Madness & Mental Health Season Review, Professor Edward Harcourt

On Wednesday 4th June, our Academic Director Professor Edward Harcourt reflected on the 2023-2024 London Lecture series, ‘Madness & Mental Health’ at a members-only event, answering questions from the online audience and bringing members together to engage in philosophy. Topics included how we should talk about mental illness and the agency that patients should have in their own treatment.

Transcript

SPEAKER_00 0:04

Hello everybody. Good afternoon. Thank you very much for joining. My name is Edward Harcourt. I'm the Academic Director of the Royal Institute of Philosophy and a professor of philosophy at Oxford. This is the webinar on madness and mental health. So just one housekeeping remark before I plunge in. If you have questions, please into the chat and we will read them out, we'll go to the QA. So I'm going to talk a little bit about the forthcoming volume on madness and mental health, which reflect the London Lecture series from 2023-2024. Some of you may have been at that. I'll probably talk for 15 or 20 minutes, and then it's over to you for questions. Well, why do a series on madness and mental health? Mental health is a big issue. 5% of the global disease burden, but only 9% of UK research funding goes to mental health research for every £228 spent on cancer research. And although it was moving up people's list of priorities even before the pandemic, I think it's even higher on people's agenda as an issue now, since the pandemic. I suspect partly because of the impact the pandemic had on young people's mental health. There's been a significant uptick in reported anxiety and depression, especially since COVID. But mental health is not only interesting as a public health, it's also philosophically interesting. So let me give you a little flavor of what some of the philosophical issues are. Is there such a thing as mental illness? Or is what we call sanity just like being slim? That's to say, one particular bandwidth on the spectrum of human variation, which society happens to single out as normative for everybody else, but for no very special reason, other than that's the way the fashion has gone. On that way of looking at things, it is just a way of being different, not a way of having anything wrong with you. If on the other hand there is such a thing as mental illness, is it a disease of the brain, or is it, as it's sometimes called, a biopsychosocial phenomenon, something implicating not only the human body, but also society and the material environment? And if it is predominantly a condition of the brain, why has psychiatric research not made more progress in recent years in identifying so-called biomarkers of mental illness? As you may know, mental illnesses can't be identified unlike bronchitis or cancer or something, independently of their symptoms. There are no biological confirming signs of any mental illness. So that's one set of broad questions. A number of you will also have heard of anti-psychiatry. Foucault, Thomas Sass, R. D. Lange, and others, a movement which started questioning the legitimacy of psychiatric knowledge and of psychiatric modes of treatment, including incarceration, from the 1960s onwards. And indeed, the title of this series, Madness and Mental Health, rather than calling it mental illness and mental health, is a kind of nod to the anti-psychiatry movement. But one reason why now is a particularly interesting time to start thinking philosophically about madness is that some of the skeptics that the anti-psychiatry movement and their disciples have been raising for decades. So is sanity medically different from madness, or is it just like the difference between being slim and having other body shapes? Is it just a way of being different? Some of the skeptical questions which anti-psychiatrists have been raising for decades are now being voiced from within mainstream psychiatry itself. So many mainstream psychiatrists are bothered by the fact that they've not been more successful than they have in identifying biomarkers. They're bothered by the fact that conventional psychiatric diagnoses simply point to symptom clusters rather than to underlying physiological causes. And they're bothered by the question whether mental illness is fundamentally a brain phenomenon or brain body phenomenon, or whether it implicates the broader social and material environment. And that points us in the direction of a philosophical question. Is the reason why mainstream psychiatry is entering this moment of self-questioning? Is the right answer to that just more research? Or is there something fundamentally philosophically wrong with the way it's asking its questions? So, in part, this volume, now to turn to the volume rather than to the general subject area in which it's located, the volume is about applying to psychiatry some of the familiar questions in the metaphysics of mind. So many of you will have heard of the idea that you can identify the mental with the physical or mental states with state the brain. And so the broken brain theory of mental illness in part reproduces those familiar issues from the general philosophy of mind. But the volume is also intended to pursue a kind of ethical inquiry. So some patients believe that the broken brain theory of mental illness isn't a controversial, still unresolved, part philosophical, part empirical thesis, but it's definitely wrong, and definitely wrong for ethical reasons. In other words, it's dismissing the idea that what patients report when they're ill has a meaning for them, or even that it's the verbal equivalent of locking people up. Of course, in former times, people diagnosed with psychiatric conditions were locked away in