Flickers of Freedom

Mental Illness and Transformative Experience

Hi again, everyone! For my last post I’d like to take the mental illness and agency cluster of issues in a slightly unusual direction… I’ve been advised to avoid the TL;DR problem in my internet philosophizing, but this one may take some time to walk toward, so bear with me!

First off, I’ve been impressed with L. A. Paul’s recent work on transformative experience. For those yet unfamiliar, the example here is becoming a vampire (or if you like, a parent). This is a difficult decision for two reasons, and the first is epistemic. You don’t have epistemic access to what being a vampire would be like. You can hear testimony from vampire friends, but you won’t really know what being a vampire is like until you become one. The second reason concerns personal transformation. Putting the epistemic difficulty aside, becoming a vampire is such a radical transformation that the very person you are—your values, goals, and preferences—would change dramatically. So there is some sense in which it doesn’t matter whether the person you are now would prefer being a vampire or not… if you become a vampire, you’ll be someone else with different, vampire-like preferences and values. (With apologies to Laurie for the slapdash summarization!)

I’ve become increasingly motivated by the personal transformation bit of this problem, for reasons to do with the transformations involved in changing from sick to well, or a typical to typical. As we’ve alluded to all month, a number of ways in which people can deviate from psychological ‘norms’ involve strange or atypical desires, values, or motivations. Depression, addiction, anxiety, and delusion are all conditions which may “gum up the works”, and it can be tempting to see this not just as a problem for our powers of self-control, but for our motivational systems themselves. To see what I mean, let’s consider the following case:

VINCENT lives alone on a remote piece of property in the Pacific Northwest. After college he began to remove himself from his social circles, and now spends most of his time in his home, making highly detailed wooden sculptures, based on the suggestions of ‘other voices.’ Vincent has no phone or internet access, and interacts mostly with the owner of the general store in a nearby town. He make a modest living by occasionally making a sale of a sculpture. His buyers find him to be distant and abrasive, and are often disturbed by his behavior, and lack of adherence to social norms.

We might say that Vincent is not responsive to a suite of reasons that most of us are (I wonder, but he is likely not rational in the RIT sense either). But what about his motivations themselves? Is Vincent acting in his best interest? Perhaps it’s true, counterfactually, that if Vincent valued family and friends more than his aesthetic pursuits, following those values would allow Vincent to flourish more, all things considered. And perhaps there are facts about his psychological condition which underlie his current preferences. So too for all of us! But whose best interests are we concerned with here… Vincent as he is now, or some possible, future Vincent-transformation? In light of the problem of personal transformation—and perhaps of Nina Strohminger and Shaun Nichols recent insights on the self—I wonder what are we asking of Vincent if we enjoin him to realign his preferences as part of being well. How should Vincent himself weigh these considerations? What grounds are there to justify change if Vincent does not already desire to?

Here are two competing intuitions one might have: first, that is it never rational to end a current self in favor of a future one (the parenthood example is especially distressing in this regard), and second that it isn’t rational to privilege a current self just because it’s yours (cases of mental disorder might pull you in this direction, especially the case of addiction). Of course, we should take care to remember that what supports flourishing all things considered is an empirical question (following Dan Haybron’s work on happiness, I am taking this for granted). And finally, lurking around the corner, we must deal with Aldous Huxley’s specter of a Brave New World. Depending on how we countenance the original counterfactual, we may have to allow that clinical paternalistic action to modify a person’s values or motivations is justified. Or maybe, in denying it, we allow that Vincent—the man he is now—is living his best life, flourishing.

Anyway, perhaps the best course of action here is to join the American tradition, and just pretend to be vampires for a day. Happy Halloween, everyone!

Whose Reasons?

Suppose we want to cash out the kind of agency important for mental health in terms of reasons responsiveness. One prominent account we might start from is George Graham’s Rationality in Intentionality (RIT) account, which proposes, roughly, that healthy human beings exhibit some standards of rationality, and that the preservation of this rational capacity is what is crucial for mental health. Says Graham,

A rational person in the RIT sense, ideally is not merely devoid of illogical or inconsistent attitudes, but someone with a definite positive description of their character and goals in life. If possible, they choose after deliberation, avoid acting on unreflective impulses, and maintain a certain level of prudence, self-regard or self-responsibility that balances their present or current preferences against next weeks, and next years, those of midlife and possible old age” (2010).

