The article provides a conceptualization of self(-illness) ambiguity and investigates to what extent self(-illness) ambiguity is ‘special’. First, we draw on empirical findings to argue that self-ambiguity is a ubiquitous phenomenon. We suggest that these findings are best explained by a multidimensional account, according to which selves consist of various dimensions that mutually affect each other. On such an account, any change to any particular self-aspect may change other self-aspects and thereby alter the overall structural pattern of self-aspects, potentially leading (...) to self-ambiguity. Second, we propose that self-ambiguity comes in degrees and should be understood as a spectrum (as opposed to there being qualitative differences among instances of self-ambiguity). Third, we argue that complexity is the most useful dimension to organize cases of self-ambiguity, with mundane instances of self-ambiguity on the one end and self-illness ambiguity on the other end of the spectrum. Fourth, we address the promises and perils of narrativity with regard to self-ambiguity. Finally, we link our deflationary account of self(-illness) ambiguity to pattern theories of self. (shrink)

Despite technological innovations, clinical expertise remains the cornerstone of psychiatry. A clinical expert does not only have general textbook knowledge, but is sensitive to what is demanded for the individual patient in a particular situation. A method that can do justice to the subjective and situation-specific nature of clinical expertise is ethnography. Effective deep brain stimulation (DBS) for obsessive-compulsive disorder (OCD) involves an interpretive, evaluative process of optimizing stimulation parameters, which makes it an interesting case to study clinical expertise. The (...) aim of this study is to explore the role of clinical expertise through an ethnography of the particular case of DBS optimization in OCD. In line with the topic of the special issue this article is a part of, we will also use our findings to reflect on ethnography as a method to study complex phenomena like clinical expertise. This ethnography of DBS optimization is based on 18 months of participant observation and nine in-depth interviews with a team of expert clinicians who have been treating over 80 OCD patients since 2005. By repeatedly observing particular situations for an extended period of time, we found that there are recurrent patterns in the ways clinicians interact with patients. These patterns of clinical practice shape the possibilities clinicians have for making sense of DBS-induced changes in patients’ lived experience and behavior. Collective established patterns of clinical practice are dynamic and change under the influence of individual learning experiences in particular situations, opening up new possibilities and challenges. We conclude that patterns of clinical practice and particular situations are mutually constitutive. Ethnography is ideally suited to bring this relation into view thanks to its broad temporal scope and focus on the life-world. Based on our findings, we argue that clinical expertise not only implies skillful engagement with a concrete situation but also with the patterns of clinical practice that shape what is possible in this specific situation. Given this constraining and enabling role of practices, it is important to investigate them in order to find ways to improve diagnostic and therapeutic possibilities. (shrink)

Can affordances help in understanding psychiatric illness and psychopathological experience? In recent work on the philosophy of psychiatry and phenomenology, the answer appears to be a clear ‘yes’, but some recent worries have emerged that the affordance-concept might be “insufficiently discerning” and thus ill-suited to make sense of psychiatric illness and experience. In this paper I briefly review recent attempts to use the affordance-concept to make sense of psychopathology, as well as the worries voiced by the critics. I argue that (...) much of this criticism is, in fact, best understood as a call for more research and offer some exploratory considerations on how this research might proceed. Specifically, I argue that an improved understanding of the self-referentiality that is inherent to experiencing affordances can be useful for psychiatry. (shrink)

In this paper, I argue for a new way to understand the integration of facts and values in the concept of mental disorder that has the potential to avoid the flaws of previous hybrid approaches. I import conceptual tools from the account of procedural objectivity defended by Helen Longino to resolve the controversy over the definition of mental disorder. My argument is threefold: I first sketch the history of the debate opposing objectivists and constructivists and focus on the criticisms that (...) led to the emergence of the debate. Second, I offer a reconstruction of the “Natural Function Approach” argument to make explicit an unsound assumption underlying this approach. The reconstruction will allow me to show that the NFO’s argument depends on the ideal of value-free science that I will criticize. Then I propose an alternative ideal for psychiatry: social objectivity. I argue that the concept of mental health should be seen as “socially objective” rather than value-free, moving the debate towards the social procedures by which the definition is produced rather than the normative and factual content of its definition. (shrink)

