The six most essential questions in psychiatric diagnosis: A pluralogue part 2: Issues of conservatism and pragmatism in psychiatric diagnosis

In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM ?C whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part I of this article took up the first two questions. Part II will take up the second two questions. Question 3 deals with the question as to whether DSM-V should assume a conservative or assertive posture in making changes from DSM-IV. That question in turn breaks down into discussion of diagnoses that depend on, and aim toward, empirical, scientific validation, and diagnoses that are more value-laden and less amenable to scientific validation. Question 4 takes up the role of pragmatic consideration in a psychiatric nosology, whether the purely empirical considerations need to be tempered by considerations of practical consequence. As in Part 1 of this article, the general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances.     

The six most essential questions in psychiatric diagnosis: a pluralogue part 1: conceptual and definitional issues in psychiatric diagnosis

In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM - whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part I of this article will take up the first two questions. With the first question, invited commentators express a range of opinion regarding the nature of psychiatric disorders, loosely divided into a realist position that the diagnostic categories represent real diseases that we can accurately name and know with our perceptual abilities, a middle, nominalist position that psychiatric disorders do exist in the real world but that our diagnostic categories are constructs that may or may not accurately represent the disorders out there, and finally a purely constructivist position that the diagnostic categories are simply constructs with no evidence of psychiatric disorders in the real world. The second question again offers a range of opinion as to how we should define a mental or psychiatric disorder, including the possibility that we should not try to formulate a definition. The general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances.     

Life-Prolonging Killings and their Relevance to Ethics

What makes killing morally wrong? And what makes killing morally worse than letting die? Standard answers to these two questions presuppose that killing someone involves shortening that person's life. Yet, as I argue in the first two sections of this article, this presupposition is false: Life-prolonging killings are conceivable. In the last two sections of the article, I explore the significance of the conceivability of such killings for various discussions of the two questions just mentioned. In particular, I show why the conceivability of life-prolonging killings renders Frances M. Kamm's attempt to provide an answer to the second question problematic.     

The six most essential questions in psychiatric diagnosis: a pluralogue part 3: issues of utility and alternative approaches in psychiatric diagnosis

In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM ?C whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part 1 of this article took up the first two questions. Part 2 took up the second two questions. Part 3 now deals with Questions 5 & 6. Question 5 confronts the issue of utility, whether the manual design of DSM-III and IV favors clinicians or researchers, and what that means for DSM-5. Our final question, Question 6, takes up a concluding issue, whether the acknowledged problems with the earlier DSMs warrants a significant overhaul of DSM-5 and future manuals. As in Parts 1 & 2 of this article, the general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances.     

Lost forever or temporarily misplaced? The long debate about the nature of memory impairment

Studies of memory impairment in humans and experimental animals have been fundamental to learning about the organization of memory and its cellular and molecular substrates. When memory impairment occurs, especially after perturbations of the nervous system, the question inevitably arises whether the impairment reflects impaired information storage or impaired accessibility. This topic has been the subject of considerable commentary and experimental work over the years. In this reappraisal, I first consider four broad areas of behavioral study from the 1970s and 1980s that led to a dominant and compelling view of memory impairment as a deficit of information storage. Second, I identify some ambiguities that arise about how the terms "storage" and "retrieval" are applied, especially when the evidence is somewhat indirect and based on a behavioral-psychological level of analysis. I then review neurobiological findings that have been largely overlooked in these discussions. The relevant studies are ones where it has been possible to monitor neurons and synapses in direct relation to behavioral memory, for example, in animals with simple nervous systems and in single cell recordings from behaving monkeys. This work provides a straightforward and illuminating perspective on the question and confirms the view that first emerged from less direct evidence.     