asylums. That hasn't been the case for many years. But some radical anti-psychiatrists think that simply calling the conditions that they're in mental illnesses, and still more saying that they're merely conditions of the brain, is the verbal equivalent of pushing people away, saying you're not one of us. Or to point to a different ethical controversy. The mere difference view, the idea that the debate about mental health or sanity and madness is really very similar to the debate about body shape, and there's no well-supported ideal body shape, it's just a matter of arbitrary fashion. The mere difference view, is it ethically bad because it fails to acknowledge the reality of suffering? So there are some people in the kind of anti-psychiatry camp who think that not only is being mad just an alternative way of being, but that there's nothing to dislike about it. Other people say it's a different way of being, but that it's painful and an unhappy way of being, a way of being that people would rather be without. So how do you fit the reality of suffering, if indeed it is real, into that anti-psychiatric perspective? And disappear if we had a more tolerant environment. To what extent is the suffering that people suffering from mental illnesses go through, at least if you take that view, the result of an unsympathetic and intolerant environment which could be massaged away if the environment was more accommodating. So that's all I'm going to say in my own voice, as it were. Because you need to remember who wrote the introduction to the volume, which incidentally should be available to buy and available online pretty soon, within the next month or so, I think. I didn't write any of the papers. I just picked the authors and invited them to give talks at the Royal Institute. So the authors of these papers are not in any sense dancing to my tune. I invited them along because I thought they were interesting people and they'd have interesting things to say, not because I thought they would take a party line, still less that they would echo my own beliefs about the subject. But I'm going to try and give you a few highlights from the collection, and I know that's an awkward thing to do. I think it would be boring if I tried to rehearse the outline of all 14 papers in it. So I hope the contributors whom have not singled out won't feel aggrieved that I've singled out some others. The other thing to before I get to that is that although I think that the questions the collection addresses are philosophical questions, by no means all of the contributors were philosophers. So it was really interdisciplinary. There were some lawyers, there was a lawyer, several psychologists, a psychotherapist, a conversation expert, and many others, a psychiatrist, at least one, and many others as well as philosophers. So getting a perspective from multiple disciplines on this same cluster of questions was a really important inspiration for the volume. So in some of the papers, you get an echo of some quite mainline anti-psychiatric themes. Thus, in Justin Garson's paper, for example, he argues that mental illness is not to be seen as anything going wrong in the human organism, not to be seen as an example of dysfunction. Rather like pain, a psychiatric symptom such as depression is what he describes as a wake-up call signalling to you that there's an issue in your life that you need to attend to, and you'll be better off if you listen to the wake-up call and attend to it rather than trying to paper over the cracks or make the symptom go away. And he uses the example, athletes who I'm not sure whether trainers do this still, but in the old days you used to get a cortisone injection. If you on the football pitch you started getting a sore knee and you couldn't perform to the to your usual uh athletic level, of course, athletes who are given a cortisone injection in order to stay on the pitch end up with terrible joint problems later in life because they continue to injure themselves even if they don't feel anything. And so his analogy is look, stay with the symptom and listen to it rather than trying to medicate it away. And similarly, Jasna Russo, who is the leading light of the contemporary anti-psychiatry movement, says that madness needs accommodation, not treatment. What we need is to find a way of making society more tolerant and more flexible, so that the needs of people suffering from psychiatric symptoms don't make such a negative difference to their lives. The last thing we should be doing is medicating them away. And similarly, uh some of you may have come across the theme of epistemic injustice. It's now a major part of the discourse on mental health and mental illness. Harvey Carell and her collaborators have contributed a paper about epistemic injustice in mental health care. But taking an original angle on this, I mean, the standard view about epistemic injustice is that the mentally ill are not listened to enough. That's to say they're the victims of silencing, they're the victims of epistemic injustice because don't count for enough. They're taking the line that silence can sometimes have a positive value. People can use it to protect their privacy, people can use it as a form of resistance. It's not just people can choose silence, it can be an exercise of autonomy as well as the result of being silenced by others. So that's one little cluster of themes. Most of the papers are about the experience of people with psychiatric diagnoses and how they're treated, what the causes are, what to do about it. But there's one paper which is Neil Armstrong and Nicola Byron's paper, which talks about patients a little bit, but it's mostly about clinicians, and it's rather interesting for that reason. One of