Ó Christian Perring, 2000
cperring@yahoo.com
Last updated: 3/15/2000
Philosophy and Religious Studies
Dowling College
Oakdale
NY 11769
Relevant Courses
I have taught philosophical issues in psychiatry in several contexts. At Georgetown University I had a small class for undergraduates and graduate students on Mental Health and Morality. At the University of Kentucky I had a course for similar level students on Mind, Science and Medicine; I have also given a graduate seminar on Irrationality and Moral Psychology; and several times I have taught a mid-level course on medical ethics, which often contained a section on Psychiatric Ethics. I have included topics directly relevant to psychiatry in both a class on Philosophy of Law: Crime, Punishment and Paternalism and another on Philosophy of Mind: The Limits of Psychology. In this short paper I will set out some of the issues that I have faced in putting together syllabi, finding appropriate texts, and explaining ideas to students.
Teaching psychiatric ethics in the context of medical ethics is relatively simple. There are a number of topics that are of obvious importance and relevance. These include the definition of mental illness, the rights of patients to refuse treatment and hospitalization, confidentiality between mental health professionals and patients, and the duty of professionals to warn those in danger when patients seem to pose a threat to the safety of others. I have also had some success with the topic of the over prescription of psychotropic medication such as antidepressants for dysthymia and stimulants for attention deficit hyperactivity disorder (ADHD). It can be helpful to give students some background on the potential abuses of psychiatry, using examples such as prefrontal lobotomy, electroshock treatment, the use of major tranquilizers as "chemical straightjackets," and the use of psychiatry for political purposes in the former Soviet Union. Other possible topics are the involvement of psychiatrists in determinations of patient competency, the inclusion of mental disorders in the Americans with Disabilities Act or similar non-discrimination legislation, and the coverage of mental disorders by health insurance, HMOs or national health plans.
In such a course one has to decide how much to focus on gender issues, and whether it is more effective to have a separate section on gender, or alternatively to highlight gender all the way through the course. In psychiatry especially, many topics are connected with gender, such as possible sexism in the definition of some mental illnesses, or the possible confusion of normal boyhood activity with pathology in ADHD. My own approach has been to raise gender issues near the start of my courses, and then to highlight them as they come up in other topics as they come up during the rest of the semester.
When teaching medical ethics, I normally use one of the many textbooks with collections of articles by different authors on a variety of different subjects. Many of these books have sections devoted to psychiatric ethics. One that is useful but is also now dated is Rem Edwards and Glenn Graber’s Bioethics. Much more recent is Robert Veatch’s Medical Ethics, which has a chapter written by Loretta Kopelman. There are several books of case studies in medical ethics, and most of them have a rich supply of cases involving psychiatry. For instance, there is Case Studies in Allied Health Ethics, by Robert Veatch and Harley Flack, which is explicitly aimed at workers in allied health. Other collections of case studies are more dated. For example, A Casebook of Medical Ethics, by Terrence Ackerman and Carson Strong has excellent extended descriptions of cases, but was published in 1989. Given the developments in medicine and psychiatry in the last 10 years, a new edition of this book is urgently needed. Accounts of mental illness from the point of view of the patient or the patient’s family, and depictions of mental illness in the popular media and entertainment, can also be useful to help bring the issues alive to students. One can find these in magazines and on the television very regularly, so one just needs to clip articles and keep a blank tape in one’s VCR to record shows when they come on TV.
I now turn to more sophisticated courses devoted entirely to mental health ethics. Here one has the opportunity to go into much more theoretical background and discuss issues in more detail. This presents one with more difficulty because there are so many ways one could approach such a course. I believe that it is essential to present students with some of the history of the treatment of the mentally ill, as well as some background in the different theories of clinical psychology. Elaine Showalter’s The Female Malady is a very readable history of the last century from the point of view of gender (although it is unfortunately currently out of print), and more recently, Edward Shorter’s A History of Psychiatry is also a reasonably concise and well written account of the last two hundred years or so. It is tempting to use Michel Foucault’s Madness and Civilization to give an account of treatment of the mad in prior centuries, but this is not only disputed in its historical facts, but is also a difficult text to read. So it only makes sense to use it if one is prepared to devote a substantial amount of time to setting out Foucault’s theoretical presuppositions and the intellectual context of his approach. There is of course a large number of other books on the history of mental illness, but it is hard to find ones which are both broad, readable, and up to date in their research.