Whew. There’s a lot to pick out there. One critique of an account like this comes from the preponderance of recent evidence in the situationist, dual process, and implicit cognition literatures, concerning whether or not healthy human beings can even meet these standards of rationality. But I am more worried about how normative theories like this have a hold on us—how we are to be sure that following the dictums of this theory (or any like it) would be good for us as individuals, with our particular goals, interests, and ways of flourishing in mind. In my view, the right normative theory for distinguishing mental illness from mental health must ground what it means to be mentally ill in the concerns of individuals. To have normative authority, a theory of mental illness must be contextualist in this way. (Just made that term up for discussion, and I’m not married to it. The right normative theory is probably going to have many other features as well!) It must consider whether standards like those that Graham picks out genuinely improve the lives of individual patients.

I’ll go ahead and say something controversial on the internet: we should make room for the idea that there are ways of flourishing psychologically that look foreign or unfamiliar to us WEIRD folks. That there can be individuals with atypical psychological features, interesting from the perspective of neuropsychology or cognitive science, which are none the less mentally healthy. That the ‘successful psychopath’ or the ‘willingly addicted artist’ are legitimate, if rare, possibilities we must remain vigilant about in clinical contexts. (This also relates to the discussion of neurodiversity movements Thomas and I were having before!)

Of course, there is much work to be done in caching out what is meant by an individuals’ best interests. Do we mean some internal psychological states or motivations? A set of values? The things an individual has reason to do? We need a way of thinking of reasons-responsiveness that (1) avoids the empirical limitations of the RIT account (2) remains contextualist in the above sense, and (3) does not fall prey to a kind of subjectivism, which does not allow for fundamental errors about ones best interests. One place where care must be taken, I think, is in considering what kind of psychological assumptions our operative notion of reasons-responsiveness has. If reasons are subservient to desire, such that anosognosia is not a legitimate possibility, then we have gone wrong somewhere. What do you think?

Exemptions and Patient Competence

When evaluating a patient in a clinical context, two central principles of modern medical ethics come to the fore, what are known as the beneficence and autonomy principles. The beneficence principle deals with patients’ good. Doctors must act in ways that are good for the patients in their charge. The autonomy principle, on the other hand, deals with patients’ rights. According to it, doctors must respect the right of every individual of autonomy over their own person—that is, they must respect patients' decisions about their medical care. 

Of course, these two principles can, and often do, come into conflict, especially in cases of anosognosia, or lack of awareness that one is mentally ill. The right thing to do in these cases is both complex, and highly contextualized, though the consensus in the literature seems to be that paternalist action—acting for the sake of a patient’s good regardless of their will—is pro tanto wrong, even if all things considered justified. In these cases, I argue, the burden of proof falls on the clinician (or philosopher) to provide such justification when dealing with competent patients.

This raises the question, what does it mean to be a ‘competent’ patient? Is there anything about mental illness generally, or anosognosia in particular that causes people to fail to meet such criteria? One obvious place to begin thinking about this is with Strawson’s work on our common practices of treating others as responsible agents. As is well known, Strawson presents us with two kinds of cases in which we do not commonly treat others as responsible agents. First, there are those who we recognize as agents, who may not have the right kind of knowledge about or control over the situation in question. These people are excused. Second, there are the much less discussed and perhaps less well understood individuals who simply fail to be appropriate targets for our reactive attitudes. These people are exempt.

Interestingly enough, Strawson's characterization of those toward whom we take this stance are, roughly, children and those with mental illness (we need not follow him in calling this second group 'warped', 'deranged', or 'neurotic'!). Despite its intuitive appeal, however, it's not clear to me that mental illness universally absolves one of responsible agency, or that it exempts one from patient competence and the respect of clinicians. A so-called kleptomaniac, for example, may not be reasons-responsive when it comes to taking things she does not own, but nonetheless perfectly capable of being a collaborative partner as regards her medical care.

I think that the right way to go about this is actually to drop the notion of exemption, and instead opt for a more complicated picture. Different mental disorders present different challenges to reasons responsiveness in different domains, and not all of those may be relevant to determining an individual patient's competency. Moreover, we must be careful about the danger of construing denials that one is mentally ill as mental illness, as in the recent case of Kamilah Brock.

(Perhaps, as extra fuel for this philosophical and ethical fire, we may consider this recent case, of a man whose rights and wishes are being respected.)

