A good therapeutic relationship in mental health services is a predictor of positive clinical outcomes for people who seek help for distressing experiences, such as voice hearing and paranoia. One factor that may affect the quality of the therapeutic relationship and raises further ethical issues is the impact of the clinical encounter on users’ sense of self, and in particular on their sense of agency. In the paper, we discuss some of the reasons why the sense of epistemic agency may (...) be especially fragile in young people with unusual experiences and beliefs. We argue that it is important to identify and avoid behaviours that can undermine young people’s contributions as epistemic agents in the clinical encounter. (shrink)

Philosophers have been long interested in delusional beliefs and in whether, by reporting and endorsing such beliefs, deluded subjects violate norms of rationality (Campbell 1999; Davies & Coltheart 2002; Gerrans 2001; Stone & Young 1997; Broome 2004; Bortolotti 2005). So far they have focused on identifying the relation between intentionality and rationality in order to gain a better understanding of both ordinary and delusional beliefs. In this paper Matthew Broome and I aim at drawing attention to the extent to which (...) deluded subjects are committed to the content of their delusional beliefs, that is, to whether they can be regarded as authors of their beliefs (Moran 2001). We consider several levels of commitment one can have to a reported belief, delusional or otherwise, and we distinguish between _ownership_ and _authorship_ of beliefs (Gallagher 2000). After examining some examples of belief authoring (or lack thereof) in psychopathology, we argue that there is no straight-forward and unitary answer to the question whether deluded subjects author their beliefs. Nevertheless, introducing the notion of authorship in the debate can significantly contribute to the philosophical literature on the rationality of delusions and can also have important implications for diagnosis and therapy in psychiatry. (shrink)

It has been argued that schizophrenic delusions are “behaviourally inert.” This is evidence for the phenomenon of “double bookkeeping,” according to which people are not consistent in their commitment to the content of their delusions. The traditional explanation for the phenomenon is that people do not genuinely believe the content of their delusions. In the article, we resist the traditional explanation and offer an alternative hypothesis: people with delusions often fail to acquire or to maintain the motivation to act on (...) their delusional beliefs. This may be due to avolition, to emotional disturbances, or to the fact that, given the peculiar content of some delusions, the surrounding environment does not support the agent’s motivation to act. (shrink)

Various authors have argued that progress in the neurocognitive and neuropsychiatric sciences might threaten the commonsense understanding of how the mind generates behavior, and, as a consequence, it might also threaten the commonsense ways of attributing moral responsibility, if not the very notion of moral responsibility. In the case of actions that result in undesirable outcomes, the commonsense conception—which is reflected in sophisticated ways in the legal conception—tells us that there are circumstances in which the agent is entirely and fully (...) responsible for the bad outcome and circumstances in which the agent is not at all responsible for the bad outcome. (shrink)

What factors should be taken into account when attributing criminal responsibility to perpetrators of severe crimes? We discuss the Breivik case, and the considerations which led to holding Breivik accountable for his criminal acts. We put some pressure on the view that experiencing certain psychiatric symptoms or receiving a certain psychiatric diagnosis is sufficient to establish criminal insanity. We also argue that the presence of delusional beliefs, often regarded as a key factor in determining responsibility, is neither necessary nor sufficient (...) for criminal insanity. (shrink)

Schuklenk and van de Vathorst's paper is a very welcome addition to the literature on the assisted dying debate and will be of great interest to clinicians working in the field of mental health.1 Many psychiatrists will have had patients who have asked them to allow them to die, to desist in their efforts to prevent their suicide, and one of us has had personal experience, outside of professional life, of being asked to aid in someone's attempt to end their (...) life in the context of an episode of mood disorder. The person with depression asking professionals, friends and family members to aid them in ending their life is a very real phenomenon. In their discussion, Schuklenk and van de Vathorst's paper uses two principles that we endorse and add weight to their argument: namely, the reality of suffering in depression and the parity of mental and physical illness. Indeed, the case Schuklenk and van de Vathorst make is a strong one and our commentary will focus on the premise of the argument around choosing death and some empirical clarification about competence in depression and the nature of treatment-resistant depression (TRD) and its prognosis. The conceptual concern we wish to discuss in relation to assisted dying, endorsed by the state and legislature, is not linked to any moral or religious concern, or even on grounds related to ‘slippery slope’ or ‘abuse’ arguments. Rather the worry is how one could operationalise decisions around assisted dying as based on competence and capacity and view such decisions as rational. I think this concern is not limited to depressive illness, but to all decisions regarding choosing non-existence. Schuklenk and van de Vathorst offer the following useful criteria to regulate assisted suicide:1. (shrink)