Once students have some historical background, the question is what sort of ethical issues to raise. One possibility is to simply discuss the topics I have already described as appropriate for a section of a medical ethics course, but go into much greater detail. An alternative approach is to start out at a more theoretical level: for instance, one might look at the dispute between antipsychiatry, the medical model, and accounts that acknowledge the normative element in the foundations of psychiatry without concluding that psychiatry is a sham. But there are so many different kinds of critiques of psychiatry that one has to narrow down the scope of reading further. I have already mentioned the problems of reading Foucault. The problems are doubled when it comes to the two major books of Deleuze and Guattari (Anti-Oedipus and A Thousand Plateaus). Should one want to carry on in the project of explicating French thought about psychiatry, one would have to read Lacan too, and possibly those reacting to Lacan such as Julia Kristeva. My own preference is to steer well clear of this tradition, because whatever its intellectual merits, (and I am skeptical about it on that count alone), the writing is far too difficult to be approachable by students not previously steeped in recent French philosophy.
There are several other sources of antipsychiatry. Most obviously there is the work of R. D. Laing and his colleagues from the late 1960s and early 1970s (Unfortunately Laing’s Sanity, Madness, and the Family is out of print), and the still-growing opus of Thomas Szasz, starting with The Myth of Mental Illness. In sociology there is the work of Thomas Scheff who argues against the medical model and for the idea that psychiatry puts people into the role of patients. Peter Breggin is carrying on the tradition of antipsychiatry in his books on psychotropic medication such as Toxic Psychiatry, although they are less theoretically oriented than the other authors I have mentioned in this paragraph. Paula Caplan is another recent author whose criticisms tend to be at a more practical level, in her book They Say You’re Crazy.
While discussion of antipsychiatry is important whether or not one is sympathetic to it, one must present defenses of psychiatry too. Most obvious in this connection is Lawrie Reznek’s The Philosophical Defence of Psychiatry, which is written in a style reasonably accessible to students. He discusses more philosophers than one might want to discuss, and each of the chapters is somewhat short and will probably not seem a sufficiently sympathetic account of the ideas to the defenders of those ideas. There are other books that also defend and set out a view of the nature of psychiatry, but they are less appropriate in the context of a classroom. For instance, K. W. M. Fulford’s Moral Theory and Medical Practice, although maybe the most sophisticated discussion and defense of psychiatry written in recent years, is dense and difficult, and would only be appropriate for a graduate seminar. He has articles summarizing the heart of his view in other places, and his chapter in Sidney Bloch and Paul Chodoff, Psychiatric Ethics (Second edition) is maybe a good place to go for his views. (This book is out of print, but a third edition is being planned.) Culver and Gert have a fairly short book on the status of medicine and psychiatry, which was influential in the formulation of the definition of mental illness in DSM-III, but it is now rather out of date considering the considerable amount of philosophical discussion that has occurred since its publication.
The collection of articles in Psychiatric Ethics is interesting, but the book is primarily aimed at mental health professionals it seems, and the authors are all psychiatrists. Each chapter covers a different aspect of psychiatry, and discusses some ethical issues that arise. The discussions are for the most part more pragmatic than theoretical, and I found the book of limited use in teaching about moral controversies in psychiatry from a philosophical perspective. Similar comments can be made about a comparable volume edited by Rem Edwards, Ethics of Psychiatry, which came out in 1997. The articles in the book are written from a large variety of perspectives, but it is very patchy. Some articles are good, while others are less interesting, and they display wide variation in their conceptual sophistication.
I have discussed in some detail the problem of assigning texts for courses on mental health and morality (although obviously much more could be said). There are also difficulties to be faced in setting out the ideas to students. My experience in these courses has been with students of greatly mixed interests and different levels of philosophical and psychiatric knowledge. So what I have learned might not carry over well to a class of psychiatric residents, for instance. What I found is that it helps to play on people’s strengths, and get them to give presentations to the class on topics on which they have some prior expertise, or if not expertise, then at least prior enthusiasm. Some students will know something about neuroscience and the role of neurotransmitters in the brain. Others will have had clinical experience in dealing with the mentally ill. Some may have particular interest in certain kinds of disorders, such as anorexia nervosa or depression, for example. It is likely that some students will be very curious about feminist criticisms of psychiatry. Requiring students to give short presentations to the rest of the class on issues relevant to the class can make it more interesting for them, and the professor may even find that the students have something to teach her.
