more people to do this sort of philosophical work. 


Zsuzsanna Chappell

August Gorman argues that by truly grappling with the lived realities of philosophers whose experiences are at times quite different from the presumed ‘Ideal/Typical/"Normal" Person’ who plays an implicit role in shaping so many of our theories, we have to upend a lot of what is assumed. They find it useful to have a community of fellow travelers to build new things back up again with. 

Elliott Porter writes that Mad people have very particular interpretive needs, and a community of mad enquirers is therefore what we need to refine our interpretive tools.  This doesn’t just allow us to navigate madness more effectively, but it also allows us to condense the particular knowledge that Mad points of view have privileged access to.  

So far, we have limited participation in our workshops to academic philosophers and philosophy-adjacent scholars who self-identify as having lived experience of mental disability / difference. (We never ask for any details or disclosure beyond a basic self-identification.) Presenters are free to give talks which are as personal or as abstract and general a they wish. Our group is not a “secret” one, but we have struggled with working out how to advertise it effectively beyond word of mouth. 

We have also talked about a workshop where we would share our work with “Sane” allies, about the possibility of starting a blog, and are planning a workshop based in an American time zone. This blog post is part of our efforts to publicise our work more widely. If you are a philosopher of psychiatry / mental health / neurodiversity with lived experience or if you are an ally who would like to support our project, we would love to hear from you at PhilPsyLivedExp@gmail.com

Six papers were presented this year. Two are described in this post while the remainder will be described in a post to appear next week. 

Sam Fellowes (Lancaster University): How the lived experience of experts-by-experience relates to the abstract nature of science

Fellowes made a really interesting argument about how an abstract concept such as “autism” will influence the study of that same concept even if we draw of the involvement of “experts-by-experience”, that is people who have a lived experience of autism. He argued that such disorder definitions require abstract science and cannot be derived from lived experience. Of course, this led to a good debate during discussions about the extent to which those with subject-relevant lived experience can be epistemic authorities on the nature of that experience. 

Fellowes made the point that since definitions and concepts are not only abstract, but also highly abstracted from reality, they will only represent individual experiences very imperfectly. This means that experts-by-experience may be best placed to help make value judgments during the process of scientific research, while they may need to accept the existing techniques for abstraction as given. Lived experience itself will need to be interpreted through scientific notions. I really enjoyed listening to a talk on what was in essence philosophy of science rather than philosophy of psychiatry, as this showed how wide the scope of our shared topics of interest are. 


Eliott Porter


Elliott Porter (University of Birmingham): Madness, Silencing, and Colloquial Terms

Porter raised the question of how Mad people can understand themselves when so much of our colloquial language uses words such as “crazy” rather liberally. I found it especially interesting how our views diverged during Q&A. Someone else found the term “crazy” objectionable, I myself draw the line at “psycho” being used as a common term to describe e.g. ex-lovers or politicians. Porter argues that using this kind of language is subordinating and silencing. Once something or someone is ruled “insane”, we are invited not to pay attention anymore. Yet, we all continue to use such language, even if we are aware of its potentially troubling aspects.  

He argued that it is better to think of these thoughts as illegitimate, rather than symptomatic.  Illegitimacy is a local failing, whereas symptomatic thought speaks to a wider deficiency.  Drawing on the self-trust literature and McGrath’s (2019) account of undercutters to moral knowledge, he argues that madness-language with connotations of illegitimacy is a valuable hermeneutic resource for Mad people particularly because it allows us to interpret illegitimate thoughts in ways that do not undercut self-trust.


Wednesday 1 November 2023

Self-narratives and Medicalization in Psychiatric Diagnosis

This post was published on the EPIC blog in July 2023. It is by Richard Hassall, a qualified clinical psychologist, now retired. After retirement, Richard enrolled at the University of Sheffield to do an MA in philosophy, followed by a PhD which was completed in 2022. At the time of writing, Richard is an affiliate researcher attached to the Department of Philosophy at Sheffield.


