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10/05/2015

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Hi Natalia,

I think that these topics are great! Thanks for raising these questions. I'm excited to see what you and others come up with.

While the issues are really complex, there seem to me to be some interesting distinctions that could be useful as a means of carving up the terrain relevant to your list of questions. In the spirit of inquiry, here they are.

One conception of competent agency has it that this requires (a) efficacy and (b) autonomy. So, and this is very rough, it is not enough that one can get done what one wants to get done, but one must also have a certain relationship to what one wants to get done. Of course, there are many ways of cashing out autonomy. But the basic idea is that a competent agent satisfies (the best version of) this. And she is (suitably) effective in pursuit of her ends as well.

As far as rationality goes, there is a narrow sense of rationality that has its root in the idea that one should not be self-contradictory or incoherent. This corresponds to a narrow sense of irrationality, which has to do with, say, believing that P and believing that not-P or intending to X and intending not to X. There are almost certainly forms of mental illness that impede rationality in this narrow sense.

But there are also certainly forms of mental illness that impeded rationality in a wider sense. Sometimes this is referred to in terms of 'reasonableness'. The rational agent, in this wide sense, is not only coherent, but also correctly responds to the reasons she has--or some such formulation. This sense of rationality is wider in that it not only requires internal consistency in the agent's mental states, but also an appropriate connection between these mental states and the normative grounds for holding them. For example, a (widely) rational agent not only fails to believe that not-P when she believes that P, but she also believes that P on the basis of good reasons. That is, her belief is appropriate (given some suitable sense of appropriate).

I'll leave it there. In part, this is because I'm inclined to think that answers to your final two questions, about valuable self-directedness and one's best interest, are likely to touch on issues related to the basis for wide rationality. That is, I'm inclined to think that whatever one thinks makes for a good reason or an appropriate response to a good reason will inform one's position on value more broadly, and so the value of various kinds of self-directedness and also various interests.

I'm also just interested to see what others think about things.

I think an awful lot is going to depend on being specific about which mental illnesses we're talking about. Those with schizophrenia or bipolar 1 are impaired in different ways than those with obsessive compulsive disorder or major depression. In short, there may very well be no such thing as "the things" that sufferers of mental illness lack. There are volitional impairments and cognitive impairments and everything in between. We would need to go on a case by case basis. Given the size of the DSM-V and the number of diagnoses (and the number of criteria per diagnosis), this will be a daunting task! It is nevertheless a very important and interesting issue that philosophers should be spending more time thinking about--especially those working on free will and moral responsibility!

Natalia, I'm looking forward to your posts this month! This is an interesting set of questions. As Thomas stated, I think a lot will depend on the specific mental illness under discussion. In some cases the problem might be the lack of moderate reasons-responsiveness, in others cases it might be lack of hierarchical integration, etc., etc., etc. These are, however, important questions--especially because they have an impact on the second part of your question: "what does this imply about the aim of therapeutic intervention?" Therapeutic treatments, I would argue, need to be directed at the specific deficit, and these will be varied and dependent on the specific mental illnesses under question.

Hi Natalia (if I may)--

A great first post, and Ben and Thomas pose some thoughtful framing for it going forward. I wish to continue that in a more practical way.

One big problem for this question is translating it all into a workable form of statutory law by which 2nd-phase trials--which determine mens rea questions of responsibility in jurisdictions that recognize them as valid--and sentencing phases that also consider the punitive status of criminals with mental health issues. I bring this up because this is how we mete out responsibility in the real world based on agency or the lack of it. I've said this here before: pre-Hinckley, there was some merging consensus on how to deal with questions of insanity and responsibility via the Model Code. Post-Hinckley, there has been a very wide divergence of how to deal with such questions, including four states that have abolished the insanity plea entirely. (And an additional complication is the muddle of procedures and standards in these cases from jurisdiction to jurisdiction--e.g., who has the burden of proof and what is the standard of evidence for determining guilt is all over the legal map.)

Ben raises the key question of how to frame issues of reasonableness that might then translate into workable legal language that might be used to guide judges and juries in assessing that part of rational intent. Thomas raises a very important question of the wide range of psychological conditions that seem to fit on a spectrum from non-exculpatory to not-guilty.

