Tuesday 28 February 2023

What is The Tinkering Mind about?

Today's post is by Tillmann Vierkant (University of Edinburgh) who presents his recent book The Tinkering Mind (Oxford University Press, 2022).

The Tinkering Mind has at its heart a puzzle about epistemic agency and cognitive control. I was always puzzled by the notion of cognitive control, because to me it seemed to combine features that are clearly incompatible. The puzzle in question is as follows: cognitive control is often said to be voluntary, and is a form of cognition. 

But cognitive control is also supposed to lead to the acquisition of new beliefs. I have always found it strange that cognitive control is supposed to have all three of these features because if it does, then that seems to indicate that the acquisition of a belief can be a voluntary action when we acquire it by means of cognitive control. This would imply doxastic voluntarism which, like most philosophers nowadays, I find unpalatable.

Very many people have pointed out to me that this initial worry is just a terminological confusion. The obvious solution to my puzzle is to say that it equivocates on the idea that cognitive control leads to the acquisition of new beliefs. This is ambiguous, because this idea could either be spelled out as the thought that cognitive control is the belief acquisition event, or as the idea that cognitive control is the process that leads up to that event. Put like that, the puzzle seems to go away, because the whole debate around doxastic voluntarism is concerned with the event, while cognitive control intuitively is about the cognitive process leading up to it.

Tillmann Vierkant

This is where the last of the themes of the book comes in. I agree that it is possible to solve the puzzle this way, but I hold that going for that solution has a consequence that is at least surprising, but for many people presumably also rather unappealing. I argue that if cognitive control can be voluntary and cognition at the same time, then that entails that extended cognition must be true. 

To see why this is so, I turn to an argument by Yair Levy. Levy has recently rightly pointed out that there is no relevant functional difference between voluntary epistemic actions inside the head and voluntary epistemic actions that involve the environment, like calculating on paper. If this is right (and it seems right to me) then it forces a surprising choice. 

Given Levy’s argument, if cognitive control consists in voluntary epistemic actions and if cognitive control is supposed to be cognition then this must be so, whether or not the cognitive control action includes the environment. If on the other hand one wants to deny that extended cognition is true, then this implies that voluntary cognitive control is not cognition.

Once the epistemic agency in cognitive control has been clarified in this way many surprising things follow, and this is what the rest of the book is for. It explores the surprising consequences for topics from dual processing (where it suggests that judgements cannot be system two if extended cognition is not true) to moral psychology where it provides an argument for extended willpower. 

More generally, the book uses the distinction between the two ways to connect epistemic agency and cognition to make some progress on the age old question of what distinctly human cognition might consist in.

Tuesday 21 February 2023

Philosophy of Psychiatry: A Contemporary Introduction

Today's post is by Sam Wilkinson (University of Exeter) on his recent book Philosophy of Psychiatry: A Contemporary Introduction (2023, Routledge).

When I started teaching philosophy of psychiatry about ten years ago I noticed that, while there was plenty of literature out of which a well-structured and coherent course could be built, there was (to my knowledge) no single textbook around which to base one. 

Year-on-year, as my module was tweaked and improved, largely thanks to feedback from my students, it occurred to me (wrongly, as it turns out) that it would be relatively straightforward to turn said module into a textbook. And that’s what I’ve done - eventually!

Like the module itself, the textbook is divided into two parts, which reflect two quite different enterprises that fall under the category “philosophy of psychiatry”. 

The first enterprise involves philosophical scrutiny of psychiatry, with “psychiatry” here including both psychiatric practice and psychiatric research. The second involves philosophical engagement with the psychiatric phenomena themselves. In light of this, Part 1 is called “Philosophy of Psychiatric Practice and Research” while Part 2 is called “Philosophy and Psychopathology”.

After an overarching introduction entitled “What is philosophy of psychiatry and why does it matter?” (Chapter 1), Part 1 begins by reflecting on the purview of psychiatry (Chapter 2), addressing different approaches to the nature of mental illness, including challenges to its very existence and, by extension, to the legitimacy of psychiatry as a discipline. Then, Chapter 3 addresses issues surrounding the “medical model” and whether psychiatry ought to proceed via diagnosis. 

Chapter 4 (“Mental illness, moral responsibility, and the boundaries of the person”) addresses questions about the way in which psychiatric conditions can impact on our autonomy, moral responsibility and sense of self. Different views about this can be seen as either tangential or central to questions about the fundamental nature of mental illness. (Viewed as central, to say that someone suffers from mental illness is, in part, to say that they are a passive victim of a condition.)