Bribery and Intimidation: A Discussion of Sandra Lee Bartky's Femininity and Domination: Studies in the Phenomenology of Oppression

A review of my undergraduate students’ commentaries on two of Bartky's essays serves as the occasion for elaborating on Bartky's analyses of factors that sustain and perpetuate the subjection and disempowerment of women. In my elaboration I draw from John Stuart Mill's statement: “In the case of women, each individual of the subject-class is in a chronic state of bribery and intimidation combined.” I conclude by raising the question, How is personal transformation possible?     

The Loop Case and Kamm’s Doctrine of Triple Effect

Judith Jarvis Thomson’s Loop Case is particularly significant in normative ethics because it questions the validity of the intuitively plausible Doctrine of Double Effect, according to which there is a significant difference between harm that is intended and harm that is merely foreseen and not intended. Recently, Frances Kamm has argued that what she calls the Doctrine of Triple Effect (DTE), which draws a distinction between acting because-of and acting in-order-to, can account for our judgment about the Loop Case. In this paper, I first argue that even if the distinction drawn by DTE can be sustained, it does not seem to apply to the Loop Case. Moreover, I question whether this distinction has any normative significance. The upshot is that I am skeptical that DTE can explain our judgment about the Loop Case.     

THE NATURE OF DIVINE REVELATION

One of the most important questions about divine revelation is the question – what is the nature of divine revelation? This conceptual question even precedes such epistemological questions as whether we can know that a divine revelation occurred, or whether divine revelation can produce religious knowledge. In this paper, I argue for a particular analysis of the concept of divine revelation. Key to my proposal is that ‘to reveal’ is a term of epistemic appraisal: if a subject revealed a proposition to a receiver, then this implies that the receiver actually accepted the information offered. I will end this paper by investigating what the consequences of my proposal are for answering the two epistemological questions.     

The Identity Status Approach: In Need of Fundamental Revision and Qualitative Change

This article is a response to the commentaries of Waterman (this issue) and Berzonsky and Adams (this issue) on my review of the identity status field (van Hoof, this issue). The commentaries illustrate that the identity status researchers attribute different meanings to the identity statuses and identity status research; while Waterman finds it difficult to recognize the field in my review, Berzonsky and Adams agree with several of my conclusions. The two commentaries represent two pillars on which the status approach rests. The difference between the review and the commentaries is that the first includes both pillars, whereas each commentary consists primarily of a selective presentation of assumptions and data. This response focuses on two main points of the commentaries: (a) are the statuses sufficiently validated? and (b) to what extent are they suitable for testing developmental identity hypotheses? Using specific examples I show that the line of reasoning in the commentaries and the data proposed in support of these arguments in fact often support the conclusions of my review, for I demonstrate that the statuses are insufficiently validated and that the statuses are unsuitable for measuring identity development. These conclusions call for a fundamental revision of the identity status approach and a qualitative change in identity theory and research. Finally, the alternative approaches presented by Berzonsky and Adams are evaluated with respect to their contribution to an indispensable qualitative change in the identity status field.     

Interrogation,Interpretation and Integration of Spirituality: Insights from Sri Aurobindo for “Care for Creation”

This paper brings together three strands of enquiry – interrogation of spirituality, interpretation of spirituality and Sri Aurobindo's integrative spirituality – which form the three natural parts of the paper. In the first part I interrogate the idea and category “spirituality” and argue that this term came to be understood in opposition to the “material” only in medieval times, and thus the common notion of spirituality as opposed to materiality is misplaced. In the second part, in light of George Lindbeck's work, I will explore the question – is it possible for different traditions that interpret spirituality differently to hold a common unifying position? I will argue that if we are to arrive at an understanding of spirituality that will be acceptable to different traditions, then the very conception of spirituality must be informed by all. In the final part, I will argue that Sri Aurobindo's integrative spirituality offers a sufficient rationale for creation‐care by proposing a view of spirituality which, on the one hand, overcomes the spiritual‐material dichotomy, while on the other, contains an implicit guard against imposing its view of spirituality on other traditions. Finally, by bringing Sri Aurobindo into the dialogue I demonstrate how insights from another tradition can be drawn to enrich our understanding of spirituality.     

