Philosophy of Psychiatry and Psychopathology

Turkheimer and Greer’s article “Spit for Science and the Limits of Applied Psychiatric Genetics” (2024) offers a devastating critique of the state of psychiatric genetics, using Spit for Science (S4S) as a case study. I have read the paper many times in the process of writing this commentary, and each time I am left inarticulate. Nonetheless, I hope that my comments, from the point of view of a practitioner who operates at the intersection of clinical psychiatry, psychiatric science, and philosophy (...) of psychiatry, will be of some value to the discussion. I have no substantial disagreements with Turkheimer and Greer. The main point I wish to convey is that there is reason to hope that findings from genetic research... Read More. (shrink)

We are grateful for the opportunity to respond to such a varied and challenging set of commentaries. They range from highly supportive to quite disputatious; we will repay the supportive ones ironically, by discussing them only briefly. That will allow us to expand a bit on the more difficult comments, and of course the thoughtful reply from Dr. Dick.Knox, Allen, and Downes imagine a world in which effective polygenic scores for alcohol use exist and conclude that even then there would (...) be no way to use them ethically. We agree, for the most part, but there are several distinctions to consider. The first is among physical, medical, psychiatric, and normal-range behavioral phenotypes. Effective polygenic scores exist... Read More. (shrink)

Back in 2011, I wrote a paper for the Journal of Bioethical Inquiry, an Australian journal, for a special issue dedicated to ethical issues associated with psychiatric genetics research. The editor was particularly excited by the recent findings of the 5-HTT allele in psychiatric illness. I had different ideas about what I wanted to write about, and the editor, Michael Robertson, graciously considered them and ultimately published the paper. At the time I was interested in the colossal investment of National (...) Institutes of Mental Health (NIMH) research dollars in psychiatric genetic research; at the time I was troubled at the lack of on-the-ground clinical implications of this research investment, and figured an... Read More. (shrink)

Turkheimer and Greer (2024) (henceforth “T&G”) make some fair points about problems in the scientific profession, including the regrettable tendency to promise practical applications of research that then never materialize. However, T&G’s sustained critique of a body of work associated with one particular researcher to make these general points struck us as uncharitable. More pressingly, we feel that the far-reaching conclusions that T&G attempt to draw from the results they review from the Spit for Science (S4S) cohort are unjustified and (...) risk misleading readers that psychiatric and behavioral genetics is in a parlous state.T&G state that S4S “produced a clear answer to the question it was designed to address,”... Read More. (shrink)

Here we articulate a negative answer to Turkheimer and Greer’s question: “Is it possible to envision a genetically informed program that ethically intervenes on campus drinking?” (Turkheimer & Greer, 2024). However, first, we note that the authors cover an immense amount of ground in their paper. They lend insight into how psychiatric genetics, at its very core, is conducted through their detailed examination of a large body of work in one specific area of this large field. A main result of (...) this is to explain the gulf between results and conclusions, work that provides an invaluable service not just to various areas in philosophy and bioethics, but that are deserving of readership by a very wide audience. This gulf... Read More. (shrink)

The pstchologist Danielle Dick and psychiatrist Kenneth Kendler (DK) began an ongoing study in 2011 called Spit for Science (S4S) in which they obtained saliva as a peripheral source of DNA along with assessment of detailed self-report information on alcohol and other substance use, selected personality traits, and psychosocial history about the students entering a large university (Dick et al., 2014). They hoped to identify the genes underlying the heritability of alcohol use and related behaviors to inform students about their (...) individual risk, and thereby to promote increased self-awareness and health. The students were highly cooperative volunteers, and many peer-reviewed research papers have been published from... Read More. (shrink)

In their paper “Spit for Science and the Limits of Applied Psychiatric Genetics,” Turkheimer and Rodock Greer use results from the Spit for Science (S4S) project to argue that the idea of psychiatric genetics1 yielding actionable results is a folly. Although there is much about which Turkheimer and I agree (I took my first psychology class from him 30 years ago), we fundamentally disagree about the outlook of psychiatric genetics. His paper suggests that our differing conclusions arise from the authors (...) misunderstanding the nature of the S4S project and a difference in our views on the broader purpose of psychiatric genetics.It is the characterization of S4S as a “program of research” that is the foundation for the... Read More. (shrink)

The research program Spit For Science was launched at Virginia Commonwealth University (VCU) in 2011. Since then, more than 10,000 freshmen have been enrolled in the program, filling out extensive questionnaires about their drinking, general substance use, and related behaviors, and also contributing saliva for genotyping. The goals of the program, as initially stated by the investigators, were to find the genes underlying the heritability of alcohol use and related behaviors, and in addition to put genetic knowledge to work in (...) ways that might aid university administrators and mental health professionals in the prevention and treatment of substance abuse. We review every empirical paper involving genetic data that has emerged from the program, and reach a surprising conclusion: the study has never identified a single genetic effect of more than trivial magnitude. Although the quantitative results of the studies were reported transparently, the theoretical ramifications of the negligible results have never been acknowledged. To the contrary, most of the papers ignore the tiny effects, reaching optimistic conclusions about the prospects for future genetic explanations of alcohol use. We explore the implications of these results for the broader prospects of applied psychiatric genetics. (shrink)

Research in the philosophy of addiction commonly explores how agency is impacted in addiction by focusing on moments of apparent loss of control over addictive behavior and seeking to explain how such moments result from the effects of psychoactive substance use on cognition and volition. Recently, Glackin et al. (2021) have suggested that agency in addiction can be helpfully analyzed using the concept of affordances. They argue that addicted agents experience addiction-related affordances, such as action possibilities relating to drugs, drug (...) paraphernalia, and drug-related activities, as aberrantly salient motivations for action. Building on this approach, we present a novel two-tiered affordance model of addiction. In doing so, we suggest that what is significant about the addicted person’s world is not simply _what_ affordances are experienced as salient, but also the _way_ in which the addicted person’s world is shaped by a dominant concern. It is not only that addiction-related affordances become more prominent as addiction progresses but that one’s plurality of concerns become monopolized by and funneled through addiction. Our model endorses Glackin et al.’s idea that addiction-related affordances become aberrantly salient, while proposing why they become and remain so. This way of viewing agency in addiction also brings to light important implications for recovery and treatment. For, if an addicted person adopts a new, even “socially approved,” dominant concern, there is a risk that the _shape_ of addiction is preserved, even though the content changes, leaving an individual at the risk of addiction substitution or relapse. (shrink)

Eugen Bleuler introduced the concept of double bookkeeping in schizophrenia to describe the tendency for people who experience delusions to simultaneously be convinced of the delusional content and yet to act as if the delusion(s) was untrue/irrelevant or be unbothered by discrepancies. We open the question of whether there exists a double reality in individuals with addiction and whether double bookkeeping can be applied to addiction. While double bookkeeping has primarily been explored in schizophrenia, this concept may hold promise in (...) elucidating insight deficits in individuals with substance use disorders. We propose two forms of addiction double bookkeeping: 1) Partial compartmentalization: individuals demonstrate some awareness of the deleterious consequences of drug use, but continue to engage in addictive behaviors; and 2) Total compartmentalization: individuals who act as if the negative consequences of addiction do not exist, reflecting a more generalized and deeper lack of awareness into their own actions. We propose that a basic alteration in the individual’s sense of self occurs in addiction double bookkeeping as it does in schizophrenic double bookkeeping. We describe the proposed double reality in addiction from first-person and third-person perspectives, accounting for their differences. Three clinical exemplar cases are presented, and conceptual implications are explored. (shrink)

Comentário Crítico. Referência do artigo comentado: LOPES, Marcelo Vieira. Para além da dúvida corporal: a dúvida como problema existencial e sua relevância para a psiquiatria. Trans/form/ação: Revista de Filosofia da Unesp, Marília, v. 47, n. 6, e02400329, 2024.