People suffering from Obsessive-Compulsive Disorder (OCD) do things they do not want to do, and/or they think things they do not want to think. In about 10 percent of OCD patients, none of the available treatment options is effective. A small group of these patients is currently being treated with deep brain stimulation (DBS). Deep brain stimulation involves the implantation of electrodes in the brain. These electrodes give a continuous electrical pulse to the brain area in which they are implanted. (...) It turns out that patients may experience profound changes as a result of DBS treatment. It is not just the symptoms that change; patients rather seem to experience a different way of being in the world. These global effects are insufficiently captured by traditional psychiatric scales, which mainly consist of behavioural measures of the severity of the symptoms. In this article we aim to capture the changes in the patients’ phenomenology and make sense of the broad range of changes they report. For that we introduce an enactive, affordance-based model that fleshes out the dynamic interactions between person and world in four aspects. The first aspect is the patients’ experience of the world. We propose to specify the patients’ world in terms of a field of affordances, with the three dimensions of broadness of scope (‘width’ of the field), temporal horizon (‘depth’), and relevance of the perceived affordances (‘height’). The second aspect is the person-side of the interaction, that is, the patients’ self-experience, notably their moods and feelings. Thirdly, we point to the different characteristics of the way in which patients relate to the world. And lastly, the existential stance refers to the stance that patients take towards the changes they experience: the second-order evaluative relation to their interactions and themselves. With our model we intend to specify the notion of being in the world in order to do justice to the phenomenological effects of DBS treatment. (shrink)

It has been argued that affordances are not meaningful and are thus not useful to be applied in contexts where specifically meaningfulness of experience is at stake (e.g. clinical contexts or discussions of autonomous agency). This paper aims to reconceptualize affordances such as to make them relevant and applicable in such contexts. It starts by investigating the ‘ambiguity’ of (possibilities for) action. In both philosophy of action and affordance research, this ambiguity is typically resolved by adhering to the agents intentions (...) and concerns. I discuss some recent accounts of affordances that highlight these concerns but argue that they tend to adopt an ‘atomistic’ approach where there is no acknowledgement of how these concerns are embedded in the agents wider concerns, values, projects and commitments. An holistic approach that does acknowledge this can be found in psychological research on agents having a sense of what they’re doing. I will discuss this research in the second part of the paper and argue that agents can analogously have a sense of what is afforded. This is deemed the entry point for understanding the meaningfulness of affordances. In the final part of the paper I apply this analysis to recent attempts which seek to make sense of authentic and autonomous agency in terms of affordances. (shrink)

This article supports calls for an increased integration of patients into taxonomic decision making in psychiatry by arguing that their exclusion constitutes a special kind of epistemic injustice: preemptive testimonial injustice, which precludes the opportunity for testimony due to a wrongly presumed irrelevance or lack of expertise. Here, this presumption is misguided for two reasons: the role of values in psychiatric classification and the potential function of first-person knowledge as a corrective means against implicitly value-laden, inaccurate, or incomplete diagnostic criteria (...) sets. This kind of epistemic injustice leads to preventable epistemic losses in psychiatric classification, diagnosis, and treatment. (shrink)

The paper defends the position that phenomenological interviews can provide a rich source of knowledge and that they are in no principled way less reliable or less valid than quantitative or experimental methods in general. It responds to several skeptic objections such as those raised against introspection, those targeting the unreliability of episodic memory, and those claiming that interviews cannot address the psychological, cognitive and biological correlates of experience. It argues that the skeptic must either heed the methodological and epistemological (...) justification of the phenomenological interview provided, or embrace a more fundamental skepticism, a “deep mistrust”, in which scientific discourse can have no recourse to conscious processes as explananda, with ensuing dire consequences for our conception of science. (shrink)