Patients with psychotic disorders experience a range of reality distortions. These often include auditory-verbal hallucinations, and thought insertion to a lesser degree; however, their mechanisms and relationships between each other remain largely elusive. Here we attempt to establish a integrative model drawing from the phenomenology of both AVHs and TI and argue that they in fact can be seen as ‘spectra’ of experiences with varying degrees of agency and ownership, with ‘silent and internal own thoughts’ on one extreme and ‘fully (...) external and clearly audible voices’ in the absence of a speaker on the other. We believe a spectral model will add emphasis to the continuity of experience and help to better understand how one type of psychotic symptom may interact with another, and put forward the argument that the experience of TI itself is not sufficient to classify as a delusion. In addition we aim to discuss some of the conceptual issues surrounding AVHs and TI with first-person accounts and current philosophical and neuropsychological theories in mind. We propose that the mechanisms behind AVHs and TI are more complex than source-monitoring deficits; indeed, to understand such phenomena one must appreciate that their very ‘existence’ and ‘reality’ as experienced by the individual have much deeper implications and meaning, both philosophically and clinically. (shrink)

Brings together and interprets previously hard-to-find texts, new translations and passages detailing the interplay between philosophy and psychopathology.

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 11.1 (2004) 35-41 [Access article in PDF] The Rationality of Psychosis and Understanding the Deluded Matthew R. Broome Campbell's important and influential paper (Campbell 2001) has framed the debate that Bayne and Pacherie (2004) most explicitly, and Klee (2004) and Georgaca (2004) more implicitly, engage in. Campbell has offered two broad ways of thinking about explanations of delusions—the empirical and the rational. He offers some (...) criticism of the former and an endorsement of the latter. Campbell uses examples from clinical psychopathology to illustrate his argument and Bayne and Pacherie in turn employ these. Campbell discusses the eponymously named delusions of Capgras and Cotard—the former a subtype of delusional misidentification and the latter a delusion whose content is colored predominantly with nihilistic and possibly hypochondriacal themes. Campbell, Bayne and Pacherie, and Klee discuss the empirical data in relation to such delusions and as an aid to discussing the empirical model more generally. It does seem a little unfortunate that these delusions, which are less than typical, become the focus of Campbell's paper, and Bayne and Pacherie's criticism of his work. Delusions are remarkably heterogeneous; this indeed may be part of the reason why there is so much difficulty in reaching a definition as Klee discusses, and occur in a wide variety of mental and neurological illnesses. The most common delusions are those of persecution and reference (World Health Organization [WHO] 1973) and typically occur in schizophrenia. By contrast, delusional misidentification occurs most commonly in patients with dementia, delirium, and focal cognitive impairment, but can occur in other functional psychoses such as an affective or schizophrenic psychosis. The most common form of delusional misidentification is not that of either the exotic Capgras or Fregoli syndromes but delusional misidentification for place; thus, although Bayne and Pacherie's arguments against Campbell may still hold, delusional misidentification tends to occur in the context of a patient believing that they are at home or on holiday rather than in hospital and may not necessarily involve close family members or other intimate relationships. Similarly, Cotard's syndrome tends to occur in the context of a severe depressive illness with mood-congruent psychotic symptoms, typically in an elderly individual. It does not have to have the content that the deluded is dead, but can include beliefs, for example, that the world no longer exists or that their internal organs are not present. Thus, a patient with either Capgras' or Cotard's syndrome is likely to differ from patients with delusions of persecution. They would [End Page 35] have different diagnoses, probably be older, and have a greater likelihood of structural abnormalities of the brain on imaging and consequent neuropsychological dysfunction. That is not to say that patients with schizophrenia have normal cerebral anatomy and neuropsychology, but rather that the Capgras' and Cotard's patients are likely to have neurological quality to their presentation that is clinically relevant, rather than what commonly the case in schizophrenia and the other functional psychoses, where the neurological abnormalities are only currently important at the level of academic research. Empirical Models of Delusion Formation Different delusions may not have that much in common, nor may the patients who believe in them. This in turn relates to the empirical paradigm that both Campbell and Bayne and Pacherie discuss. It is true that current research, and indeed the clinical practice of cognitive behavioral therapy for psychosis, is indebted to the work of Maher and it is within his legacy which we work. This, however, is not to say that we think his initial formulation was correct. Maher's (1988, 1992) work focused attempts in explaining delusions—both to support and refute his thesis that delusions are the consequence of normal cognitive mechanisms seeking to explain an anomalous sensory experience. Such a view initially led to work demonstrating delusions in the absence of anomalous perceptions, the presence of reasoning biases in the deluded population, and the possibility that abnormal sensory experience may be consequent upon biased cognitive processes (Garety and Freeman 1999). More recent work has demonstrated the prevalence of... (shrink)