Richard Hassall

My area of interest is philosophy of psychiatry, with a particular interest in the nature of psychiatric diagnostic categories and the effect these have on the individuals who receive them. I argue in my PhD thesis that a psychiatric diagnosis may, in some cases, lead the recipient to becoming a victim of epistemic injustice, and specifically of hermeneutical injustice. I argue that this effect can be understood in terms of narrative theory and the self-narratives that individuals construct for themselves.

People gain meaning in their lives through their self-narratives, but such narratives can be changed by the person’s social circumstances and by extraneous events. Receiving a psychiatric diagnosis is one such event in some people’s lives, and it can significantly impact on the recipient’s self-narrative.

The codification of psychiatric diagnoses in disease nosologies, such as the DSM-5 of the American Psychiatric Association, can convey the implication that these represent disease entities of some sort. Patients are often told that their condition is “an illness like any other”. The reductionist methodology characteristic of the biomedical model of diseases can suggest that mental disorders are somehow caused by neurochemical abnormalities in the brain, an idea reinforced by the frequent treatment of such disorders with medication. Consequently, the diagnosis may be understood as a medicalized explanation of the person’s difficulties. However, most such diagnoses are based purely on symptom descriptions and do not explain how the person’s symptoms arose.




The medicalization implicit in psychiatric diagnoses conveys a biomedical narrative which may conflict with or marginalise the recipients’ previous self-narratives at a time when they will be experiencing significant emotional distress. As such, the recipients’ own hermeneutical resources can become marginalised. In other words, their capacity for understanding and expressing their own experiences can be minimised or neglected by clinicians. This can result in them becoming victims of hermeneutical injustice, particularly if they are mistakenly led to believe that their condition is a chronic one, from which full recovery is unlikely to happen.

The biomedical narrative associated with such diagnoses can undermine the recipients’ beliefs about their sense of agency and lead to feelings of hopelessness about recovery. While it is not an inevitable consequence of such diagnoses, there is evidence from testimonies of former service-users that this can happen to some people.

Wednesday 25 October 2023

Revisiting Maher’s one-factor theory of delusion

Today's post is by Chenwei Nie on his recent paper, "Revisiting Maher’s one-factor theory of delusion" (Neuroethics, 2023). Currently, he is a Teaching Fellow in Philosophy at the University of Warwick, UK.

Chenwei Nie


Suppose your friend, Ava, is suffering from a delusional belief that her partner is replaced by an imposter. Despite overwhelming evidence to the contrary - such as the supposed imposter's identical appearance to her partner and knowledge of intimate details, and reassurances from you and her other friends - Ava steadfastly maintains this belief. In this unfortunate circumstance, it is obvious that something must have gone wrong in the formation and maintenance of Ava’s belief. It is likely that Ava would be diagnosed with the Capgras delusion. Unravelling what exactly has gone wrong, however, has proven challenging.

According to a classic one-factor theory of delusion developed by Brendan Arnold Maher (1924-2009), the only factor, i.e. departure from normality, is the patient’s anomalous experience, of which the delusion is a normal explanation. Let us call this sort of anomalous experience the Maherian experience. If this theory is true, then Ava’s belief that her partner is an imposter should be considered as a normal explanation of her particular Maherian experience. Here, ‘normal’ means that if a typical, non-delusional person were to have Ava’s experience, they might also formulate the imposter hypothesis and come to believe that their partner is an imposter.

But is the one-factor theory a satisfactory explanation for delusions? In the past decade or so, a growing number of papers have argued in its favour. My paper, ‘Revisiting Maher’s One-Factor Theory of Delusion’, scrutinizes these one-factor arguments and reveals two fundamental issues.

First, the notion of the Maherian experience is too elusive. For example, advocates of the one-factor theory have been unable to articulate what exactly the Maherian experience is in the Capgras delusion. More often than not, they suggest that the Maherian experience could be an ‘intense’, ‘prolonged’, and ‘profound’ feeling of unfamiliarity. However, these descriptors are not informative enough to tell us why a far-fetched hypothesis like the imposter belief could somehow become a normal explanation.

Second, the notion of normal explanation is overly encompassing. In recognition of the above issue, some supporters of the one-factor theory suggest that suboptimal reasoning might play a part in delusion formation, but they maintain that these suboptimal reasoning processes are still within ‘the normal range’. Yet, without a more tangible account of the Maherian experience, it remains obscure how the reasoning processes that result in delusional explanations are normal.