Theorists commonly maintain that addiction involves compulsion or diminished self-control. Some enactivist theorists have conceptualized this disruption to autonomous agency in terms of embodied habits that become overly rigid, so that an agent enacts this pattern of behavior even in circumstances that call for the activation of a very different set of habits. What is more, because addiction crowds out other goals and priorities, agents may become more one-dimensional and begin to lose a hold on values and commitments that are (...) important to them. Rather than engaging in self-regulation to balance competing priorities and gain a better understanding of how different aspects of their identity relate to one another, agent’s lives become dominated by addictive behavior. I argue that enactivist notions of _habit_ and _self-equilibration_ can help to make sense of how the disruptions to autonomous agency characteristic of addiction are linked to diminished self-insight. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Spit for Science and the Progress and Promise of Psychiatric GeneticsDanielle M. Dick, PhD (bio)In their paper “Spit for Science and the Limits of Applied Psychiatric Genetics,” Turkheimer and Rodock Greer use results from the Spit for Science (S4S) project to argue that the idea of psychiatric genetics1 yielding actionable results is a folly. Although there is much about which Turkheimer and I agree (I took my first psychology (...) class from him 30 years ago), we fundamentally disagree about the outlook of psychiatric genetics. His paper suggests that our differing conclusions arise from the authors misunderstanding the nature of the S4S project and a difference in our views on the broader purpose of psychiatric genetics.It is the characterization of S4S as a “program of research” that is the foundation for the conclusions Turkheimer and Rodock Greer draw about the unlikely potential for meaningful results from psychiatric genetics. But S4S was never intended to be a program of research. The dataset was established as a registry, owned and administered by Virginia Commonwealth University (VCU), and intended as a resource for the field. Accordingly, what is presented as a series of studies that bounce from one topic to another (which the paper mischaracterizes as resulting from “desultory progress”), actually reflects the use of the dataset by many scientific teams, including trainees and early career investigators, to explore various questions. The fact that the project attracted researchers from a diversity of fields (>140 faculty/trainees from 28 departments across VCU and 16 external collaborators) to study the many factors that impact college behavioral and emotional health is, to my mind, one of the strengths of the project.Within my own program of research, S4S is just one of many datasets with which I work; the papers included in their review account for only 3% of my more than 450 papers. Accordingly, my outlook on psychiatric genetics is not based solely, or even largely, upon S4S. As of 2021, I am no longer involved with the project, having ceded its stewardship to another VCU faculty member. Like with the other genetically informative datasets we analyze, the individual papers from S4S reflect the state of the science at the time they were initiated (often years before the eventual publication date). This fact is evident in the evolution of methods applied to S4S and would be true of a review of papers from Collaborative Study on the Genetics of Alcoholism, Avon Longitudinal Study of Parents [End Page 425] and Children, The National Longitudinal Study of Adolescent to Adult Health, the UK Biobank, or any other dataset made available as a resource for the field. Turkheimer’s paper abstract states “the negligible results have never been acknowledged,” but in fact, many papers have been devoted to discussing small effect sizes in psychiatric genetics (Gordon, 2021).The success of S4S was never intended to be evaluated based on the number of genetic loci identified. Turkheimer wrote, “S4S was not designed to investigate whether individual level genetic data might be useful at the scale of a mid-sized institution including about 10,000 students… it assumed as much.” In fact, they were correct only in the first part of that statement; studying whether individual level genetic data might be useful in a college setting (although a question I find interesting) was never the point of S4S. Turkheimer refers to the findings (of tiny effect sizes, few robust genetic loci identified) as “unexpected” and “surprising”; in fact, we find the results to be neither, as anyone following the progression of the field of psychiatric genetics would agree. The university administrators with whom we worked to launch the study never expected us to deliver actionable individual-level genetic findings. To use that as the benchmark for evaluating the success of S4S, and then to extrapolate to the larger field of psychiatric genetics, misses the point.The ways in which the S4S project made a significant contribution to the field can be found in other metrics. I am most proud of how we used a community-engaged approach (Dick, 2017) and were intentional about the recruitment of underrepresented populations (Dick et al., 2014), which were uncommon in... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Setting the Scientific Bar for the Genetics of BehaviorEric Turkheimer, PhD (bio) and Sarah Rodock Greer, BA (bio)We are grateful for the opportunity to respond to such a varied and challenging set of commentaries. They range from highly supportive to quite disputatious; we will repay the supportive ones ironically, by discussing them only briefly. That will allow us to expand a bit on the more difficult comments, and of (...) course the thoughtful reply from Dr. Dick.Knox, Allen, and DownesKnox, Allen, and Downes imagine a world in which effective polygenic scores for alcohol use exist and conclude that even then there would be no way to use them ethically. We agree, for the most part, but there are several distinctions to consider. The first is among physical, medical, psychiatric, and normal-range behavioral phenotypes. Effective polygenic scores exist for height, and to a somewhat lesser extent for medical conditions like coronary heart disease. Whether or not it is a good idea to deploy them in embryo selection or clinical medicine, that is already happening.We do not think an R2 of 0.35 polygenic scores for complex behavioral phenotypes will ever exist, for all the reasons we outlined in the original paper. If we allow ourselves to imagine it happening, however, there are two explanatory pathways to follow. The first is the raw R2, and let’s stipulate that with more enormous samples or exome sequencing or whatever, respectable values are eventually achieved. The second involves the causal validity underlying black-box prediction. Scientists are taking the first step down that path (although not in Spit for Science [S4S], see the reply below to Lee and Morris) by investigating direct and indirect effects between and within families and examining the portability of polygenic scores (PGS) across environments and ancestries. The most convincing causal evidence would involve the kind of mechanistic causal biology about which enthusiasts like to speculate, but there is little sign of that.We will grant another possibility. Suppose there was a PGS for alcohol at an R2 of 0.35 that worked between families and within them, in [End Page 455] North America, South Asia, Central America, and West Africa. Animal models confirmed that it is related to specific metabolic pathways involved in alcohol. It was related but not identical to other successful PGS that predict cannabis use and other addictions. Ancient DNA studies find that it is high in human remains that were preserved next to the casks of wine that they apparently loved. Pharmacologists use it to develop effective medications for withdrawal. This hypothetical PGS, mechanistically opaque though it might remain, would exist in what Cronbach and Meehl (1955) called a nomological network. It would have construct validity, similar to a good self-report questionnaire. Like PGS for coronary heart disease, people would want to have access to construct valid PGS, and there would probably be no way to prevent people from obtaining them. We repeat that we do not expect this to happen, and as we discuss in the response to Dick below, hypothetical discussions of future scientific outcomes usually turn out to be unscientific wishcasting. It is like insisting that cities need to develop traffic control systems for flying cars.SadlerSadler is probably correct that the exigencies of grant funding explain much of what we have observed in S4S. It is certainly a more charitable explanation than the alternatives. It is interesting to consider that one of several revolutions that have occurred in the years since S4S was conceived is in the realm of scientific design and reporting. Preregistration of research hypotheses might have prevented many of the more dubious outcomes of S4S. Yet those ideas have never been applied to grant proposals, as far as we know. Grant reviews reward grandiose promises. No one has ever received funding for announcing that they hope to make incremental progress at the margins of a difficult and perhaps intractable problem. There is no mechanism to check on whether the big promises in proposals were ever fulfilled. What does get checked is whether and where investigators have published, often without regard to what the... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Post-Genomic RevolutionA Paradigm Shift for Biopsychosocial SystemsClaude Robert Cloninger, MD, PhD (bio)The pstchologist Danielle Dick and psychiatrist Kenneth Kendler (DK) began an ongoing study in 2011 called Spit for Science (S4S) in which they obtained saliva as a peripheral source of DNA along with assessment of detailed self-report information on alcohol and other substance use, selected personality traits, and psychosocial history about the students entering a large university (...) (Dick et al., 2014). They hoped to identify the genes underlying the heritability of alcohol use and related behaviors to inform students about their individual risk, and thereby to promote increased self-awareness and health. The students were highly cooperative volunteers, and many peer-reviewed research papers have been published from these data.Eric Turkheimer, a psychologist who studies how genes and environments shape the development of human behavior (Harden et al., 2007; Loehlin et al., 2009; Turkheimer et al., 2003), reviewed all the resulting publications coming from S4S along with coauthor Sarah Greer (Turkheimer & Greer, 2024). Turkheimer and Greer (TG) were surprised to find the study has failed to identify any genes that have substantial (“nontrivial”) effects on reported levels of consumption or problems related to their use of alcohol or other substances, except for a variant of the gene for aldehyde dehydrogenase (ALDH2), which was already known to cause many people of Asian descent to flush when they drink alcohol. TG state that, “Again and again, the results of S4S investigations demonstrated tiny, and frequently null, contributions of genetics to differences in drinking and related behaviors among college students. GWAS [genome-wide association studies] revealed practically no genome-wide significant SNPs [single nucleotide polymorphisms], and the SNPs identified at less stringent levels of significance were never mentioned more than once” (Turkheimer & Greer, 2024).TG concluded that the design, execution, psychometric measures, and analysis of the data were excellent. However, they also discuss facts that raise doubts about the adequacy of the design and methods. Namely, it is an inconvenient fact, [End Page 429] but widely known, that approaches to GWAS that are frequently used in psychiatric genetics require huge samples (often hundreds of thousands) to detect statistically significant genes because the observed effects have consistently been weak whenever genes are assumed to act independently, as did DK. Consequently, polygenic risk scores are weak and inconsistent predictors of behavioral phenotypes (Zwir et al., 2020c). Nevertheless, TG fault DK and their coauthors for an overemphasis on statistical significance in large samples rather than prominently reporting that the observed effect sizes of genes were only weakly and inconsistently associated with any measured features of substance use.TG report that they were surprised by the weak and inconsistent findings from genetic variants from this GWAS because they knew that twin and family studies (i.e., what they call “genetics at altitude”) have previously found strong and consistent evidence of the heritability of phenotypes like those measured by DK. For example, in my own research with adoptees separated from their biological parents at an early age and reared by adoptive parents, the risk of alcohol abuse in adoptees was strongly predicted by alcohol abuse and related behaviors in their biological, but not adoptive, parents (Bohman et al., 1981; Cloninger et al., 1981; Sigvardsson et al., 1996) and by their childhood personality, particularly novelty seeking, when the children were followed into young adulthood (Cloninger, 1987; Cloninger et al., 1988). However, it is well-known that the methods used by DK for GWAS consistently fail to detect most of the heritable variance for behavioral phenotypes estimated in twin studies, which include much variability from complex patterns of gene–gene interaction (Table 1) (Cloninger & Zwir, 2022). This consistent observation in GWAS studies that assume genes act independently is called the missing or hidden heritability problem.Nevertheless, DK expressed optimism in 2011 that genome-wide measurement of genetic variants would identify genetic markers to predict risk of alcohol-related phenotypes in college students. They do so because they assume that all the information about heritable processes can be extracted from genome-wise scans of SNPS. The heritable phenotypes of interest in S4S included patterns of use of alcohol and other recreational... (shrink)

