Nature and Narrative: An Introduction to the New Philosophy of Psychiatry PDF
Preview Nature and Narrative: An Introduction to the New Philosophy of Psychiatry
al perspectives in philosophy and psychiatry nature and narrative an introduction to the new philosophy of psychiatry BILL FULFORD KATHERINE MORRIS JOHN SADLER GIOVANNI STANGHELLINI OXFORD Oxford Medical Publications Nature and narrative national institutes of health nihlbrmy BLOG 1®, 1® CENTER DR. BETHESM, MO 2Q6S2-11S0 International Perspectives in Philosophy and Psychiatry Series editors Bill (KWM) Fulford Katherine Morris John Z Sadler Giovanni Stanghellini Forthcoming volumes in the series: Concise Oxford Textbook of Philosophy and Psychiatry Fulford, Thornton and Graham Postpsychiatry Bracken and Thomas The Philosophical Understanding of Schizophrenia Chung, Fulford and Graham (eds) Values and Psychiatric Disorders Sadler Handbook of Philosophy and Psychiatry Radden (ed) Mind, Meaning and Mental Disorder, 2e Bolton and Hill The Vulnerable Self: The Clinical Phenomenology of the Schizophrenic and Affective Spectrum Disorders Parnas, Sass and Stanghellini \ injti V « f ---1-; ^ Nature and narrative I ! i An introduction to the new philosophy of psychiatry Edited by Bill (KWM) Fulford Katherine Morris John Z Sadler Giovanni Stanghellini OXFORD UNIVERSITY PRESS OXPORD UNIVERSITY PRESS Great Clarendon Street, Oxford 0X2 6DP Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide in Oxford New York Auckland Bangkok Buenos Aires Cape Town Chennai Dar es Salaam Delhi Hong Kong Istanbul Karachi Kolkata Kuala Lumpur Madrid Melbourne Mexico City Mumbai Nairobi Sao Paulo Shanghai Taipei Tokyo Toronto Oxford is a registered trade mark of Oxford University Press in the UK and in certain other countries Published in the United States by Oxford University Press Inc., New York © Oxford University Press 2003 The moral rights of the author have been asserted Database right Oxford University Press (maker) First published 2003 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, or under terms agreed with the appropriate reprographics rights organization. Enquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above You must not circulate this book in any other binding or cover and you must impose this same condition on any acquirer A catalogue record for this title is available from the British Library Library of Congress Cataloging in Publication Data (Data available) ISBN 0 19 852611 3 10 987654321 Typeset by Integra Software Services Pvt. Ltd, Pondicherry, India Printed in Great Britain on acid-free paper by Biddles Ltd, Guildford & King’s Lynn /fo . 9 %] 3 qO 51 Foreword Paul Appelbaum As we welcome this initial volume in the series on International Perspectives on Philosophy and Psychiatry, it seems fair to ask why psychiatric clinicians and researchers should care about philosophic approaches to their field. Philosophers can hardly be faulted for seeking to apply their methods to whatever area of human endeavor catches their fancy. But psychiatrists, psychologists, and members of other mental health disciplines, whether practitioners or researchers — in what way might philosophical explorations, such as those collected here, be of help to them? Without attempting to catalogue fully the answers to this fundamental question, let me sketch some possible responses. One of the things that philosophers do well is to force us to clarify the concepts with which we deal. In the press of everyday cfinicarwofk^ and even in the routine of clinical investigation, it is remarkably easy to elude the broader issues. Where are the borders between mental illness and mere idiosyncrasy? How ought we to think about causal influences in mental life and hence in the mental disorders? Are our diagnostic categories constructed with a rigor that permits them to withstand close conceptual examination? Philosophy should matter to the mental health professions not least because it may help us to refine the ideas and notions that lie at the core of what we do. There is, moreover, an important thread in philosophical inquiry that has involved close observation of mental function — normal and deviant — from, as it were, the inside. Phenomenology, a methodologic approach linked to a number of philosophical schools, has put phdoj,qphy..al.theTb.refxanLaf. empir- ical investigation of psychological -ati'd psychopathological processes by the examination of subjective experience. This was true even during a time when psychiatry itself had refreateTTTrom empiricism, spinning itself a theoretical web from which it has only recently broken free. And it remains true today, when psychiatric empiricism, now resurgent, routinely slights the lived experi¬ ence of people with mentaTBisorderrin favor of more ‘objective’ sources of data. The phenomenological tradition not only promises to sharpen our approaches to diagnosis and allow us better to understand the effects of treat¬ ment. By bringing mental health professionals closer to the experience of their patients, a reinvigorated phenomenology also holds the key to strengthening the alliance between treaters and the people whom they treat. Perhaps the area of philosophical work most familiar to clinicians is ethics: the systematic examination of the behavior of practitioners in relation to their VI Foreword patients, with the goal of identifying morally preferable options. Even to list the major issues in psychiatric ethics today is to encapsulate the day-to-day experience of the clinician. Under what circumstances is the use of coercion legitimate? When may patients’ confidences be breached? What obligations does society have to provide care and treatment for persons with mental dis¬ orders and how can they be balanced with competing needs? Absolute and universal answers to these dilemmas are vanishingly rare. However, it is not rules that clinicians need most from philosophical ethics, Jmtvvays to