Today's post is by Max F. Kramer, an Assistant Professor of Bioethics at Geisinger College of Health Sciences, and Clinical Ethicist at Geisinger Health System. Kramer discussed the recent paper "Depressed, Not Disordered: Fittingness and Pathologies of Emotion", published in the Journal of Medicine & Philosophy.
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| Max F. Kramer |
A once-prevalent view in philosophy – and possibly still prevalent in public life – holds that reason and emotion are inherently opposed. An extension of this view would have us characterise mental illness as some imbalance between the two; typically, a pattern of excessive emotion or deficient reason. Although this perspective is misguided in certain important ways, it serves as a point of entry into the affective dimensions of psychopathology and especially the class of psychological phenomena categorised as affective disorders: mental illnesses characterised by some defect, impairment, or aberration in the functioning of one’s emotional and other affective capacities.
Perhaps the most well-known affective disorder is major depression, the incidence of which among adult Americans the NIMH estimates at a staggering 8.3%. It is appealingly simple to say that a person who is depressed experiences sadness and low mood more than they should, given their circumstances. This caveat – “given their circumstances” – is reflected in the newest edition of the DSM diagnostic criteria for Major Depressive Disorder (MDD), which acknowledges that “Responses to a significant loss…may include the [symptoms diagnostic of MDD, such as] feelings of intense sadness,” and is quick to note that “such symptoms may be understandable or considered appropriate to the loss” and therefore clinical judgment must be exercised to determine whether this syndrome only “resemble[s] a depressive episode,” rather than warranting psychiatric diagnosis.
What is it about the presence of significant loss that can make the difference between psychopathology and understandable, even normal emotional responses? The answer lies in the idea that depression is a fitting response to such an event.
In recent years, there has been a push to reconcile emotion and reason, resulting in widespread philosophical work on the concept of fittingness. The basic idea is that there are different sorts of reasons that can support and justify emotional responses. Many are related to the value of emotions. The CDC, for instance, suggests that feeling and “practising” gratitude can reduce stress; if you are in need of stress relief, that is a reason to feel gratitude. In contrast, fitting reasons are supposed to justify emotional responses independently of the value attached to them. D’Arms and Jacobson give the example that it is fitting, and in that sense rational, to feel envious of a colleague who’s received tenure before you – even though it could sink your tenure chances and so is disvaluable, as well as (potentially) reflective of poor character.
In my recent article, I argue for the Fit-Necessity Thesis: for any affective disorder, an individual has that disorder only if their affective attitudes are systematically unfitting. This implies that, no matter how distressing or impairing a pattern of affective responses is, this would not constitute or evidence a psychiatric condition if there were fitting reasons for these responses. In addition to the theoretical virtues I discuss in the paper, I think that incorporating the theory of fittingness into the theory of mental disorders is one of the best methods to counter the threat of the so-called “medicalisation of ordinary life.”
It forces us to look beyond the individual’s psychic life to the social and material context in which it occurs to see whether these align or diverge. In that way, it promises both to capture the sense in which mental illness corresponds to dysfunction in one’s psychology and to resist the urge to fallaciously equate mental health with moral character, economic productivity, or any other value-based consideration likely not constitutive of health and/or illness.