The Council of Newton: A Pedagogical Exercise for Understanding Conceptual and Historical Difference with Respect to Intra‐Religious Notions of Divinity

In this essay, I examine the following pedagogical question: how can we unlock students' mistaken notions that religious “traditions” are monoliths, and instead help them to recognize, puzzle over, and appreciate the complex multiplicity and vibrant set of doctrinal and ritual conversations that characterize religious traditions? More specifically, how can we teach students to recognize these differences with respect to a religion's notions of god? And how can we do so even when students are particularly stuck on, invested in, or trained to see homogeneity? In answer to these questions, I present an exercise that I have used in my World Religions courses. This exercise – which I call the “Council of Newton” (named for the building in which I first taught it) – is particularly effective because it helps students uncover and wrestle with this diversity at two levels: conceptually and historically.     

Managed Care's Reconstruction of Human Existence: The Triumph of Technical Reason

To achieve its goals of managing and restricting access to psychiatric care, managed care organizations rely on an instrument, the outpatient treatment report, that carries significant implications about how they view psychiatric patients and psychiatric care. In addition to involving ethical transgressions such as violation of patient confidentiality, denial of access to care, spurious use of concepts like quality of care, and harassment of practitioners, the managed care approach also depends on an overly technical, instrumental interpretation of human beings and psychiatric treatment. It is this grounding of managed care in technical reason that I will explore in this study. I begin with a review of a typical outpatient treatment report and show how, with its dependence on the DSM-IV, on behavioral symptoms and patient 'functioning', on the biomedical model of psychiatric illness, and on gross quantitative measures, the report results in a crude, skeletonized view of the human being as a congeries of behavioral symptoms and functions. I then develop the managed care construal of human existence further by showing its grounding in technical reason, exploring the latter in its modern embodiment and deriving it and its opposite, practical reason, from Aristotle's distinction between technical and practical reason, techne and phronesis. In this analysis of the role of technical reason in managed care, I point out that managed care did not have to develop its rationale de novo but could rather lift its arguments, e.g. the biomedical model, from contemporary psychiatry and simply apply them in a restrictive manner. Finally, I conclude this study by arguing for psychiatry's status as a discipline of practical knowledge.     

Deliberation,Reasons, and Alternatives

A plausible constraint on normative reasons to act is that it must make sense to use them as premises in deliberation. I argue that a central sort of deliberation – what Bratman calls partial planning – is question‐directed: it is over, and aims to resolve, deliberative questions. Whether it makes sense to use some consideration as a premise in deliberation in a case of partial planning can vary with the deliberative question at issue. I argue that the best explanation for this is that reasons are contrastive or relativized to deliberative questions.     

Humor as an Optics: Bergson and the Ethics of Humor

Although the ethics of humor is a relatively new field, it already seems to have achieved a consensus about ethics in general. In this paper, I implicitly (1) question the view of ethics that stands behind many discussions in the ethics of humor; I do this by explicitly (2) focusing on what has been a chief preoccupation in the ethics of humor: the evaluation of humor. Does the immoral content of a joke make it more or less humorous? Specifically, I analyze whether a sexist joke is more humorous because of its sexism. Contra recent trends in the ethics of humor, I answer this question affirmatively. To this end, the paper presents a detailed and novel reading of Bergson's philosophy of humor, which I argue connects most easily and significantly to the alternate view of ethics I have in mind.     

Perceived Job Discrimination: Going beyond a science of mean effects

This comment responds to the major issues raised by the papers of Anseel (2011) and Patterson and Zibarras (2011) as discussant commentaries to my keynote paper on perceived job discrimination (PJD) and applicant propensity to case initiation in employee selection. I respond first to the two main themes noted by these authors – (i) theoretical explanations for PJD, and, (ii) methodological and research design imperatives. In conclusion, this brief paper extends these issues to propose that applicant reactions research needs to develop from being a science of mean reactions to becoming a paradigm that can account for pragmatically important outlier reactions and responses as well.     