Some critics argue that the types of psychiatric diagnosis found in the Diagnostic and Statistical Manual of Mental Disorders and International Classification of Disease are superfluous and should be abandoned. These are known as categorical polythetic psychiatric diagnoses. To receive a categorical polythetic psychiatric diagnosis an individual need only exhibit some, rather than all, of the symptoms on the diagnostic criteria. Consequently, categorical polythetic psychiatric diagnoses only associate an individual with a range of symptoms rather than specify which symptoms they (...) have. Drawing on Giere’s account of scientific models, I portray categorical polythetic psychiatric diagnoses as abstract models that guide the building of less abstract models. These models can specify which symptoms a particular individual has. Additionally, categorical polythetic psychiatric diagnoses can guide investigation of symptoms towards difficult to spot symptoms, guide investigation towards changing symptoms, and guide investigation towards how symptoms manifest. These important roles mean categorical polythetic psychiatric diagnoses should not be abandoned. (shrink)

In their article, “Patients’ beliefs about deep brain stimulation (DBS) for treatment resistant depression,” Lawrence, Kaufmann, DeSilva, and Appelbaum analyze the responses of 24 psychiatric inpat...

This paper explores the factors that contribute to the degree of a mood disorder patient’s self- insight, defined here as her understanding of the particular contingencies of her life that are responsive to her personal identity, interpersonal relationships, illness symptoms, and the relationship between these three necessary components of her lived experience. I consider three factors: (i) the Diagnostic Statistical Manual of Mental Disorders (DSM), (ii) the DSM culture, and (iii) the cognitive architecture of the self. I argue that the (...) symptom-based descriptions of mood disorders which eliminate the subjective features of the patient’s illness experience, in conjunction with the features of the DSM-culture and the cognitive biases that guide the patient, contribute to the impoverishment of her self-insight. The resulting impoverished self-insight would prevent her from developing resourceful responses to her interpersonal problems. In analyzing how these factors combine to influence the patient’s self-insight, I distinguish the therapeutic impact of receiving a psychiatric diagnosis, which facilitates patient’s clinical treatment, from its reflective impact, how the diagnosis informs the patient’s reflection on who she is, how her mental disorder is expressed, and how her interpersonal relationships proceed. I substantiate my argument by considering a patient’s memoir of psychopathology. (shrink)

The article provides a conceptualization of self(-illness) ambiguity and investigates to what extent self(-illness) ambiguity is ‘special’. First, we draw on empirical findings to argue that self-ambiguity is a ubiquitous phenomenon. We suggest that these findings are best explained by a multidimensional account, according to which selves consist of various dimensions that mutually affect each other. On such an account, any change to any particular self-aspect may change other self-aspects and thereby alter the overall structural pattern of self-aspects, potentially leading (...) to self-ambiguity. Second, we propose that self-ambiguity comes in degrees and should be understood as a spectrum (as opposed to there being qualitative differences among instances of self-ambiguity). Third, we argue that complexity is the most useful dimension to organize cases of self-ambiguity, with mundane instances of self-ambiguity on the one end and self-illness ambiguity on the other end of the spectrum. Fourth, we address the promises and perils of narrativity with regard to self-ambiguity. Finally, we link our deflationary account of self(-illness) ambiguity to pattern theories of self. (shrink)

This paper challenges the exclusion of patients from epistemic practices in psychiatry by examining the creation and revision processes of the Diagnostic and Statistical Manual of Mental Disorders (DSM), a document produced by the American Psychiatric Association that identifies the properties of mental disorders and thereby guides research, diagnosis, treatment, and various administrative tasks. It argues there are epistemic—rather than exclusively social/political—reasons for including patients in the DSM revision process. Individuals with mental disorders are indispensable resources to enhance psychiatric epistemology, (...) especially in the context of the crisis, controversy, and uncertainty surrounding mental health research and treatment. (shrink)