Unless one-factor theory advocates can adequately address these issues, I think a more promising approach may involve abandoning the idea that the Maherian experience is the only factor in the aetiology of delusion and instead concentrate on searching for additional contributing factors.


Wednesday 18 October 2023

Naturalistic understandings of mental disorder can be epistemically empowering

Today's post is by Dan Degerman on his recent paper, "Epistemic injustice, naturalism, and mental disorder: on the epistemic benefits of obscuring social factors" (Synthese, 2023). Dan Degerman is currently a Leverhulme Early Career Fellow in Philosophy at the University of Bristol. 

Dan Degerman

Naturalistic understandings that frame human experiences and differences as biological dysfunctions constitute a major source of epistemic injustice in disease and disability, according to many philosophers.

Epistemic injustice refers to injustices committed against people in their capacity as knowers. This occurs, for example, when someone is disbelieved because of their social identity or when a lack of suitable interpretive resources means that someone cannot make their experiences intelligible to themselves or others. Critics have argued that naturalistic understandings of human experiences and differences can lead to both kinds of epistemic injustice because they tend to obscure the social factors involved in causing those experiences and differences. 

Though such understandings can indeed contribute to epistemic injustice, I think the epistemic benefits they can offer people vulnerable to epistemic injustice have been overlooked.

Consider an apparent exemplar of a naturalistic understanding, namely, the neurobiological understanding of mental disorder. According to that understanding, the key cause of the disorder is some dysfunction in the individual’s brain.

Critics of the neurobiological understanding of mental disorder argue that it prevents people from considering the range of possible factors that might contribute to their often distressing experiences. That is because it decontests the experiences involved, making alternative understandings that focus more on social factors seem irrelevant. Empirical research on what has been called the seductive allure effect of neuroscience indicates the critics are right. But what those critics generally fail to appreciate is that for some people with mental disorder, this is an epistemic feature rather than a bug.

After all, people with psychiatric diagnoses often struggle to get others to take their distress and needs seriously. For instance, participants in a recent ethnographic study by Rebecca Lane recounted how their efforts to discuss their bipolar disorder had been met with trivializing responses. Those responses drew on the contested status and alternative understandings of bipolar disorder to make it appear less serious. As Jake Jackson has argued, such trivialization can constitute and perpetuate epistemic injustices against people diagnosed with mental disorder. 

The decontesting capacity of the neurobiological understanding of mental disorder can help people with psychiatric diagnoses avoid trivialization and associated epistemic injustices. At least, that is what the experiences of some participants in the Lane’s study suggest. For example, one of them said: 

[W]ith bipolar[,] people generally think oh he’s lazy—it’s fashionable—a lot of people get misdiagnosed and you know—but if I say brain disorder and my neurotransmitter[s] don’t do what they’re supposed to… people just leave it like that. (pp. 161-2) 

This person has effectively deployed the neurobiological understanding of bipolar disorder to decontest his suffering and, thereby, avoid epistemic injustice.

Their testimony is not evidence that would-be trivializers abandon their trivializing beliefs when met with a neurobiological understanding of mental disorder. But it is evidence that such an understanding can prevent outright dismissal and that some people with mental disorder value that function highly.

I’m not trying the argue that the neurobiological understanding of mental disorder or naturalistic understandings of disease and disability more generally is unproblematic. Some research shows that people who endorse a neurobiological understanding of mental disorder are more likely than others to endorse stigmatizing claims about people with a psychiatric diagnosis. So we should think carefully about how and when that understanding is deployed.

But, if we are serious about addressing the epistemic injustices that people with psychiatric diagnoses suffer, we cannot simply ignore first-hand testimonies about the value that naturalistic understandings of mental disorder have for those people. Doing so and simply pushing ahead with projects to undermine those understandings risks exacerbating the very problem we are trying to solve.

Wednesday 11 October 2023

The experience of dysmenorrhea

Today's post is by Carlota Serrahima on her recent paper, "The experience of dysmenorrhea" (Synthese,  2023). She is a postdoctoral fellow within the ERC funded project "Rethinking Conscious Agency", based at the Universitat de Barcelona.