The role of culture in our thinking about pathology is addressed in Chapter 5, with religion as a salient test case. One important distinction here is between the context of formation and the context of evaluation. The former denotes the way in which culture may impact on the presence or prevalence of certain problematic phenomena, whereas the latter denotes the way in which culture impacts on the way in which certain phenomena are evaluated as pathological or otherwise. These two often interact in interesting ways.

The final chapter of Part 1 (Chapter 6) applies thinking in philosophy of science on the nature of explanation to the issue of scientific explanation in psychiatry. What is it to properly scientifically explain a phenomenon of psychiatric interest? A broad family of “pragmatic” views is presented in a particularly sympathetic light.

Sam Wilkinson

Part 2 can be more swiftly summarized. It goes through various phenomena of psychiatric interest, trying to shed light on what they are and what philosophical issues they raise. So, Chapter 7 examines schizophrenia, and some important controversies that arise when thinking about that concept, and how that concept is not simply a different concept, but a different kind of concept, from that of psychosis. Building on this, Chapters 8 and 9 examine voice hearing and delusions, respectively. The former touches on various issues, including the nature of perceptual experience and inner speech. The latter touches especially on the nature and norms of belief. 

Chapters 10 and 11 discuss depression and addiction. One of the big challenges surrounding depression concerns how we are to delineate depression as a clinical phenomenon. In turn, addiction raises fundamental questions about the nature of motivation, rationality and internal conflict.

The final chapter concerns my hopes and predictions for the future of the discipline. This involves discussion of i) overlooked phenomena that have received some philosophical scrutiny but would benefit from more (e.g. PTSD, personality disorders), ii) mental health in the digital age, iii) the exciting field of computational psychiatry, iv) approaches to mental health that might be called “externalistic”, and v) innovative approaches to psychiatric discourse.

Finally, I’d like to say a bit about how the book is written and its aims. Clearly one thing that lecturers avoid is a straight-up presentation of the canonical literature (“So-and-so said such-and-such”). What I’ve tried to do, with this book, is introduce each topic in an intuitive and relatable way that makes it clear what philosophical itches there are to scratch. That way, when the existing work is presented, the reader can see what exactly it is in the service of.

Tuesday 14 February 2023

Schizophrenia as a Disorder of Self, and Clinical Practice

Today's post is by Nimra Ahsan. Nimra is a fifth year medical student at the University of Birmingham, where she is currently completing a Masters in Mental Health. She is interested in how the study of mental health can help inform and improve future clinical practice, including her own. This is the last post in a series of perspectives from students taking the Philosophy and Ethics of Mental Health and Wellbeing module.

Nimra Ahsan

The interaction between psychiatry and psychopathology is one that is blending (Stanghellini and Broome, 2014). With a contemporary focus on patient experience, human subjectivity (or phenomenology) is creating a holistic perspective concerning mental health conditions, such as schizophrenia. Described as a ‘disturbance of minimal self’, our understanding of schizophrenia has deepened and the ipseity-disturbance model developed by Sass and Parnas has contributed to this substantially (Nelson, Parnas and Sass, 2014).

This model led to the formation of a symptom checklist, the Examination of Anomalous Self-Experience (EASE), which explores a patient’s ‘experiential or subjective anomalies’ in a semi-structured interview (Parnas et al, 2005). Built upon a Husserlian approach to phenomenology, this tool was established through descriptions from patients with schizophrenia spectrum disorders which collectively have an altered sense of self to help identify experiences of self-disturbance. However, it cannot be used alone diagnostically and does not yet include a comprehensive basis of anomalous experiences.

Regardless, research has shown that EASE not only demarcates schizophrenia from other disorders (Parnas and Henriksen, 2014), but could enable early recognition of self-disturbances and become a useful prognostic tool in those of clinical high risk (Værnes et al, 2021). Furthermore, in assessing basic self-disturbances, it was shown to aid detection of those at higher risk of non-remission or deterioration.

This study conducted by Værnes et al (2021) demonstrated that after one year of follow-up, increased levels of basic self-disturbances correlated with higher baseline levels (assessed using EASE) and were linked ‘with higher severity of positive, negative, disorganisation and general symptoms, and with a lower level of global functioning’. Additionally, a recent meta-analysis utilising EASE, concluded that self-disorders are specific to schizophrenia spectrum disorders, encouraging the idea that it should be considered a core clinical feature of schizophrenia (Burgin, Reniers and Humpston, 2022).

There have long been calls for diagnostic classification systems, such as the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD), to revise their definitions and symptomology to include the patient’s subjective experience in order to curate a person-centred approach to diagnosis (Irarrázaval, 2015). The aforementioned developments in our understanding of schizophrenia further reinforce this notion; hence, these significant advances should be incorporated into clinical practice to help better treat those with schizophrenia. 