Eugen Bleuler introduced the concept of double bookkeeping in schizophrenia to describe the tendency for people who experience delusions to simultaneously be convinced of the delusional content and yet to act as if the delusion(s) was untrue/irrelevant or be unbothered by discrepancies. We open the question of whether there exists a double reality in individuals with addiction and whether double bookkeeping can be applied to addiction. While double bookkeeping has primarily been explored in schizophrenia, this concept may hold promise in (...) elucidating insight deficits in individuals with substance use disorders. We propose two forms of addiction double bookkeeping: 1) Partial compartmentalization: individuals demonstrate some awareness of the deleterious consequences of drug use, but continue to engage in addictive behaviors; and 2) Total compartmentalization: individuals who act as if the negative consequences of addiction do not exist, reflecting a more generalized and deeper lack of awareness into their own actions. We propose that a basic alteration in the individual’s sense of self occurs in addiction double bookkeeping as it does in schizophrenic double bookkeeping. We describe the proposed double reality in addiction from first-person and third-person perspectives, accounting for their differences. Three clinical exemplar cases are presented, and conceptual implications are explored. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Dialectical Tension Between Gloomy and Rosy Prospects of Behavioral GeneticsAwais Aftab, MD (bio)Turkheimer and Greer’s article “Spit for Science and the Limits of Applied Psychiatric Genetics” (2024) offers a devastating critique of the state of psychiatric genetics, using Spit for Science (S4S) as a case study. I have read the paper many times in the process of writing this commentary, and each time I am left inarticulate. Nonetheless, I (...) hope that my comments, from the point of view of a practitioner who operates at the intersection of clinical psychiatry, psychiatric science, and philosophy of psychiatry, will be of some value to the discussion. I have no substantial disagreements with Turkheimer and Greer. The main point I wish to convey is that there is reason to hope that findings from genetic research will contribute to clinical progress in psychiatry in an incremental and iterative manner, but because psychiatric genetics has overpromised and underdelivered, we find ourselves vacillating between bullish and bearish moods.Some critics may say that the choice to selectively focus on S4S is unfair, or that it gives a misleading impression of the current state of psychiatric genetics. The launch and implementation of S4S captures a particular moment in the history of psychiatric genetics when it was known that individual associations will be small and that large samples will be needed for significant associations, but it was not appreciated exactly how small and how large respectively. Initial estimates of sample sizes needed for successful genetic associations turned out to be wildly inadequate. Progress occurred only with unprecedented international collaboration and extremely large sample sizes. For example, a 2022 genome-wide association study (GWAS) of schizophrenia included more than 76,000 people with schizophrenia and 240,000 controls (Trubetskoy et al., 2022)! S4S is one project from one institution. It is understandable in retrospect that a sample of 10,000 freshmen could only have delivered so much. It may be argued that whatever the promise of psychiatric genetics as a field, it is not constrained by the success or failure of S4S.On the one hand, it is true that S4S did not have the requisite sample size. On the other hand, the contemporary understanding of the genetics of alcohol use has not improved on insights from S4S by that much (Deak et al., 2019). SNP-based heritability estimate of problematic alcohol use [End Page 451] is close to 10% based on a GWAS of 435,000 individuals (Zhou et al., 2020), consistent with statistically non-significant estimates from S4S. The same GWAS has identified 29 risk variants, and genetic correlations with more than a hundred other phenotypes. Transcriptomic analysis has revealed that implicated genes are expressed in the brain but also in gastrointestinal, adipose, and liver tissue, pointing toward pathways of protection and vulnerability. A polygenic risk score (PRS) derived from associated variants is consistently and significantly associated with alcohol dependence, with variance explained ranging from 0.77% to 2.12% in different samples (Zhou et al., 2020).At present, PRS for problematic alcohol use has little predictive value at the individual level and is practically worthless from the standpoint of clinical practice. There are hints that genetic associations can point toward brain mechanisms involved in alcohol use disorder, but we have little to show for it yet. That PRS will achieve clinical utility is not guaranteed but neither is it impossible. A PRS for externalizing behavior explains approximately 10% of the variance, which is on par with factors such as socioeconomic status and neighborhood disadvantage (Karlsson Linnér et al., 2021). And even if PRS does not become a common part of clinical practice, it can still be a useful tool in clinical research. With regard to understanding mechanisms, the trivial effect size of the genetic association is by itself irrelevant. This point is made eloquently by Steven HymanWhen used as a tool to associate a trait with biology, the effect size of the allele on the ultimate phenotype does not matter… what makes a gene product a good drug target is not the effect size of the associated allele, but its overall role in biology… Once a pathway is shown to... (shrink)