Seems to me that coming up with a sweeping account of how minds are sorted into even being less- or more-responsible is a daunting task, and to make that workable as law--well, whew!

But these are such very basic but important questions--and this should be an exciting month! Thanks in advance for this.

Hey Natalia, I am definitely looking forward to reading your posts!

I get the sense you point out in which people sometimes say sufferers of mental illness lack control over their lives. Interestingly though, a lot of research suggests that people actually do not think that this is because of lack of agency. Part of the stigmatization of many disorders seems to stem from this harmful attitude that the lack of control is some kind of personal weakness, not anything distinctive about agency and mental disorders themselves. Perhaps that is a reason to pursue your thesis in and of itself. I was just observing the deep resistance to it from how we, perhaps very wrongly, tend to think and talk about mental illness.

I also had a question about whether characterizing mental disorders in terms of absent agency might be counterproductive in treatment scenarios. For example it seems like helping patients realize that they actually do have cognitive agency can be very effective in treatment. Do you think there’s a negative there? I guess one response might be the idea that those forms of treatment actually function on the level of adding agency that was impaired by the disorder, which is why they often work well.

Excellent post! And like others, I am very much looking forward to your featured stint.

I agree with Thomas and others that it's going to be a case by case basis. That said, I do think control is going to be a prominent answer in what is lacking for many of those inflicted by mental illness.

I think this implies that we ought to rehabilitate in ways that give more control to the agents that are lacking.

BTW, way to leave us with one hell of a list of questions...

Ben--You bring up a lot of good things here, some of which I hope we don’t simply pass by! In particular, I’m inclined to think that the notions of ‘reasonableness’ and ‘reasons-responsiveness’ are both crucial for this debate, and philosophically slippery. Different accounts of what it means to be reasonable have different normative considerations packed in, and I find myself erring on the side of caution when it comes to applying these as standards for mental health. For one, it’s not clear to me that the intuitive or folk notions of reasonableness apply all that well even to healthy people, given evidence in the situationist literature, and about implicit social cognition. (Relatedly, I have a suspicion that the very notion of ‘reason’ as in ‘she has a reason to x’ should be treated with care, given different commitments people may have in the internalism/externalism debate.) I actually plan on devoting one of my posts to reasons-responsiveness, so let’s keep hashing this out in the comments!

On another note, I really like the efficacy/autonomy distinction. If I’m reading this right, autonomy has to do with what ends one has, and efficacy with how effectively one pursues them. I totally agree that what there is to be said about reasons-responsiveness will bear on autonomy in this sense. (To tip my hand, it seems to me that some objective list of ‘appropriate’ reasons that applies universally to all of us as humans is a bad way to go. More on that later!)


Thomas--So true! One of the things I’m hoping might happen over the course of the month is that experts on specific mental disorders (like you!) can bring this discussion to bear on them.

An important thing to note, though, is that I do think there is an important distinction between saying someone is mentally ill and saying that they have a mental disorder. (As a historical sidebar, theorists thinking about psychiatry have differing commitments on what these terms mean, whether they carry normative implications or merely descriptive ones, and which term does which job, and this has led to an enormous amount of confusion!) Here and in my work generally, I’m going to use the following conventions:

(1) Mental illness—refers to any way of being in which an individual's flourishing is significantly impaired or limited by some features of their psychology irrespective of what those features are.
(2) Mental disorder—refers to a psychological condition fitting one or more diagnostic categories that causes mental illness.
(3) Typical deviation—refers to a psychological condition fitting one or more diagnostic categories irrespective of whether there is mental illness.

Thus, to say someone is mentally ill is to make an evaluative claim, to say someone has a typical deviation is to make a descriptive claim about their psychology, and to say someone has a mental disorder does both. I think this is important, not only because it helps us distance ourselves from reifying the diagnostic categories of the DSM, but also because of the possibility that the disorders we are interested in share something in common—that we tend to find mental illness in those cases where an individual does not have the full suite of resources (whatever those are) to pursue their own interests/flourishing/well-being.