In this article, we focus on a particular kind of emotional impact of the pandemic, namely the phenomenology of the experience of moral injury in healthcare professionals. Drawing on Weber's reflections in his lecture Politics as a Vocation and data from the Experiences of Social Distancing during the COVID-19 Pandemic Survey, we analyse responses from healthcare professionals which show the experiences of burnout, sense of frustration and impotence, and how these affect clinicians’ emotional state. We argue that this may relate (...) to the ethical conflicts they experience when they are forced to make clinical decisions where there are no optimal outcomes, and how in turn that impacts on their own emotional state. We then further examine the notion of ‘burnout’ and the phenomenology of ‘moral injury’. Our argument is that these experiences of moral injury across a range of clinicians during the pandemic may be more prevalent and long-standing in psychiatry and mental health than in other areas of healthcare, where ethically difficult decisions and resource constraints are common outside times of crisis. Hence, in these clinical arenas, moral injury and the phenomenology of emotional changes may be independent of the pandemic. The insights gained during the pandemic may provide wider insights into the challenges of developing services and training the workforce to provide appropriate mental health care. (shrink)

In this paper, recent publications in the field of psychiatric nosology, classification, and diagnosis are reviewed. An attempt is made to group such writings into three broad themes: "essentialist/realist," "anti-essentialist/pragmatic," and "eliminative." The conceptual nature of these groupings is explored, and similarities between some elements of biological psychiatry and phenomenological psychiatry are outlined. The paper attempts to undercut current ways of thinking about psychiatric disorders by drawing on John McDowell's criticism of the idea of a value-free objective standpoint, and further (...) relates our difficulties in thinking about mental disorders to McDowell's wider diagnosis of problems in contemporary philosophy. (shrink)

Psychiatric interviewing highlights the apparent tension between psychiatry's quest for objectivity and its aim to chart the particular experiences and values of individuals. Neo-Kantian philosophy can help to shed light on this apparent tension. There need be no conflict between an exploration of individual values and scientific inquiry, not least because values play a central role in the selection of facts in scientific observation in general and psychiatric history taking in particular.

The computational approach to psychiatric disorders, including delusions, promises explanation and treatment. Here, we argue that an information processing approach might be misleading to understand psychopathology and requires further refinement. We explore the claim of computational psychiatry being a bridge between phenomenology and physiology while focussing on the ontological commitments and corresponding methodology computational psychiatry is based on. Interconnecting ontological claims and methodological practices, the paper illustrates the structure of theory-building and testing in computational psychiatry.First, we will explain the ontological (...) commitments computational psychiatry is grounded in, theBayesian Brain hypothesis(BBH) of unconscious inference, paired with normative deontic approaches applied to gauge psychopathology. We then turn to the steps taken in empirical paradigms, from definitions, which are used as starting points, to the operationalisation and isolation of cognitive processes and hypothesis testing based on algorithmic models, to consecutive interpretations regarding the aetiology of psychiatric disorders. We outline how experimental paradigms in computational psychiatry are specifically designed to confirm aberrations in assumed inferential processes, which are thought of as being the underlyingcore invariant features.We will illustrate a gap between the ontological commitments of computational psychiatry and the operationalisation and testing of the cognition assumed to be relevant for psychopathology. This conceptual gap is of utmost importance when designing computational paradigms and may impede a crisp understanding of the approach. Lastly, in evaluating the conceptual gap, it becomes apparent that the information processing formalism used in computational psychiatry is still grounded in rational cognitive psychology. (shrink)