Research in the philosophy of addiction commonly explores how agency is impacted in addiction by focusing on moments of apparent loss of control over addictive behavior and seeking to explain how such moments result from the effects of psychoactive substance use on cognition and volition. Recently, Glackin et al. (2021) have suggested that agency in addiction can be helpfully analyzed using the concept of affordances. They argue that addicted agents experience addiction-related affordances, such as action possibilities relating to drugs, drug (...) paraphernalia, and drug-related activities, as aberrantly salient motivations for action. Building on this approach, we present a novel two-tiered affordance model of addiction. In doing so, we suggest that what is significant about the addicted person’s world is not simply what affordances are experienced as salient, but also the way in which the addicted person’s world is shaped by a dominant concern. It is not only that addiction-related affordances become more prominent as addiction progresses but that one’s plurality of concerns become monopolized by and funneled through addiction. Our model endorses Glackin et al.’s idea that addiction-related affordances become aberrantly salient, while proposing why they become and remain so. This way of viewing agency in addiction also brings to light important implications for recovery and treatment. For, if an addicted person adopts a new, even “socially approved,” dominant concern, there is a risk that the shape of addiction is preserved, even though the content changes, leaving an individual at the risk of addiction substitution or relapse. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Uselessness of Polygenic Scores for Addressing Campus DrinkingBennett Knox (bio), Hannah Allen (bio), and Stephen M. Downes, PhD (bio)Here we articulate a negative answer to Turkheimer and Greer’s question: “Is it possible to envision a genetically informed program that ethically intervenes on campus drinking?” (Turkheimer & Greer, 2024). However, first, we note that the authors cover an immense amount of ground in their paper. They lend insight into (...) how psychiatric genetics, at its very core, is conducted through their detailed examination of a large body of work in one specific area of this large field. A main result of this is to explain the gulf between results and conclusions, work that provides an invaluable service not just to various areas in philosophy and bioethics, but that are deserving of readership by a very wide audience. This gulf is explained via a careful accounting of the statistical measures used to assess the impact of genes on alcohol-related behavior in the college students sampled and comparisons between the strength of these measures and the strength and scope of conclusions drawn by the Spit for Science (S4S) researchers.A brief mention of the statistical measures in question helps set up our main focus. As Turkheimer and Greer note, before advances in sequencing technology, human behavior geneticists generated heritability coefficients for traits of interest. These coefficients were standardly produced from twin study work, which historically was the best way of getting a sense of the relative contribution of genes to a trait of interest as we cannot, or rather should not, conduct breeding experiments on humans. Current descendants of heritability coefficients come from genome-wide association studies (GWAS), which can be conducted on large groups of unrelated people. One key measure of interest arising from GWAS is a polygenic score (PGS), which “can be thought of as an observed manifestation at the individual level of the abstract variance ratio estimated by a heritability” (Turkheimer & Greer, 2024). Turkheimer and Greer focus on R2 values, which roughly “describe the magnitude of the relationship between the polygenic score and the phenotypes [of interest]” [End Page 437] (Turkheimer & Greer, 2024). They point out that the largest R2 reported in an S4S study is 6.5% (0.065). R2 are taken to be small at 0.01, medium at 0.09, and large at 0.25 in many areas of social science research but there are fields, for example, drug assay work, where only much higher R2 values are considered indication of a large effect. By this assessment, most of the R2 values reported by the S4S researchers, or calculated by Turkheimer and Greer when not reported, are very, very small, sitting well below the level of small effect of 0.01.Given these very low R2 measures, we agree with Turkheimer and Greer that S4S researchers did not uncover genetic information that could be informative, let alone actionable, for administrators concerned with campus drinking. However, it is worth asking what it would have looked like if S4S had produced such information. Suppose that S4S had been wildly successful, producing the Gattaca-like genetic information of “polygenic scores making reliable predictions that individuals had a 35% chance of developing a psychiatric disorder [here, alcoholism]” (Turkheimer & Greer, 2024). If a student was given their PGS, how are they to interpret it and act on it? How would this information be put to use by an administrator to address the problem of campus drinking?For the information to be leveraged at all, it would require consent from a significant number of students to have their PGS calculated and made available to themselves or administrators. Were scores to be calculated without active consent from the student (perhaps by using the sample provided to S4S), this would be a serious ethical violation. But even if a sufficient number of students did consent to having their PGS for alcoholism calculated, it is still not clear how this information could be used in an ethical manner to address the problem of campus drinking.If this student was already aware of a family history of alcoholism, then the PGS might do little more than quantify... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Crushing Pressures and Radical IdeasJohn Z. Sadler, MD (bio)Back in 2011, I wrote a paper for the Journal of Bioethical Inquiry, an Australian journal, for a special issue dedicated to ethical issues associated with psychiatric genetics research. The editor was particularly excited by the recent findings of the 5-HTT allele in psychiatric illness. I had different ideas about what I wanted to write about, and the editor, Michael Robertson, (...) graciously considered them and ultimately published the paper. At the time I was interested in the colossal investment of National Institutes of Mental Health (NIMH) research dollars in psychiatric genetic research; at the time I was troubled at the lack of on-the-ground clinical implications of this research investment, and figured an Australian journal and referees would be more generous to a critical paper on U.S. funding priorities. I dug into the National Institutes of Health (NIH), NIMH, and National Science Foundation websites and found some crude dollar evidence of respective expenditures for research funding in various disorders and focus areas, and compared these investments to psychiatric genetic research funding commitments. I will not go into details (Sadler, 2011), but the gist was that the psychiatric genetics research enterprise was and had been an extraordinarily expensive enterprise, when other research questions that could be immediately implementable into clinical care improvements remained marginally funded at best. The paper was not read widely and other than a couple of annoyed responses from psychiatric genetic researchers, not much came of it.This concern about funding priorities was one of the reasons why I was pleased to see this paper by Turkheimer and Greer which explores the long term results of the Spit for Science (S4S) initiative, which was launched grandly the same year as my paper’s whisper from down under. I hope this Philosophical Case Conference explores the many dimensions of interest for this paper, which is extraordinarily careful and even handed in its attitude, while at the same time being incisive in its analysis.My focus here is not in the science per se, which is beyond my competence. I’m interested in Turkheimer and Greer’s (T&G) conceptual overview of this research program. More specifically, I focus on T&G’s highlighting of the extraordinary willingness of the S4S authors to interpret prevailingly negative results in the most generous, even misleading, degree possible. I try to provide some possible ways of understanding this kind of research rhetoric exhibited by a cohort of highly respected, very successful scientists.I acknowledge the well-described varieties of interpretive bias that all of us are subject to. First on the list must be confirmation bias, our tendency to interpret situations in terms consistent [End Page 447] with our preconceived notions—in this case, the idea that genetics has something important to do with addictive disorders. Another might be epistemic overconfidence—the tendency to fail at interpretive skepticism in favor of one’s preferred conclusion. Related to this may also be interpretive momentum, the tendency to maintain a conviction about the correctness of one’s expectations and disregard inconsistent findings over the course of a research program—in this case, the multiple S4S studies (O’Sullivan & Schofeld, 2018). However, these kinds of biases tend to “blame” the individual authors’ thinking styles. I opine, though, that other vectors shaping the declaring-success rhetoric are more important.These sources have to do with the state of practice in doing biomedical science research in universities and particularly academic medical centers (AMCs) today. I identify several causal vectors that compel, however subtly, researchers to declare success in the face of failure. I have only picked three, and in no order of importance: 1) funding caps for NIH grants, 2) the overleveraging of university budgets and ballooning dependence on soft money, and 3) the incentivizing of intellectual property development within AMCs.Funding Caps for NIH GrantsIf you are a university or AMC, one way you hold onto your most productive scientists (e.g., grants, publications, discoveries, and status) is by paying them well. Single NIH grants today commonly amount to millions of dollars, and often tens of millions. These bring... (shrink)