Laws and Causal Relations

How are causal relations between particular states of affairs related to causal laws? There appear to be three main answers to this question, and the choice among those three alternatives would seem to be crucial for any account of causation. In spite of this fact, the question of which view is correct has been all but totally neglected in present-day discussions. Indeed, since the time of Hume, one answer has more or less dominated philosophical thinking about causation. In this paper I shall attempt to show that the view in question is exposed to decisive objections.     

Two questions about surrogacy and exploitation

In this article I will consider two related questions about surrogacy and exploitation: (1) Is surrogacy exploitative? (2) If surrogacy is exploitative, what is the moral force of this exploitation? Briefly stated, I shall argue that whether surrogacy is exploitative depends on whether exploitation must be harmful to the exploited party or whether (as I think) there can be mutually advantageous exploitation. It also depends on some facts about surrogacy about which we have little reliable evidence and on our philosophical view on what counts as a harm to the surrogate. Our answer to the second question will turn in part on the account of exploitation we invoke in answering the first question and in part on the way in which we resolve some other questions about the justification of state interference. I shall suggest, however, that if surrogacy is a form of voluntary and mutually advantageous exploitation, then there is a strong presumption that surrogacy contracts should be permitted and even enforceable, although that presumption may be overridden on other grounds.     

Secularity,gender, and emancipation: thinking through feminist activism and feminist approaches to the secular

In this article, I engage with feminist discussions about secularity, gender, and emancipation. The feminist study of the secular was spurred by interventions of Saba Mahmood [2005. The Politics of Piety: The Islamic Revival and the Feminist Subject. Princeton: Princeton University Press], and can be seen as a critical engagement with at least one basic assumption that underlies much of progressive thinking – that secularism is beneficial for women and LGBTQ subjects. I begin by exploring how the Belgian feminist activist platform Baas Over Eigen Hoofd! (Boss Over One’s Own Head!) builds a locally suited theory and practice of emancipation. I analyse how BOEH! raises questions about gender and secularity. Second, I zoom-out by mapping feminist studies of the secular in Western European contexts, distinguishing various analytical approaches and visions on social-political secular emancipatory alternatives. To conclude, I relate local feminist activism to feminist academic discussions, and argue that there is a continued need for thinking about shared emancipatory futures.     

Adorno,Interpretation, and the Body

Abstract

Adorno sees experience as intrinsically interpretative. As interpretation requires normative constraints, in order to guide and channel this interpretative engagement, this opens the question of how experience acquires its motivating criteria. If experience is from the first criterially structured, how are these criteria acquired? Moreover, as these criteria are acquired in isolation from experience – as they are the precondition of that experience – are these criteria sensitive to the particularity of the experiences they produce? In order to address these questions, and the problems they threaten to create for Adorno’s epistemology, I look at Adorno’s theory of impulse and cognition. I argue that Adorno grounds the criterial structure of experience and reason in self-preservation. This provides both a motivation and a determining constraint on the criterial structure of experience. It is also a determining influence which is epistemically flexible and compatible with Adorno’s project of tracing the ‘non-identical’.     

The pessimistic origin of Nietzsche’s thought of eternal recurrence

ABSTRACT

In this article I argue that we should understand Nietzsche’s doctrine of eternal recurrence as the ideal of life affirmation opposed to philosophical pessimism, the view that life is not worth living. I first articulate Nietzsche’s psychological account of pessimism as a vengeful focus on the past and an aversion to time understood as transience. I then consider the question of why a person with the opposite psychological orientation – a creative relation to the future and an endorsement of time – would will the eternal recurrence of all things. My answer appeals to Nietzsche’s notions of will to power and the redemption of the past from its senselessness. The interpretation of eternal recurrence that emerges from this approach takes Nietzsche’s vision of a great, world-redeeming individual to be integral to his doctrine of eternal recurrence. This is just one way in which it differs from common interpretations of eternal recurrence as a cosmological theory or thought experiment.