The Place of Agency in Mental Health

Hi, everyone. First of all, thanks for sharing this opportunity with me! As Thomas mentioned, I’ve been thinking about the place of agency in mental health recently, and I’m excited to get to work through some of my most recent questions and conundrums with you. From what I can tell, this topic is a bit peripheral (might we say, ‘refreshing’?) for Flickers, so I hope you’ll have as much fun thinking about it as I plan to.

Let me start with some background. In my work, I’m concerned with the discipline of psychiatry as both a scientific and an evaluative enterprise. Because of this dual nature, it is simultaneously our most critical and most dangerous tool for alleviating the harms caused by mental illness. As I’m sure I don’t have to rehearse here, psychiatry has historically been used as a tool of social oppression. That being said, I find myself principally motivated to address the very real and pernicious effects of mental illness. The goal is to heal or to help people flourish psychologically.

So what, then, of agency? One thing which is frequently remarked upon is the perception that healthy people have a kind of control over their lives which sufferers of mental illness lack. We often say of the compulsive person that ‘she just couldn’t help it’, or of the addict that ‘he slipped’. First person accounts of depression can invoke the complaint from the agent herself that she her behavior is ‘idiotic’ or ‘unreasonable’. Here, then, is a speculation:

A theory of mental health might be cached out in terms of agency. Perhaps, what is significant about mental disorders is the way in which they impair agency.

As philosopher of psychiatry George Graham likes to put it, mental disorders “gum up the works” (2010).

As perhaps no one knows better than readers here, our perceptions of what it means for human beings to exercise agency are changing—and this only makes this issue more complicated. Here then, is my basic question. In light of recent empirical evidence from the sciences of the mind, what is it (if anything) that sufferers of mental illness lack, and what does this imply about the aim of therapeutic intervention? This is a huge subject of course, and over the next few weeks I hope to examine only a few pieces of the puzzle. I hope also that you all will offer more! Until next time, here are a few questions to mull over:

1. What does it mean to be a ‘competent’ patient?
2. In what sense must we be rational?
3. What kind of self-directedness is valuable?
4. What is in our best interest?

Passing the Torch!

As the we shift from September to October, it is once again time for a changing of the tides here at Flickers of Freedom. Last month, we were fortunate to have some interesting food for philosophical thought from Heidi Maibom. In a series of insightful posts about how we can and should conceive of actions (rightly or wrongly), Heidi provided us with the opportunity to visit some issues that are especially timely given the state of our field--e.g., sexism, sexual harassment, and discrimination. So, I wanted to thank her once again for agreeing to be a Featured Author here at Flickers--a tradition which has spanned three years and which has included 32 philosophers and scientists. During this time, these authors have provided the blog with an embarrassment of philosophical and empirical riches.  I remain eternally grateful for their collective time and effort.

That said, it is now time to pass the torch to Natalia Washington--this month's Featured Author.  Here is a brief excerpt from her bio:

 

I am a McDonnell postdoctoral scholar in the Philosophy Neuroscience and Psychology program at Washington University in St. Louis, and a member of the Moral Psychology Research Group.

Originally from Chicago’s south side, I completed my B.A. in Philosophy with honors in the major at the University of Wisconsin – Madison in 2010, and earned my PhD in philosophy at Purdue University in 2015 under the direction of Daniel Kelly. I’m interested in externalist perspectives in philosophy of mind, psychology, and cognitive science, with the over-arching goal of understanding the ways in which minds and environments interact. Sometimes I like to think about Philosophical Taoism.

My dissertation research, entitled ‘Mental Health and Human Minds: Some Theoretical Criteria for Clinical Psychiatry’, investigates the theoretic and conceptual foundations of psychiatry as a science, and how mental health can be used as a lens through which to view human psychological nature.  I have also worked on projects on implicit bias and implicit cognition.

Given my own interests in moral psychology and the philosophy of psychiatry, I am especially excited to see what Natalia comes up with this month. As we wait on her first post (which may be a few more days in the making), please take the opportunity to join the discussion thread from Heidi's last post!

p.s. Natalia is the last Featured Author I have lined up through next summer--when Patricia Greenspan will doing a stint. So, let's make a collective effort to be especially active in the discussion threads this month. We'll have plenty of time to catch up on our other work in the months ahead!