Theorists commonly maintain that addiction involves compulsion or diminished self-control. Some enactivist theorists have conceptualized this disruption to autonomous agency in terms of embodied habits that become overly rigid, so that an agent enacts this pattern of behavior even in circumstances that call for the activation of a very different set of habits. What is more, because addiction crowds out other goals and priorities, agents may become more one-dimensional and begin to lose a hold on values and commitments that are (...) important to them. Rather than engaging in self-regulation to balance competing priorities and gain a better understanding of how different aspects of their identity relate to one another, agent’s lives become dominated by addictive behavior. I argue that enactivist notions of habit and self-equilibration can help to make sense of how the disruptions to autonomous agency characteristic of addiction are linked to diminished self-insight. (shrink)

The research program Spit For Science was launched at Virginia Commonwealth University (VCU) in 2011. Since then, more than 10,000 freshmen have been enrolled in the program, filling out extensive questionnaires about their drinking, general substance use, and related behaviors, and also contributing saliva for genotyping. The goals of the program, as initially stated by the investigators, were to find the genes underlying the heritability of alcohol use and related behaviors, and in addition to put genetic knowledge to work in (...) ways that might aid university administrators and mental health professionals in the prevention and treatment of substance abuse. We review every empirical paper involving genetic data that has emerged from the program, and reach a surprising conclusion: the study has never identified a single genetic effect of more than trivial magnitude. Although the quantitative results of the studies were reported transparently, the theoretical ramifications of the negligible results have never been acknowledged. To the contrary, most of the papers ignore the tiny effects, reaching optimistic conclusions about the prospects for future genetic explanations of alcohol use. We explore the implications of these results for the broader prospects of applied psychiatric genetics. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Peculiarly Favored Condition of GeneticsJames J. Lee, PhD (bio) and Damien Morris, MSc (bio)Turkheimer and Greer (2024) (henceforth “T&G”) make some fair points about problems in the scientific profession, including the regrettable tendency to promise practical applications of research that then never materialize. However, T&G’s sustained critique of a body of work associated with one particular researcher to make these general points struck us as uncharitable. More pressingly, (...) we feel that the far-reaching conclusions that T&G attempt to draw from the results they review from the Spit for Science (S4S) cohort are unjustified and risk misleading readers that psychiatric and behavioral genetics is in a parlous state.T&G state that S4S “produced a clear answer to the question it was designed to address,” namely, that its results “unambiguously contradict the hypothesis that alcohol-related behaviors have a meaningful genetic basis.” But S4S cannot possibly have provided affirmative evidence for the null hypothesis, because as a single cohort it lacked the statistical power to do so. Elsewhere T&G acknowledge that the sample size of S4S does not suffice for many purposes; they cannot have it both ways. When GCTA has been applied to samples of greater size, it has unambiguously supported the hypothesis that alcohol-related behaviors have a meaningful genetic basis. The UK Biobank yielded estimates exceeding 0.10 for the contribution of single nucleotide polymorphisms (SNPs) with minor allele frequency of greater than 0.05 to the heritability of drinks per week, estimates more than ten times their standard errors (Liu et al., 2019).This heritability contributed by common variants is sometimes called “SNP heritability,” and T&G disparage it for the alleged “disadvantage of being substantially smaller” than “twin and family heritabilities.” Nowhere do T&G consider what the precise numbers actually mean—an approach that can be hazardous to your scientific health, as the late John Loehlin might have said. Let us, then, consider these numbers. Under a model of pure neutrality, SNP and pedigree narrow-sense heritabilities should be fairly close, essentially as a result of factors p(1 − p) canceling in the multiplication of the numbers of SNPs to be found at a given allele frequency by the average heritability contributed per SNP (Hill, 2010). If SNP and pedigree heritabilities are not close, then natural selection must have been acting on [End Page 441] the trait, preventing new mutations of large effect from becoming common and thereby concentrating heritability at allele frequencies lower than those typically studied in genome-wide association studies (GWAS). This deduction has been abundantly confirmed: the tendency of GWAS SNPs to reside in evolutionarily conserved regions (Finucane et al., 2015; Kim et al., 2019), the younger age of GWAS SNPs when compared to control SNPs of comparable frequencies (Gazal et al., 2017), the discovery of several rare variants with larger effects than those observed in typical GWAS (Barton et al., 2021; Chen et al., 2023; Marouli et al., 2017), the directly measured deleterious fitness effects of mutations in evolutionarily constrained genes (Gardner et al., 2022), and the substantial additional genetic variance accumulated when rare variants are included in GCTA-type studies, sometimes enough to close the gap between SNP and pedigree heritabilities (Evans et al., 2018; Jang et al., 2022; Pathan et al., 2024; Wainschtein et al., 2022).The genetic architecture of a typical quantitative trait consists of many sites across the genome that can mutate to affect it, numbering potentially in the millions (Agarwala et al., 2013; Zeng et al., 2021), of which those that are common SNPs have very small effects as a result of selection. This is the message, but T&G seem to find fault with the messenger, painting “tiny” effect sizes as an embarrassment to the field of behavioral genetics as a whole. We prefer to view the finding of high polygenicity as a revelation about nature, rather than as a debating point. What is this finding telling us? If one takes the action of stabilizing selection as the initial assumption (Uyeda et al., 2011), then the extreme polygenicity revealed by GWAS becomes part of the answer to the question regarding how traits can... (shrink)