Carlota Serrahima

My main research topic is the philosophy of bodily awareness, and Manolo Martínez has worked on the philosophy of pain. We were both surprised that, in the literature our work overlaps on, menstrual pain — technically, “dysmenorrhea” — is rarely mentioned. For one of us, dysmenorrhea is the pain most often experienced, and we suspected that this was so for many people. Indeed, according to conservative estimates almost half of menstruators experience dysmenorrhea. That’s probably close to a billion people.

Our paper highlights an important tension: various assumptions operative in the philosophical literature about pain are actually doubtful, or maybe even false, of dysmenorrhea. In the paper we criticize  the model of pain conjured up by those assumptions, which we call the injury-centered model of pain [ICMP], and investigate the phenomenological and functional profile of dysmenorrhea beyond this model.

The first assumption of the ICMP is that pain is primarily a tool for the management of bodily damage. Pain is then adaptive when and because it is a response to such damage. But uterine contractions that expel endometrial tissue during menstruation are part of the correct functioning of the reproductive system, and hence, typically, not damaging. Yet, they are painful in dysmenorrhea. 

This is problematic for mainstream intentionalist views on pain, which would disappointingly deem dysmenorrhea an illusory or misguided pain. Fixing this requires significant elaboration of the intentionalist picture, and in particular of the kind of damage pain is supposed to respond to.

The second assumption is that pains subside as the triggering injury disappears. In other words, injury-centered pains are acute. In fact, dysmenorrhea cannot be readily categorised as either acute nor chronic: it is a cyclical pain, sharing features of both. On the one hand, it occurs in relatively short-lived episodes; on the other, because it recurs, it can result in central sensitisation, as chronic pains do.

We speculate that this temporal profile puts dysmenorrhea in a special position regarding pain catastrophising. First, because its recurrence allows for dysmenorrheic women to get used to the typical unfolding of their pain. Second, because of the widespread, but false, belief that dysmenorrhea is normal. We hypothesize that this broader network of pain-related beliefs will affect the way in which women feel threatened by and catastrophise about dysmenorrhea.

Finally, the ICMP sees pain as an affective kind independent from others, in particular moods. Dysmenorrhea, however, belongs to a class of affective conditions that includes both pain and negative mood intertwined in phenomenologically inextricable ways. Because of this phenomenological profile, and because it is likely that mechanisms underlying pain and mood in dysmenorrhea overlap substantially, the experience of dysmenorrhea is in important respects close to those conditions that fall under the so-called “pain-depression dyad,” such as fibromyalgia.

Anyway, we’ve tried to pay attention to the peculiarities of the lived experience of women, hoping that it will result in a richer understanding of the intricacies of pain, beyond injury management.

Wednesday 4 October 2023

Hinge commitments as arational beliefs

Today's post is by Aliosha Barranco Lopez (Bowdoin College) on her recent paper  "Hinge commitments as arational beliefs" (Synthese, 2023).

Aliosha Barranco Lopez

We all have a worldview—an understanding of the world. Our beliefs shape this worldview allowing us to perceive the world as inhabited by mind-independent objects, where concepts like love hold value, gravity governs, etc. One important claim I argue for is that some of our beliefs, which I call hinge commitments, inform our worldview at a fundamental level by providing meaning to the rest of our beliefs in a particular realm.

Let me explain, we all share the belief that there is an external world populated by mind-independent physical objects, which causally produce our experience in much the way we normally suppose. Let’s abbreviate this belief as ‘there is an external world’. This belief is a hinge commitment because it gives meaning to all our perceptual beliefs. 

When I believe that there is a computer in front of me, for example, part of what I believe is that there is a mind independent object—a computer—that is causing a particular perceptual experience in me. If, somehow, I were to lose the hinge commitment that there is an external world (without replacing it), my belief about the computer—along with all my perceptual beliefs—would lose their meaning.

One consequence of this view is that our hinge commitments are arational beliefs, meaning they are neither rational nor irrational. The reason for this is that hinge commitments, given the fundamental role they play in our understanding of experiences (e.g., as perceiving mind-independent objects in the world), determine what counts as empirical evidence for specific propositions.