The papers included in the thesis, and summarized in this covering document, were selected, in discussion with my supervisor, Dr. Roessler, from papers I have published in the philosophy of psychiatry. In parallel to this philosophical work, I have worked clinically as a psychiatrist and academically as a research psychiatrist. My clinical work has largely been working with Early Intervention Services, both in South London and in Coventry and Warwickshire, and this work has been acting as a psychiatrist in clinical (...) teams who work with young people who may either be at risk of developing a psychotic illness, or are in the earliest stages of such an illness. My empirical work has been in the same clinical group and has used functional neuroimaging and cognitive neuropsychology to characterize those at risk of psychosis and to chart the onset of psychosis and the formation of delusions. As required by the university guidelines, a full list of publications, both empirical and philosophical, is detailed in appendix 1. The papers included in the thesis hence parallel many of these clinical and empirical interests: papers 2 and 4, in particular, examine the role neuroimaging may play in studying delusions and relate the prodromal phase of psychosis to both the neurodevelopmental and continuum models of psychosis. Paper 3 is one of two papers written with Lisa Bortolotti drawing on Richard Moran’s work and examining delusions. Paper 1 is perhaps the paper least connected to my empirical and clinical work as has a wider focus and tries to examine what mental illnesses are and to begin to describe a position Lisa Bortolotti and I later expanded on and referred to as ‘psychological realism’, with Paper 2 being a case example of this account being applied to a particular area of psychopathology, namely delusions. The papers form a progression with Paper 1 outlining a general conception of mental disorder, Paper 2 being a case study of this approach specifically in the area of delusion. Paper 3 takes the example of thought insertion and develops ideas from Paper 2 that reason giving is a crucial feature that helps highlight what is pathological about certain experiences. Paper 4 brings together the philosophical concerns regarding a wholly neuroscientific conception of psychopathology, and how this is of clinical and scientific relevance when we use psychopathology to demarcate the various stages of psychotic experience and illness. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Ubiquity of MoodsMatthew R. Broome (bio) and Havi Carel (bio)Keywordsphenomenology, Heidegger, moods, affects, meaning, self, philosophyPhilosophy is often caricatured as one of the most disconnected and anemic academic enterprises. Yet in philosophers’ own accounts of what drew them to the problems they have sought to address they answer, typically, in two broad, passionate, ways: wonder or anxiety. As such, philosophy, and philosophers’ self-understanding of themselves and their enterprise, (...) can serve as a way to address some of the important topics raised by Rosfort and Stanghellini. Even for philosophers, the emotional experience of moods and affects is employed in narrativity, or at least, employed when one is called to give an account of oneself. One could envisage a party conversation along these lines:So why did you become a philosopher?Well, I wanted to go to university but wasn’t interested in science or in the humanities and I’ve always been dreadful at languages.(Laugh) But you must like something about it as you wouldn’t have become a professor?You know how it is... you drift into things. I did well as an undergraduate, my tutor suggested I should do a PhD. Found an excellent supervisor, and got a few papers published and then a teaching post....You must be very committed to the subject.Ummm—I guess so. I thought about joining the civil service after my PhD, but always managed to find work and the hours are much more flexible at universities!Well I think it is amazing: to think and teach about such important things.Do you?There is something slightly baffling here that may simply be part of the inherent irony and self-deprecation of some academics. The philosopher's interlocutor is asking about what philosophy means to the philosopher: why he has given his life to it. As such, she is alluding to a deeper, philosophical question that, after decades of falling out of favor, is returning to the attention of philosophers: namely, how has philosophy given your life meaning? The philosopher responds with possible irony, banality, or superficiality and invokes luck rather than meaning in his narrative. He serves as Nietzsche's feared nihilist. The account offered also seems to fail to meet normative standards, and depending on how the philosopher carries it off, this gap between expectation and reality in the conversation may generate humor.However, the greater likelihood is that the conversation engenders perplexity and disappointment in the interviewer. Rather like the characters in Evelyn Waugh's early novels, the philosopher is buffeted passively by life and luck and eschews agency or meaning. In Waugh's skilled hands this becomes tragic comedy; for the philosopher and his interlocutor we have disconnection and sadness. The crucial reason for this is that we need to use terms referring to moods, affects, meaning, and emotion when we offer an account of ourselves and when we try to understand ourselves. [End Page 267] Otherwise, something is missing and the reason a person gives for their actions either look like poor reasons or not reasons at all (Bortolotti and Broome 2008). Further, agency, rationality, and self-knowledge may themselves be dependent upon reason-giving.In invoking moods and affects in one's narrative the practical understanding (or ‘affordances’) of the world one inhabits are laid open in clear view. Hence Aristotle's account of wonder as the stimulus for philosophy. Aristotle says: ‘For it is owing to their wonder that men both now begin and at first began to philosophize; they wondered originally at the obvious difficulties, then advanced little by little and stated difficulties about the greater matters’ (1984, 1554). Conversely, given the experience of transcendence, of ambiguity, of finitude rather than wondrous awe, the philosopher may be motivated by anxiety (Kant's awakening from his dogmatic slumbers, Heidegger's battles with ‘Crisis’ and the flight of the gods). Either manner of accounting for one's interest seems to work normatively in the giving of reasons and in generating a narrative, and, moreover, a philosophical narrative.Our fictional dialogue and discussion aims to reinforce the important link between narrative, reason-giving and moods and affects argued for by Rosfort... (shrink)

In this recently published book, Jefferson provides a lucid and detailed examination of, and answer to, its provocative title. In doing so, the focus of Jefferson’s analysis is largely on what a br...