the standard views in the anti-psychiatry literature, or one of the standard themes in the anti-psychiatry literature, is the power imbalance between clinician and patient, and the imbalance of prestige between psychiatric knowledge and patient-generated knowledge, what patients know in virtue of being unwell. But Armstrong and Byron kick off their paper by saying, well, if clinicians really have so much power, why is it that they feel so powerless? And indeed, in my own experience of talking to not only clinicians in the National Health Service, but also National Health Service administrators, everybody seems to have this feeling of being stymied by the system, and nobody quite knows where to locate the power that's stymied them. Anyway, Armstrong and Byrum have an interesting theory about this, which is that clinicians feel under pressure from what they call an audit culture, culture of being audited and investigated for results and also for foul-ups, for mishaps, things that go wrong. They're encouraged by this audit culture to place an excessive emphasis on risk management, and that gets in the way of their building up a genuine face-to-face relationship with their patients. So often they're reciting scripts, according to Armstrong and Byron, that they only half believe in themselves rather than speaking authentically in their own voice. So that's the clinicians. But if there is a theme connecting a number of the papers or a main theme of the volume, I think it's probably trying to show how the dignity and humanity of the psychiatric patient can shine through despite their illness. So a standard view in not just the philosophy of psychiatry, but a kind of standard assumption applying some form for mental illness, and indeed some legislative programs around mental illness, is that mental illness deprives you of rationality, it deprives you of autonomy, and so it means that it's okay to treat you with less respect for your perspective than would be the case for a well person. And various authors in the volume pick this up in different ways and try in their different ways to push back against it. So Mona Gupta, for example, who's both a philosopher and a clinician working in Canada, writes about the assisted dying legislation in Canada, for which at the moment there is a blanket exclusion for anybody with a psychiatric diagnosis. So you can see why sometimes you might doubt the authenticity of somebody's wish to take advantage of assisted dying legislation if they have a psychiatric diagnosis, because of course suicidality is a diagnostic criterion for some mental illnesses. So it might be the illness talking, as it were. But she wants to say, look, there shouldn't be a blanket exclusion, because sometimes people who've been suffering from lifelong treatment-resistant conditions, and particularly people who are not in the middle of a psychotic or depressive episode, let's say, might simply have had enough in a way that somebody with motor neurone disease might have just had enough. And so this idea that there's a blanket exclusion for mental illness requires more philosophical probing. Similarly, Mary Boyle and Lucy Johnston, who may be known to some of you as the authors of the Power Threat Meaning framework, they don't like the medical model of mental illness because, according to them, it severs the link between psychiatric symptoms and the patient's life experience, and therefore denies that those symptoms have a meaning. So rather than saying, what are your symptoms? they prefer to ask the question, what's your story? So that to restore that connection between life experience and symptoms, a little bit like Garson says your symptoms rather than trying to suppress them. Again, Claire Hogg, who is a lawyer, a legal academic, writes about why mental illness exculpates, why mental illness gets you off the hook in certain sorts of criminal investigation. And she's rather interested in the idea, not that mental illness exculpates because, like the blanket exclusion in Canada, because it means you're not responsible for what you do. She's interested in comparing different cases where she compares the case of somebody who jumps out of a window because she mistakenly believes that her flat is on fire, clutching her young child, but makes sure to land in such a way that the child is protected, the child isn't hurt. And she compares that with the case of a person who beats up his wife because he's suffering from the delusion that his wife is being unfaithful. Now, both of these patients are equally deluded. One is deluded that the wife's being unfaithful, the other is deluded that the flat is on fire. But she argues that one is more deserving of exculpation than the other, because in one case, the person's motivation was to protect her child, and in the other, the person's motivation was to punish his wife. And so think about what their motivations were independently of the illness, and so what separates them, rather than thinking about what they've got in common in the way of suffering from delusion. And this echoes a theme in Richard Gibbs's paper, which is my final example. I won't rehearse the whole argument of the paper, but he makes the point, and I think it's a point that's common to Gupta's paper, Hogg's paper, and the Boylan Johnston paper, which I've already referred to. He says that mental illness doesn't swallow the whole person. So I think if there is a connecting thread to the papers, which was not imposed on them by me, it's something like that. I'll end there and I look forward to hearing your questions, although be warned that because I didn't write the papers apart from the introduction, I can't promise that I'll be able to answer them, but I'll do my best.