Understanding this disturbance of self and the way in which patients perceive the world can help clinicians to accept the conflict of realities between themselves and the patient. An emphasis should be placed on ‘recovery of the patient’s sense of unity with himself when rebuilding his capacity of doing and being’, allowing patients to lead fulfilling lives alongside their symptoms through repairing their sense of self (Irarrázaval, 2013). It is now incredibly important for clinicians to comprehend and apply this phenomenological approach to schizophrenia – in doing so, patients may gain a deeper understanding of their condition, empowering them, which in turn can ‘alleviate self-stigmatisation, diminish guardedness, and equip patients with better coping mechanisms’ (Humpston and Broome, 2020).

Psychotherapeutic approaches need to be developed based upon the ‘recognition of the self-disorders’ crucial importance in the patient’s life-world’, for example, through an emphasis on psychoeducation (Nordgaard, 2021). The use of psychopharmacology may aid management of symptoms, but approaches need to focus on empathetic understanding and open, effective communication between clinicians and patients, rather than correction of perception and thought (Wilson, Humpston and Nathan, 2021). Clearly, human subjectivity needs to be at the forefront of the management of schizophrenia.

Tuesday 7 February 2023

Responsibility without Blame for Psychopathy: A Utopia?

This post is by Olivia Siegfried, currently studying for a Master’s degree in the School of Psychology at the University of Birmingham. Olivia is interested in youth mental health, personality disorders, and forensic psychology, and adopts a social constructionist perspective to understand these issues.

This is part of a series of posts by students of the Philosophy and Ethics of Mental Health and Wellbeing module at the Institute for Mental Health. They share some of their views on key topics discussed in the module.

Olivia Siegfried

Responsibility without blame

As personality disorders are notoriously hard to treat, Hannah Pickard has put forward the ‘responsibility without blame’ approach (Pickard, 2011) for clinicians to adopt to foster the best clinical outcomes. Although sounding inherently paradoxical, we can hold people responsible without blaming them by segregating responsibility from morality and instead defining it through a person’s agency. 

Taking responsibility for their actions allows patients to own their behaviour and emotions and provides them with the foundation to make changes in the future. Blaming them, however, strips them of their agency and encourages therapeutic nihilism. 

Pickard advocates for clinicians to treat people with compassion and view adverse behaviour as the result of great psychological distress. She emphasises that considering the patient’s history of trauma (which is common in people with personality disorders) allows for this compassion to develop, which in turn counteracts the impulse to blame. 

People with antisocial personality disorder (Fisher and Hany, 2019) who possess high levels of antagonistic personality traits (e.g. callousness) come closest to our understanding of a ‘psychopath’. I will outline here how psychopaths differ from other personality disorder patients and thereby put into question the viability of the ‘responsibility without blame’ approach for cases of psychopathy.


According to the ‘responsibility without blame’ framework, clinical compassion is fostered through understanding a patient’s behaviour as the result of severe psychological distress stemming from past traumatic environments. 

However, not all psychopaths have experienced trauma in their lives. Blair and colleagues (2006) argue that psychopathy predominantly arises through genetic pathways, and is less closely linked to social environments. For example, a twin study (Viding et al., 2008) found that the heritability of antisocial behaviour for children with co-occurring callous-unemotional traits was far greater than for those without them. 

Furthermore, the reactive aggression observed in other personality disorders is not always mirrored in psychopaths. They tend to demonstrate instrumental aggression (Blair et al., 2006) which is motivated by egocentric goals rather than being the result of hypervigilance. 

Thus, it is hard to envision how clinicians can adopt a compassionate approach to psychopaths’ aggressive behaviour if it does not constitute a coping mechanism for psychological distress stemming from trauma.

Aggression in psychopaths is more goal-directed. 


Neil Levy (2013) argues that psychopaths show impairments in mental time travel. This means that their ability to visualise themselves in past or future environments is diminished. 

The present is more salient to them, which is demonstrated through their nomadic lifestyle and ever-changing relationships. Thus, the DSM-5 (American Psychiatric Association, 2013) has included impulsivity and irresponsibility as diagnostic criteria for APD. Moreover, ‘temporal inefficacy’ (Petrican and Burris, 2011), a construct characterised by displeasure about the passing of linear time is associated with a reduced capacity for mental time travel and greater levels of psychopathic traits. 

Pickard states that holding patients responsible provides them with the agency to make future changes. However, this approach is unlikely to have the same merit for psychopaths who lack such prospection.

Psychopaths have difficulties looking into the future

In conclusion, the ‘responsibility without blame’ approach may be inappropriate for psychopaths, as they lack the personality disorder characteristics that the framework assumes. Although blaming them is unlikely to be the answer, it is important to be aware of these differences between personality disorders.