For instance, the belief that it seems like there is a computer in front of me only counts as evidence for the belief that there is a computer in front of me because I hold the hinge commitment that there is an external world. Without hinge commitments, we would lack a sense of what qualifies as empirical evidence for various propositions. This entails that no evidence can support our hinge commitments because they exist outside the realm of beliefs that can be rationally evaluated. 

One might think that hinge commitments are not beliefs but rather some other mental state. This is because agents who hold them have dispositions to give up their beliefs when they judge that their evidence does not sufficiently support them, but they do not have such dispositions when they judge the same about hinge commitments—think about how philosophers keep believing that there is an external world even after agreeing that we do not have evidence for this belief. 

What I argue is that our beliefs inform our worldview with different degrees of importance. The more important the belief is in our worldview—like our hinge commitments or political beliefs—the harder is to give them up. This diagnosis not only gives us a reason to believe that hinge commitments are beliefs, but it also aligns with how people actually manage their beliefs. 

The resulting view is that hinge commitments are arational beliefs. This view also broadens our understanding of epistemic rationality: some beliefs must be arational for the rest to be either rational or irrational. 


Wednesday 27 September 2023

Losing the light at the end of the tunnel: Depression, future thinking, and hope

Today's post is by Juliette Vazard on her recent paper "Losing the light at the end of the tunnel: Depression, future thinking, and hope" (Mind & Language 2023). Juliette Vazard is a postdoctoral researcher at the University of Toronto and she works at the intersection of philosophy of mind (particularly emotion), epistemology, and cognitive science.

Juliette Vazard

Patients with clinical depression show a significant decrease in their ability to entertain thoughts of future positive events that could happen as part of their lives (MacLeod et al., 1996; Bjärehed et al., 2010; Thimm et al., 2013; Anderson & Evans, 2015; Szőllősi et al., 2015). Understanding the mechanisms which sustain this change in prospective cognition is of major clinical import, since developing a perspective on the future is key in the recovery of these patients (Cooper, Darmody, & Dolan, 2003). 

Although the connection between lack of hope and depression is well established in the literature (Cheavens, 2000; Beck et al., 1979; Lazarus, 1980), much empirical research is focused on the idea that pessimism and hopelessness are the result of an inability to imagine desirable possible futures. Instead, in this article I take seriously the hypothesis that a loss of the affective capacity to experience hope is causally responsible for the change in the prospective cognition of patients. This hypothesis rests on the more general idea that our ability to engage with desirable hypothetical futures might depend in large part on our affective disposition to experience the anticipatory emotion of hope.

I thus propose, using a viable concept of “hope” as developed by philosophers of emotion, that a reduction in the affective disposition towards hope might be a direct cause of the reduced ability of depressive patients to generate rich mental representations of desirable futures. In the philosophy of emotion, hope is viewed as an evaluative state which immediately apprehends a given possibility p as a genuinely possible and desirable state of affairs. As a positively valenced emotion, hope takes the phenomenological shape of a longing towards its target state of affairs, and involves a motivation to pursue and promote it. Because hope is an “anticipatory emotion”, this motivated pursuit includes attempts to practically promote p, but also the recruiting of imagination and counterfactual reasoning to create a rich (conceptual and sensory) mental representation of p that one can entertain and manipulate in thought. 

In short, feeling hope towards p acts as a motivating reason to deploy certain possible futures (the ones that we view as both desirable and genuinely attainable) in thought, enrich and refine our mental presentations of them, so as to explore them, learn about them, and promote them. According to this conception of hope, hope is an evaluative and motivational mental state which functions to direct our attention and our motivation to identify and pursue hypothetical futures that we desire for ourselves. Accordingly, subjects who lose the disposition to experience hope lose this important source of motivation to generate positive episodic future thinking. An affective dysfunction could thus be directly responsible for the decrease in positive prospective cognition in depression individuals.

This idea implies a reversion of the assumptions and methods of future‐directed therapies (FDT) for major depressive disorder (MDD). Rather than focusing on developing goal-setting and planning skills in patients, eliciting genuine hope could be a useful, primary goal of future-directed therapy.