SPEAKER_01 20:32

Thank you.

SPEAKER_00 20:32

One reason why the DSM and ICD are still used is that we don't have anything yet to replace them with. And I think one should separate the question of the utility of these diagnostic criteria from what it is best to do with somebody when they receive a psychiatric diagnosis. So one of the interesting features about the power threat meaning of the framework, and this is me talking, not something that Boyle and Johnston themselves say, is that it's quite deferential towards traditional diagnostic categories. So they don't say that there's no real difference between depression or major depression and schizophrenia. They don't say we should stop thinking in terms of these categories, as some advocates of or some some other critics of DSM and ICD do. They're happy enough with those classifications. They just think that we should react to the symptoms when we encounter them in a patient in a different way. From the standard psychiatric way. And so I think it's really interesting, a really interesting thought that we should ask what the meaning of a symptom is. And there's some really impressive work. I think the I I you know not a psychiatrist, so I know what I read. I don't haven't gathered independent evidence for this stuff myself. But there's some very interesting work on voice hearing. So voice hearing is a symptom of schizophrenia that's been developed, particularly in the Netherlands, in which, according to the authors, successful treatments of voice hearing have been pursued, which look for meaning in the symptoms by relating them to people's life experience. And they don't always seek to, the other interesting thing about this treatment is that they don't always seek to make the voices disappear. They see sometimes they seek to make the voices less persecutory and more friendly, but don't try them. I don't know of comparable body of evidence for other psychiatric symptoms where asking the Boyle and Johnston style question, you know, what's your story, what's the meaning of this, has similarly impressive results. But you know, m maybe further research would reveal that. And the final thing I want to say is that I don't think there's necessarily any kind of opposition between using a drug treatment and asking the what's your story question. So in the hearing voices cases, some of those have been combined. If somebody comes into AE in the middle of a psychiatric emergency, it may be necessary to use medication to stop the person causing themselves great harm, and it may be pursued in tandem with the what's your story or kind of approach, in other words, the kind of approach that seeks to relate symptoms to life experience. So that's not a complete answer to your question, but I hope it presses some of the right buttons. I mean, academia is very balkanized. People tend to listen to others who are working in their own sub-specialism. But certainly there is a healthy sub-specialism in the philosophical in the philosophy of psychiatry in universities. There's quite a lot of it in the United States, there's quite a lot of it in Britain, there's quite a lot of it in the in the Low Countries, and some of it in other countries of the world, in Germany. And I in my own experience, there is much more interest among students in pursuing these kinds of questions than there was six or seven years ago. It's remarkable how many people turn up in Oxford wanting to study this stuff, and I can give a class on it and get an audience, which I don't think I could have done six or seven years ago. So it is making an impact on its own little sub-corner of philosophical discourse, whether it's making an impact on philosophical discourse more broadly, I'm not sure. But then, you know, as I say, um uh philosophy, like other branches of academia, tends to subdivide into little specialisms, so that's probably what we should expect. I really hesitate to kind of dictate to psychiatric colleagues what they ought to be doing, because I have no psychiatric training, and also I'm not at the sharp end of psychiatric care. So there are lots of people who will say, look, I'm a total skeptic about DSM diagnostic categories. I'm a total skeptic about the idea that psychiatric medication targets chemical imbalances in the brain. But if you're in AE and somebody walks in in a terribly distressed state, what are the alternatives available to you? So I think there's a little bit of slack between raising philosophically skeptical questions about the foundations of psychiatry and conjuring up new forms of treatment. The other thing that makes that question rather complicated is that as soon as you get to questions about how should we do stuff differently, which is a real-world practical question, you immediately get into this dreadful question of resourcing. So the NHS is terribly short of money. And in particular, mental health services are terribly short of money. So to say, well, in an ideal world, what we would do is pursue X, Y, Z course of action, it may simply not be open to you if your trust is already in deficit. You can you can do all the theorizing you like, but it requires some hugely creative thinking to innovate in mental health treatment in the context of very cash-strapped budgets. So I'm reading this incredibly depressing book at the moment called You Don't Have to Be Mad to Work Here by a psychiatrist, a young psychic or young-ish psychiatrist called Benji Waterhouse. And he goes into the profession, it's about his days as a junior doctor. He goes into the profession all idealistic. And in fact, you know, it's just very dispiriting, the kinds of questions that there are always more people than there are beds. So the only discussion they have are not sort of therapeutic, properly therapeutic conversations, but conversations about who to kick out of the inpatient ward, you know, whose needs are the least, so that we can accommodate the most recent urgent case. So, you know, the down at the resourcing end of things, things are not uh rosy at all. All the same, I think there are examples where um innovations in care and a bit of imagination have made a difference. So I mentioned the literature on hearing voices, where a kind of sometimes a combined psychopharmacological approach and a listening, please relate this symptom, you know, tell me what it represents, tell me about your past life, has seemingly really helped people. And I'll give you another very low-level intervention. One of the things that really often happens in inpatient psychiatric wards is that nurses go around in the middle of the night every hour or every couple of hours with a light, um, checking that people are okay. And in a ward in Northumberland, somebody had the bright idea to trial just not walking around in the middle of the night and leaving the lights off so that people could get a decent night's sleep. And it worked really well because people were discharged more swiftly and had better recovery rates because they were sleeping better. And that just shows that a little bit of listening to patients can sometimes make I mean that's a documented case, can sometimes make a positive change. So I'm not a complete pessimist about the possibility of service innovation for the better.