This paper examines the relations between stubbornness and weakness of will, adopting Holton’s definition of weakness of will as an over-readiness to revise one’s resolutions. It posits that both stubbornness and weakness of will are responses to pessimism – the negative perception of a task or its outcome. Contrary to naive judgement, stubbornness is not merely the opposite of weakness; rather, it serves as a preventive behaviour stemming from a fear of weakness of will. Weakness of will and stubbornness can (...) be viewed as two facets of the same phenomenon, both influenced by pessimism. The paper explores the implications of this unified account, particularly at the therapeutic level, suggesting that enhancing self and other trust could reduce both weak and stubborn behaviours. (shrink)

There are a number of conflicting accounts of thought insertion, the delusion that the thoughts of another are inserted into one’s own mind. These accounts share the common assumption of _realism_: that the subject of thought insertion has a thought corresponding to the description of her thought insertion episode. I challenge the assumption by arguing for an anti-realist treatment of first-person reports of thought insertion. I then offer an alternative account, _simulationism_, according to which sufferers merely simulate having a thought (...) inserted into their heads. By rejecting realism, the paper undermines a widespread explanatory framework that unites otherwise competing cognitive models of thought insertion. (shrink)

In addressing the question of what mental health is we might proceed as if there is a single phenomenon – mental health – denoted by a single overarching concept. The task, then, is to provide an informative analysis of this concept which applies to all and only instances of mental health, and which illuminates what it is to be mentally healthy. In contrast, mental health pluralism is the idea that there are multiple mental health phenomena denoted by multiple concepts of (...) mental health. Analysis and illumination of mental health may still be possible, but there isn’t a single phenomenon or concept to be analysed in addressing the question of what mental health is. The question of pluralism has been overlooked in the philosophy of mental health. The discussion to follow is an attempt to get us to take mental health pluralism seriously. To that end, in this essay I have three primary goals: (1) to give a precise account of what mental health pluralism is, (2) to show that the question of pluralism should not be neglected in debate about what mental health is, and (3) to argue for mental health pluralism. I also draw out some implications of this discussion for philosophy, science, and psychotherapy. (shrink)