Gregg--Yes, and I want to know much more about reasons-responsiveness generally (see my response to Ben, above). It’s possible even that treatment should vary not only by disorder, but by contextual characteristics that vary from person to person! It’s funny to me that this idea appears taken for granted among clinicians and therapists, but is not reflected in the ways we pursue research into therapeutic intervention. In this respect, I’m excited about future work with the NIMH’s Research and Domain Criteria (RDoC) project! http://www.nimh.nih.gov/research-priorities/rdoc/index.shtml

Natalia,

An anecdote: I used to call people psychopaths. When doing my stint as post-doc with the Law and Neuroscience Project, Kent Kiehl (and others) encouraged me to instead to refer to these individuals as people with (or who have) psychopathy (or psychopathic traits). This way of talking certainly seems less stigmatizing and I think that it comports with the norms in disability studies more generally. Rather than saying someone is disabled, the norm is to say a person has a disability.

This brings me to my question: You distinguish mental illness from mental disorder (which is fine as far as it goes), but then you want to say that while someone can *be* mentally ill, they can merely *have* a mental disorder. Two questions: First, do you think this is unduly stigmatizing and essentialist? Second, why do you need the *be* vs. *have* distinction once you already have the mental illness vs. mental disorder distinction? If I am understanding your distinction correctly, having a mental illness is just the more generalized state of having a mental disorder. So, why not just say that a person with psychopathy has both a mental disorder (specifically) and a mental illness (more generally)? What purchase do you get by saying instead that someone *is* mentally ill in virtue of having a mental disorder?

Oh, one last question about your taxonomy: If we adopt the standard disability and dysfunction model of mental illness that is at work in the DSM-V, it doesn't seem like anyone could fit your "typical deviation" classification. On the D & D model, to have a mental illness is to have disability and dysfunction. So, a person who satisfies the diagnostic criteria for a particular disorder will have a mental disability/illness.

Thomas,

I definitely take your point about 'being' being more stigmatizing and essentializing language, and that's by no means what I want to do! Let's say 'having a mental illness'and 'having a mental disorder' then... What I think this distinction buys us is the ability to talk about a person from an evaluative standpoint without making reference to the underlying condition which is of interest from the standpoint of the sciences of the mind. For example, it seems to me that there are mental health issues which don't neatly fit our idea of 'proper diagnoses' (stress, grief, lack of coping skills etc.)

More importantly, separating the normative and descriptive issues by making space for a 'typical deviation' category allows us to countenance the idea that there may be individuals who descriptively fit categories of interest to scientific psychiatry, but who are none the less flourishing. For example, of two people experiencing the symptom of hearing voices, one may find that this is interfering with their work/family life/goal pursuit and causing them suffering, while the other may be perfectly untroubled, and in fact happy with their way of being. I think this makes sense of things like autism rights and other neurodiversity movements. It's especially important to me that we aren't making paternalistic evaluations of people like this, since the issue of diagnosis comes with many practical complications like limits to autonomy and stigmatization.

Alan—I‘m just getting into the literature on the insanity defense and other legal applications of mental health concepts, and I hope you have more to teach me! Prima facie, it does seem like a sweeping account isn’t the right move in the legal setting, but I do hope that our practices here can remain consilient with our best theories of agency and illness. I suspect that, while sufferers of mental illness share some agency-related things in common, what we can reasonably hold them responsible for will vary.

Hey Wesley--I tend to think of agency as the kind of thing that comes in degrees, and that we can take control over situations we may have lacked control over before--for example, we can act more or less as agents in situations where our behaviors may be influenced by implicit biases, by taking steps to mitigate those biases. (I hope there’s nothing too controversial about this!) In this way of thinking, we can frame psychiatric therapy as a way of increasing control in a domain specific sense. Perhaps this is a helpful move against the kind of stigmatization you’re worried about?

Justin, it sounds like this is something you were thinking about as well!(?)

This study on clinicians' perceptions of mental illness also seems relevant! https://theconversation.com/blame-it-on-biology-how-explanations-of-mental-illness-influence-treatment-48578

Justin,

My wife is a psychologist, and would definitely agree "we ought to rehabilitate in ways that give more control to the agents that are lacking." Also, being deprived of agency is very often an important part of how someone gets into difficulties in the first place.

Natalia,

Thanks for opening this topic.

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