There may of course be some students with very little knowledge about anything to do with mental health, and it is important to give them some feel about how the theoretical debates play out in the practical realm. It may be useful to get them to read one or two of the numerous first-person accounts of mental illness, or some therapists tales. These are of course written with certain biases or presuppositions, but they will almost always explain some of the symptoms, reactions of family members, encounters with psychiatrists, nurses, psychiatric wards and other patients. Most of these accounts will at least mention the problems of inefficient bureaucracy, under funding, fear and distrust from the general public, side effects of medication, and the experience of coming to see oneself as a mentally ill person and a mental patient.
If one is more enterprising than I have so far been, one might contact local interest groups and try to get visiting speakers from patient rights groups, local divisions of the National Alliance of the Mentally Ill, or local mental health professionals. I suspect that this would also be useful in giving students more than "book knowledge." At some point in such a class, it is likely that some students will talk about their own experience of their own emotional problems and their encounters with the mental health profession. This can be very enriching for a class, but there also some dangers. One wants to avoid the student’s personal life becoming too much a matter for class discussion, because it can so easily become uncomfortable and intrusive for the student. It can also be awkward for the rest of the class who might not be comfortable expressing some of their ideas when they are so intimately related to their classmate’s emotional stability. So one needs to steer the class in ways that avoid these problems. It might be useful to set down some guidelines at the beginning of the course.
Finally I come to teaching about psychopathology in connection with the study of moral psychology, personal identity, philosophy of mind and philosophy of science. It is my opinion that the fundamental issue here is how to integrate different levels of description and understanding of mental illness and irrationality. For instance, how is one to integrate neuropsychological research with the experiences of the person suffering from the disorder. Does scientific research on mental illness shed light on how we should distinguish freely chosen action from symptoms of mental disorders, or whether we should make such a distinction at all? Can we make sense of irrationality without making the phenomenon disappear through redescribing it as a rational or reasonable response to circumstances? I think that these issues present the most conceptually difficult parts of the philosophical encounter with psychiatry, and the most exciting area of new research in the field. However, partly because of their "cutting-edge" nature, they are not easy to teach.
In order to teach these issues, one can try to explain some of the basic ideas of reductionism as they occur in philosophy of mind and philosophy of science. There has been a good deal written on reductionist approaches in social science. I used several articles from Readings in the Philosophy of Social Science, MIT, 1994 in one class on the philosophy of psychiatry, which was useful in introducing some of the basic issues, but students found it hard to draw clear links to controversies about psychiatry. Another way to introduce the debate of how to integrate social, individual psychological, and neurobiological explanations of psychopathology is through Michel Foucault’s Mental Illness and Psychiatry. This text is somewhat dated, and the writing is difficult, but it is nevertheless a provocative book, and it can be helpful if one intends to also use Madness and Civilization to give some historical background to psychiatry. It can be helpful to show students some of the more popular writings that set out mental illness as a disease of the brain, as in recent discussions of schizophrenia, depression and bipolar mood disorder, and even alcoholism. I believe that this sort of view is becoming so widespread that it is important to show students that there are more complex alternatives, which acknowledge the importance of neuroscientific discoveries without reducing the whole understanding of mental illness to neuroscience.
Another issue that may capture students’ interest is the controversy over the reality of multiple personality disorder. One can give some useful unpacking of the concept of ‘reality,’ here, and sort out different forms of skepticism about MPD. Hacking’s Rewriting the Soul is an essential resource in this connection, since it is filled with relevant information and is engagingly written. It is a little short on careful philosophical discussion, but one can turn to Hacking’s many recent articles if one wants to pursue that debate in detail.
An alternative way to go is to discuss the meaning of the symptoms of schizophrenia and related disorders. Louis Sass has done some very interesting work interpreting these symptoms in quite different ways from traditional approaches, and using these one can introduce the question of the relation of "finding the meaning of the symptoms" to the understanding of the illness as a disease of the brain. Sass’s two books on the subject might be forbidding to undergraduates, but he has written a number of articles that summarize his main ideas. Madness and Modernism has an interesting appendix on just this topic.