flunk about these problems, knowledge of pitfalls to avoid, and at best heljTin identifying those options that may be morally suspect. In an era in which clinical work threatens to sink into a routine of unexam¬ ined practice, an endless cycle of diagnosis and" prescription, dtvorcod-from g-enuine human interaction and performed at an unsustainable pace dictated by economic concerns, philosophy can remind those of us in the clinical discip¬ lines of what attracted us to the mental health professions in the first place. It can immerse us in the resources of diagnosis, expose us to the felt experience of illness, and help us navigate the ethical challenges we face along the way. Philosophical examination shows the mind and its afflictions in all their com¬ plexity, encouraging us to reject reductionism of all sorts and fostering our will to sustain a critical and inquisitive attitude toward practice and research. It may be that philosophy too benefits from this endeavor, learning methods from psychiatry and cognitive science and finding ground on which to test approaches and theories of broader applicability. Others, though, are better suited to opine on that matter, and I will leave it to them to do so. For me, I have no doubt that psychiatry is enriched by its involvement with the phil¬ osophic enterprise, and I am grateful for it. May this series grow from strength to strength, bringing our fields ever closer together. Foreword Baroness Mary Warnock The philosopher, J. L. Austin, once remarked that the task of philosophy was to speculate about those subjects which had not, or not yet, become science. The history of the presocratic Greek philosophers who theorized about the true hidden composition of the universe before the birth of physics as an empirical science seems to confirm this view. It may therefore seem surprising that as psychiatry seems, to the lay person at least, at last to be becoming more scientific, it should at the same time be more and more closely interlocked with philosophy. Nature and Narrative explores the reasons for this appar¬ ently indissoluble marriage. One superficial place where psychiatry and philosophy may seem to overlap, and where psychiatrists might be thought to need the service of philosophers, is in Ethics. But in my view Medical Ethics is a somewhat over¬ rated subject, and in any case is in danger of getting into a rut. If this is so, then ethicists have more to learn from psychiatrists than the other way round. For example the idea of Informed Consent, a central building block in medical ethics, surely needs to be further-examined in a context of mental illness. At a much more interesting level, philosophy has much to learn from psychiatry. Ever since Descartes, philosophers have been obsessed with the relation between what we experience and what there is. Having divided the mind from the bodyTancTthus from sensory input, Descartes was at a loss to provide any satisfactory answer to the question whether or not the outside world exists. He had to rely on faith in a fair-minded non-deceiving God to reassure sceptics. But the great empiricist Hume had no such faith to fall back on, and was bound to remain sceptical, taking his mind off the problem only by forgetting it in social life. He had no answer to the question how, if all my impressions are my own and momentary, I can communicate them to you. Kant’s effort in the Critique of Pure Reason to explain a priori how the human mind is bound to conceive of the perceived world, and why it is, therefore, that we agree about the world of perception, about space, time, causation, and the other categories of understanding, was magnificent and impressive. But it was a priori nevertheless. It was not, though he hoped it was, capable of proof. Nor did it purport to tell us about the real world, but only about the world as it appears. The beginning of phenomenology, which brought the existing outside world into consciousness by the definition of what consciousness was, came viii Foreword with the publication in 1874 of Franz Brentano’s book Psychology from an Empirical Point of View. He defined consciousness as essentially Intentional, that is, as consciousness of something. You could not describe your awareness of a tree without mentioning two things, yourself and the tree. Hitherto, there had been three parts to the description, you, your idea or impression, and the (putative) tree. In his early days, Edmund Husserl took over this simple prin¬ ciple, and from then onwards the philosophical problem of the relation between the inner and the outer was radically transformed. When Sartre came back in 1939 from visiting Germany to learn about Husserl’s work, he was in a state of high excitement about the revolution he had found. In particular he delighted in the thought that perception-ean-no-loager be separated from emo¬ tions: consciousness of things is not limited to knowledge of them. ‘IfisTtTfngs that reveal themselves to us as hateful, sympathetic, horrible, lovable . . . Husserl has restored things to their horror and their charm.’ Wittgenstein denied that he had read Husserl, but whether or not he had, his new insistence that language is essentially and not inexplicably for communication, is certainly a part of the same philosophical history. From the moment of entering the world we are caught up in a network of interpretations and communications. Nowhere does this become more obvious than in Karl Jaspers’ descriptions of anomalies of perception in General Psychopathology (not published in England until 1963). We may be in danger of being so respectful of the objectivity of science that we forget the element of imagination which we necessarily bring to the world that we, however objectively, try to explore. Philosophers will welcome and benefit from the series of books now to be launched. The books will be right up their street.
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