SPEAKER_01 29:45

Yes, it's a nice question.

SPEAKER_00 29:47

Yes, there's a absolute ton of literature, the lorry load of literature on this, um, and it's a very interesting question. So the philosophical question is well, l let me take one step back. So Britain is the kind of what was a pioneer here, but this is now being picked up by other countries. It's a condition of getting any kind of state funding for medical research that you involve people who have lived experience of the condition you're investigating. And that's also true. That's true of psychiatric research as much as of any other branch of medical research. And I guess there are two kind of two bits of philosophical controversy about this. So I myself am involved in what's called PPIEP, patient and public involvement, engagement and participation in the Oxford Psychiatry Department. In other words, trying to get patients involved in research programs. But one of the philosophical debates about this, which stems from the anti-psychiatry or the radical end of the anti-psychiatry literature, which I mentioned earlier, says: look, any attempt to involve people with lived experience in mainstream research programs is just a way of neutering their insights, but at the same time getting a kind of seal of legitimacy from their token involvement. And so this is the worst of all possible worlds. You know, if you're going to exclude patient voices, be honest that that's what you're doing. But if you're going to involve them, let them take the lead. Don't try and bring them in as kind of subordinate partners because they've got much more interesting things to contribute than that. As you've probably gathered from my turning the light off at night example, I think that there are some quite impressive examples where mainstream research programs in both physical medicine and psychiatric medicine have benefited, actually, have discovered stuff that they wouldn't have discovered otherwise through listening to patients. So I don't um accept that uh that skeptical view, but there is certainly literature on this. And you could look at Yasna Russo's work, who's written about this quite a lot. There's another woman called Helen Spandler who's written about this, interestingly, so and there are many others. They all have bibliography. Oh, this so there's there's that radical end of the literature, but then there's another interesting philosophical question, which is why is it exactly that having suffered from a medical condition gives you a special epistemic privilege, if it gives you an epistemic privilege at all? So, what sort of epistemic privilege does it give you? What form of expertise do you have if you're a so-called expert by experience? And there's a big literature on this as well. So there's an interesting paper by a woman called Mazander Rani on this, which has tons of references, and there's an interesting paper by Ilena Singh and Phoebe Freesen on this too, which also has a ton of references. So if you look up those, that should get you started. But it's a really interesting area of work. Well, look, um, thank you all very much for your questions. If you're tempted by what you've heard in this sort of taster session, do look out for the edited volume called Madness and Mental Health when it comes out. It's a Royal Institute of Philosophy supplementary volume. And before the volume comes out, you can see on YouTube recordings of all these sessions. You can find out more about the people whose work I've been describing, and you can listen to the audience QA as well. And that's right now available on the Royal Institute of Philosophy YouTube channel. So I hope you've enjoyed the session. And this is the first of many webinars of this kind that the Royal Institute will host. Please look out for others. I think there's going to be another one in September. And of course, please look out for the new series of London lectures, which will be our 100th series of lectures, our centenary lectures, which will take place in London from October this year. So I look forward to seeing as many of you as possible there. Of course, I won't know who you are because I can't see you, but do come along. Um, and thank you very much for your participation. Bye now.