A final topic that one might introduce is the philosophical discussion of irrationality in the forms of self-deception and weak-willed action. Most of the literature focuses on the question of whether these forms of irrationality are possible (i.e., can we find a description of the phenomena which is both true to the phenomena and internally self-consistent?), and only a few go further into discussions of how they actually occur, and integrate the philosophy with psychology. Almost no work has been done on relating these mild forms of irrationality with the more bizarre phenomena of psychopathology. There is much more work to be done in this area. One of the most approachable introductions to the philosophical literature is Irrationality, by Alfred Mele, giving his own account of self-deception and weak-willed action, but also surveying much of the relevant literature too, and using many compelling examples of irrationality to make his points.
In focusing on the books one might use in courses on philosophical and
ethical issues in psychiatry, I hope to do more than just give a practical
guide to which books would work well. My discussion of the possibilities
has anyway been far from exhaustive. Rather, I am using them to illustrate
some of considerations one might take into account in putting together
such a course. There are of course many other aspects to teaching well.
In particular, one wants to get students interested and to stimulate some
careful thought on their part. Their readiness to talk in the classroom
is a rough index of how enthusiastic they are about getting involved in
difficult deliberations about psychiatry. As I have emphasized, it is easy
to overwhelm students because of the wide range of knowledge and skills
to do such interdisciplinary work well, so it is useful to build on their
existing strengths. But by the end of the course, I hope that my students
come out with a greater ability to integrate different approaches to psychopathology
and are able to formulate and defend their own opinions on the topics in
ways that they may ultimately find useful in contexts outside of the classroom.
Bibliography
Terrence F. Ackerman, Carson Strong, A Casebook of Medical Ethics, Oxford University Press, 1989
Sidney Bloch and Paul Chodoff (editors), Psychiatric Ethics (Second edition), Oxford Medical Publications, 1991
Peter R. Breggin, Toxic Psychiatry: Why Therapy, Empathy, and Love Must Replace the Drugs, Electroshock, and Biochemical Theories of the New Psychiatry, St. Martin's Press, 1993
Paula J. Caplan, They Say You're Crazy: How the World's Most Powerful Psychiatrists Decide Who's Normal, Addison-Wesley, 1995
Charles M. Culver and Bernard Gert, Philosophy in Medicine: Conceptual and Ethical Problems in Medicine and Psychiatry, Oxford University Press, 1982
Gilles Deleuze and Felix Guattari, Anti-Oedipus: Capitalism and Schizophrenia, University of Minnesota Press, 1985
Gilles Deleuze and Felix Guattari, A Thousand Plateaus: Capitalism and Schizophrenia, University of Minnesota Press, 1987
Rem B. Edwards, Glenn C. Graber (editors), Bioethics, HBJ, 1988
Rem B. Edwards (editor), Ethics of Psychiatry: Insanity, Rational Autonomy, and Mental Health Care (Second Edition), Prometheus, 1997
Michel Foucault, Mental Illness and Psychiatry (Second Edition), University of California Press, 1987
Michel Foucault, Madness and Civilization: A History of Insanity in the Age of Reason, Vintage, 1988
K. W. M. Fulford, Moral Theory and Medical Practice, Cambridge University Press, 1990
Ian Hacking, Rewriting the Soul: Multiple Personality and the Sciences of Memory, Princeton University Press, 1995
R. D. Laing, The Divided Self, Penguin, 1991
Michael Martin and Lee C. McIntyre (Editors), Readings in the Philosophy of Social Science, MIT, 1994
Alfred R. Mele, Irrationality: An Essay on Arkrasia, Self-Deception, and Self-Control, Oxford University Press, 1987
Lawrie Reznek, The Philosophical Defence of Psychiatry (Philosophical Issues in Science), Routledge, 1991
Louis A. Sass, Madness and Modernism: Insanity in the Light of Modern Art, Literature, and Thought, Harvard University Press, 1993
Thomas J. Scheff, Being Mentally Ill: A Sociological Theory (Second Edition), Walter De Gruyter, 1984
Edward Shorter’s A History of Psychiatry: From the Era of the Asylum to the Age of Prozac, John Wiley & Sons, 1997
Elaine Showalter’s The Female Malady: Women, Madness and English Culture, 1830-1980, Pantheon, 1985
Thomas Szasz, The Myth of Mental Illness: Foundations of a Theory of Personal Conduct (Revised Edition), HarperCollins, 1984
Robert M. Veatch and Harley E. Flack, Case Studies in Allied Health Ethics, Prentice Hall, 1996
Robert Veatch, Medical Ethics (Second Edition) (Jones and Bartlett Series in Philosophy), Jones & Bartlett, 1996