This paper advances a theory of disease as domino dysfunction. It is often argued that diseases are biological dysfunctions. However, a theory of disease as biological dysfunction is complicated by some plausible cases of dysfunction, which seem clearly non-pathological. I argue that pathological conditions are not just dysfunctions but domino dysfunctions, and that domino dysfunctions can be distinguished on principled biological grounds from non-pathological dysfunctions. I then show how this theory can make sense of the problem cases; they are not (...) diseases because they are not domino dysfunctions. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Social Psychiatry Inside-OUTGiulio Ongaro, PhDA heartfelt thanks to all commentators on this trio of papers. The idea that animates these papers is that placing modern psychiatry in a comparative perspective lays bare its weaknesses, for it shows that some of the problems that dominate our contemporary discussions in journals such as Philosophy, Psychiatry & Psychology (e.g., the problem of diagnostic validity, the demarcation challenge, stigma on mental illness), do (...) not actually exist elsewhere, at least not to the same degree or in the same form. I believe this should raise the question of why certain healthcare systems manage so differently and what, if anything, might modern psychiatry learn from them. My proposed answer is externalism: the development of a set of conditions that allow people to place the causes and treatment of psychiatric illness out of the psyche and into the social world. The contributors offer important insights and critiques regarding these conditions.Derek Bolton’s (2024) commentary is a good place to start since his focus on the biopsychosocial (BPS) model is also the starting point of the tryptic. I began with it because, I felt, previous attempts at externalism (I am thinking here of the cluster of approaches often referred to as ‘anti-psychiatry’) were skewed precisely by the absence of a model of BPS interaction. This has led to a lot of binary thinking between biological and social explanations of illness (Aftab, 2020) that fly in the face of the “interacting causal pathways, including feedback and feedforward mechanisms, within and between [bio, psycho and social systems]” (Bolton, 2024, p. 321), which frameworks such as enactivism and predictive processing bring to light. So, when Bolton says that there need to be no deep cuts in the BPS model, I agree entirely. The vignette he presents from Morocco shows that, when the will to recover trumps any ideological commitment, people act pragmatically, and tend to flexibly move across different kinds of therapeutic resources in a way that is compatible with our picture of BPS integration.Nothing in all this is at variance with what I describe in Ongaro (2024b). As I note, pragmatism and pluralism are the norm among the Akha as well. Akha shamans might encourage sick people to visit the hospital if they feel there are no more spiritual causes to address. I should have mentioned that the relatives of the young man with psychotic symptoms that I discussed on p. 13 (Ongaro, 2024b) even asked me if I have medicine ‘for his brain,’ much like Bolton’s Moroccan acquaintances did to him.But although I agree we should posit no deep cuts in the use of therapeutic resources, there are [End Page 341] clear cuts between the types of resources people can flexibly avail of. The therapeutic effects of cognitive-behavioral therapy—psychological, internalizing—are different in kind from those of finding meaningful work or housing security—social, externalizing. In Ongaro (2024b), I argue that Akha rituals are more similar to the latter than to the former, and that Akha society is structured in such a way that social affordances can be easily mobilized. There is a resourceful externalist framework in place. When viewing modern psychiatry from a broad anthropological perspective, it is the absence of anything like this externalist system that stands out, at the detriment of therapeutic efficacy. If anything, Bolton’s incisive point that even our ‘social determinants of health’ tend to be psychologized underscores this contrast.In the end, I resist the dichotomy Bolton draws between ‘small’ and ‘homogeneous’ societies and ‘large,’ ‘diverse,’ and ‘complex’ societies, along with the implicit suggestion that one cannot speak to the other. The Akha carve their own community within a rather complex and ethnically diverse environment in the Lao highlands. In turn, Akha shamans carve their own within Akha society. Conversely, I discussed in Ongaro (2024c) examples of therapeutic movements that achieve ‘collective effervescence’ in modern ‘complex’ contexts. Evidence of superior recovery rates in spiritually treated psychosis comes from megaci-ties like Chennai. The challenge of developing an externalist framework for psychiatry is, therefore, cultural and political. A tall order, no doubt, but there is nothing about ‘modernity,’ ‘scale,’ or ‘complexity’ that inherently... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Toward a Fictionalist Psychiatry?Sam Wilkinson, PhD (bio)I am deeply sympathetic to what Giulio Ongaro (2024a, 2024b, 2024c) writes in these three excellent interlocking papers. I will argue that there is a slightly more efficient way of approaching these issues. It involves adopting fictionalism rather than externalism (although fictionalism can accommodate externalist insights). Fictionalism is something that Ongaro briefly, and approvingly, mentions, in the final paper, but there is an (...) implicit realism in the initial approach. I am not sure there is much disagreement, however, and perhaps we end up in the same place, having approached from different starting points. The fictionalist approach is largely compatible with all of the substantive things Ongaro wants to say, but is, strictly speaking, in tension with the most natural interpretation of externalism, namely, construed as a form of descriptivism and realism (two notions I unpack later).Externalism, Evaluativism, and Social IntegrationA major theme of the first paper is that mainstream internalist Western psychiatry is bad at integrating the social dimension of mental illness. I agree. Furthermore, recent externalistic (enactive and predictive processing) approaches, while better, are still lacking in that they collapse the “social” into the “psychosocial.” Again, I agree. But my diagnosis (excuse the pun) is slightly different. The social dimension of illness concerns in large part the evaluative nature of illness, not the need to descriptively, causally capture a complex, objectively real phenomenon called “illness.”Having said this, in integrating this evaluative social dimension, we need to tread carefully lest we fail to meet the “demarcation challenge” (Murphy, 2008). This concerns the challenge of demarcating different kinds of problem. Humans have always had problems, for which they have needed help, accommodation, allowances made, and so on, but how do you distinguish mental health problems, from other kinds of problems? How do you distinguish money woes, or marital strife, both of which certainly cause unhappiness, or even psychological states that look like psychiatric symptoms (e.g., anxiety, low mood), from properly mental health problems?The biomedical “internalist” says: Easy! Either there is something objectively wrong with you, or there is not. However, notice that this is exactly [End Page 337] what externalists can say too, to the extent that they are trying to describe and define disorder in value-free terms. The only difference is that the internalist will talk about what is wrong within the biological boundaries of the organism, whereas the externalist will go beyond that.Externalism about a particular phenomenon, if it is to be a non-trivial position, needs to be sensitive to the distinction between cause and constitution (or what Adams & Azaiwa [2001] call “coupling-constitution confusion”). We see this in externalism about the mind in general. In the Extended Mind Hypothesis (Clark & Chalmers 1998), the claim is not that Otto’s notebook causally contributes to Otto’s mind (his belief about where MOMA is). Nobody would deny that. The interesting claim is that the notebook is constitutive of his belief: it is literally part of his mind. Similarly, nobody is denying that external (e.g., social) factors cause mental health problems, the question is: Do they constitute those problems? Externalism takes this question seriously and answers in the affirmative, at least in some cases. But the articulation of this has to be nuanced.Suppose I have crippling anxiety over financial concerns. Anxiety can be a mental health problem, but if, in this case, you transferring money into my bank account makes my anxiety disappear, then one might think this is not a mental health problem. It is a money problem. Or is it? Enter fictionalism (Wilkinson, 2022).Fictionalism is the view that calling someone mentally ill is not describing them as having a particular property, but involves something like engaging in a fiction, a fiction that has been constructed in order to encourage certain courses of action. According to fictionalism, given the facts, there is a lot of wiggle room about how we are to think of, and respond to, people’s problems.To borrow some insights from meta-ethics, when we examine normative discourse (one canonical domain being ethics) we can ask: what does the discourse do? And what... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Psychiatric Practice and the Living Force of the Social in the BiopsychosocialGeorge Ikkos, BSc, FRCPsych (bio) and Giovanni Stanghellini, MD, DPhil (HC) (bio)One of the handful of universally acknowledged founders of his discipline, sociologist Emile Durkheim (1857–1917; see Fournier, 2013) is best known to psychiatrists for his seminal “Suicide: A Study in Sociology” (1897/2002). Arguably, he should have been at least as well known for his last completed work (...) “The Elementary Forms of Religious Life” (1912/1995), the best book of sociology ever written according to some (Bellah, 1995). In this magisterial work, through a comprehensive survey of the anthropological evidence available at the time and fine conceptual analysis, Durkheim came to define from a strictly secular perspective phenomena such as the sacred and the profane, soul and magic, but also “mana” (a penetrating and connecting force) and collective “effervescence” (wild gesticulating, copulating, or aggressing when aboriginal family groups came together). The last two concepts can help us to understand the origin and persistence of the living force of the social in our daily experience, that is, what it is, what it feels like and how it plays itself out in relationships (Ikkos & McQueen, 2019). Although he makes no reference to Durkheim, nor to mana nor effervescence, social anthropologist Ongaro’s welcome ambition is to lift the social out of the shadow of the dominating bio- and psychological in the use of the biopsychosocial model and, thus, bring it to bear as an immediately experienced and enacted living force akin to mana and effervescence in contemporary psychiatric practice.In this commentary, we first review issues relating to the biopsychosocial model, Ongaro’s externalist foundations, and predictive processing and functional neurological, somatic and mental symptoms. We then discuss our formulation of contemporary anorexia nervosa and hysteria as examples of our attempts at enhanced engagement with the social. We conclude by suggesting the work of social historian and cultural critic Walter Benjamin (1892–1940) as a vital resource for better engagement with the social in biopsychosocial practice in the future. [End Page 325]The Biopsychosocial ModelMany find that in current practice the biopsycho-social model is simply the biomedical cloaked in another name (Mohtashemi et al., 2016). Those most expert in it acknowledge doubts about what it is exactly (Bolton, 2022). Most would agree with Ongaro and Williamson that though not yet dead, if it is to survive as a clinical force in practice, it needs clarification and revival (Williamson, 2022). Bolton suggests that “we can make use of the term ‘biopsychosocial model’ as a shorthand for methodological assumptions that causes and/or cures of specific conditions at specific stages, including matters of adjustment and quality of life, will generally—across a wide range of conditions—include biological, psychological and social factors, and interactions between them. The contrast here is with the ‘biomedical model’, which deals with biological factors only” (Bolton, 2022). Bolton then discusses the utility and advantages of his definition of the model specifically in relation to research on the social determinants of disease and on pain. That is fine, as far as it goes, that is, research methodology and clinical theory. Ongaro, however, wants to ensure that the social is understood as a more immediately experienced and directly enacted force in clinical encounters. To achieve his aim, he argues, we need a more balanced and persuasive integration of all three components of the model: bio-psycho-social. In effect what he proposes is to vitalize psychiatry with something related to Durkheim’s ideas of mana and effervescence.Externalist FoundationsIn his first paper, Ongaro argues that he can partly achieve his aims by using the tools provided by our contemporary neuroscience research on “predictive processing” and philosophical theories of “enactivism” (Ongaro, 2024a). In his second paper he reports on his anthropological experience of living for 19 months with the Akha, a group of swidden farmers in highland Laos. Here he investigated how they respond to functional neurological disorders (FNDs), functional somatic symptoms (FSS) (Burton et al., 2020), also to what Western medicine defines as (functional) mental disorders (FMDs) and what the Akha and he sometimes conceive as spiritual... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Externalist Psychiatry, Mindshaping, and Embodied InjusticeMichelle Maiese, PhD (bio)Ongaro maintains that although enactivist approaches to psychiatry help to account for the integration of biological, psychological, and social factors, they gloss over an important distinction between patient-centered (bio and psycho) approaches and externalist (social) approaches to mental illness. The central problem is that they lack the means to account for the social causes of illness and do not specify how (...) social determinants can be addressed in the clinic. Since much of an organism’s interaction with the external world is social in kind, the implementation of externalist psychiatry could make the enactivist model truly biopsychosocial and usher in novel forms of treatment.According to Ongaro, this externalist orientation gives rise to an important question about ontology: what are the social causes of psychiatric illness made of, and how can these be conveyed in the clinic to facilitate treatment? A “shared social etiology” would allow for a “rich explanatory framework” that accounts for the social causes of mental disorder. For example, by pointing to spirit affliction as the social cause of mental illness, the Akha transform amorphous pains (which are difficult to capture naturalistically) into meaningful and familiar experiences. Such an approach involves combining a realist understanding of biopsychosocial integration with an anti-realist, social constructivist outlook on social etiology. For them, an illness that is explained as a rupture of a human-spirit relationship is experienced as a ‘problem in living’ that affects the person in an immediate and meaningful way, and can be treated via ritual action.Ongaro then considers social causation in a more familiar context, one where social determinants of mental illness include factors such as employment. Losing one’s job is a significant life event because it signals a change in social status and prompts feelings of uselessness. Ongaro characterizes these feelings of low subjective status as “socially constructed experiences that depend on collectively ingrained ideas about status, value, and self-realization that a person accepts—one could say ‘believes in’—by virtue of living in a particular society.” Because social worlds differ and what counts as social defeat is culturally specific, [End Page 333] social determinants of illness such as unemployment are either negligible or non-applicable in Ahka (non-capitalist) society.To acknowledge the impact of these social constructions, Ongaro maintains, clinical psychiatry should abandon its commitment to naturalism and embrace methodological constructivism instead. Methodological naturalism treats social causes as ‘real’ and holds that the social causes of disorder should be investigated using the scientific method; research focuses on social determinants, social stressors, and social capital. However, despite acknowledging that declining mental health correlates significantly with political and economic factors, Ongaro maintains that methodological naturalism when it comes to social causes will be insufficient to bring about meaningful changes in clinical practice. For one thing, individual psychiatrists lack the political power and economic resources to bring about the sorts of societal changes that are needed to address social determinants of health. Second, social determinants are probabilistic factors rather than definitive causes of mental disorder; psychiatric illnesses often do not have a well-defined cause or a clear-cut social trigger. Third, an explanation that points to ‘lack of social capital’ does “not possess the immediacy, emotional charge, and embodied meaning that could make them therapeutically effective in the same way that Akha explanations for spirit afflictions are.”Philosophically, Ongaro’s embrace of ‘methodological constructivism’ when it comes to social etiology entails a commitment to antirealism about social causation and fictionalism more specifically. Wilkinson (2022) notes that the core tenet of psychiatric fictionalism is that “when we engage in psychiatric discourse... we are not attributing a robust, objective property, but are instead engaging with a useful, perhaps even an indispensable, fiction” (p. 91). For Ongaro, this fiction consists in a meaningful explanatory narrative about the social causes of illness. However, if we take the notion of integration seriously, and characterize this integration naturalistically (as Ongaro does), then questions arise as to how these fictional narratives about social causes can impact people both biologically and psychologically, and thereby have such a powerful impact.I argue that an enactivist approach to treatment will be... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Better to Have No Deep Cut Anywhere in the Biopsychosocial SystemDerek Bolton, PhD (bio)It is very good to see theoretical work on the biopsychosocial model, acknowledging the causal role of these three kinds of factors in health and disease. I think Ongaro is right to argue that the biopsychosocial model requires an account of these three also being one—integrated—and that systems theoretic concepts such as dynamic, nonlinear causation are (...) helpful for capturing this. In a recent paper (Bolton, 2023) I have described Engel’s original (1997) paper as visionary but programmatic: visionary in seeing radical theory change afoot, citing von Bertalanffy’s new general system theory, but programmatic because the changes had not happened. The systems theoretic approach applies across the life, behavioral and social sciences, and typically envisages multiple interacting systems and causal pathways, including feedback and feedforward mechanisms, within and between systems. However, linear mechanisms are less complicated to research, and early social epidemiology used standard linear regression models (e.g., see the Whitehall II study [Marmot et al., 1991]). Such models do not capture non-linear connections in which the dependent variable also functions over time as an independent variable. However, the background theory typically would not exclude nonlinear dynamic causation, but on the contrary envisages it. Lower social status raises risk of ill health in a linear model, but it is also a plausible hypothesis that ill health in turn raises risk of lowering social status, which is testable in another or in a composite linear model. As well as social epidemiology, another large-scale theory change was underway at the time Engel wrote, the so-called cognitive revolution in psychology. Axiomatic in this shift was the idea that behavior is a response to the environment as perceived, thus merging the psychological/behavioral with the environmental, including the social. This latter point bears on Ongaro’s main proposal that the biopsychosocial model should envisage social causes as externalist, distinguished from the bio-psychological orientation of current psychiatry—and will be picked up below.Paper 2 makes some bold claims about the positive therapeutic value of construing causes [End Page 321] of mental health problems in external terms that have shared social meaning. These claims are made for functional neurological problems, but with extension to other kinds, in relation to a culture in which the shared social meanings refer to spirit possession, which, as a general type, is found in many non-modern Western cultures, as well as now, in our globalized world, in subcultures worldwide. One of the author’s claims is that within the spirit possession framework the shared framework of external causes enables society to adapt to the problem of living, to make it manageable, by shifting the social environment around the patient. As appropriate for ethnomethodology, there is no reference to controlled studies of outcome or mechanisms and I follow this immersed observational methodology here, with an experiential story that illustrates absence of personal and social acceptance and manageability of problematic conditions. While wandering recently with a friend in the mountains in the northern part of Africa, the local guide, in conversation in the local language and in English, having found out that two of us worked in “psychiatry/psychology,” asked us what we knew about; our brief reply included “obsessive-compulsive disorder” (OCD) and “anxiety”; the guide responded by asking whether OCD was washing hands a lot, and then wanted to discuss with us two people he knew well. One was a relation engaged, since many years, for many hours a day washing and cleaning, avoiding many daily tasks, sometimes childcare; friends and wider kinship structures had tried everything, except modern Western psychiatry (which was unavailable anyway), and, to put it briefly and colloquially, they were not at all happy about the person’s state and wished the person would get better. This person lived at a distance and we could not see them, so we do not know their view, but to judge by people with definite or probable OCD that we are familiar with, they may or may not have been happy in their reclusive state. Also to mention that the local healer had investigated... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Grounding Psychiatry in the Body and the Social WorldLaurence J. Kirmayer, MD, FRCPC, FCAHS, FRSC (bio)The sensing body is like an open circuit that completes itself only in things, in others, in the surrounding earth.—David Abram (2012)Giulio Ongaro has written an interesting set of papers that aim to advance our thinking about ‘externalist’ (i.e., social) approaches to psychiatry by rehearsing an enactivist account of mental disorder and elaborating an (...) ethnographic example of social explanation rooted in a different cultural ontology and system of healing. I am completely onboard with his calls for more attention to the social world in psychiatric theory, research, and practice. What is especially novel in his work is the use of ethnographic research to inform philosophical thinking about psychiatry.Despite my enthusiasm for this effort, I have three concerns with his argument that I can only briefly outline in this commentary: i) the lack of attention to a large body of work in social epidemiology, psychosomatics, and cultural psychiatry that speaks directly to the goals of the biopsychosocial (BPS) approach and that vitiates much of the recent critique of that model; ii) the use of an ethnographic example to idealize an ‘externalist’ system of medicine that patently cannot address the many social structural and sociophysiological processes that psychiatry needs to understand; and iii) most importantly from a philosophical perspective, the fact that the enactivist framework he endorses actually breaks down the distinctions between internalist/externalist psychiatry and naturalist/constructivist ontologies around which he organizes his critique and proposed remedy (Kirmayer & Ramstead, 2017).Integration and the BPS ApproachOngaro’s first paper begins by acknowledging the recent critiques of the BPS approach that claim the BPS leaves vague or underspecified the ways in which the biological, psychological and social domains interact to give rise to mental disorders and how they can be included in systematic case formulation to guide assessment and treatment [End Page 315] intervention. Ongaro notes that current efforts to elaborate an embodied, enactivist approach to psychiatry hold the promise of outlining a more systematic approach to the relationship between levels or domains in the BPS. However, he argues this still leaves psychiatry with excessive emphasis on ‘internalizing’ explanations that appeal to biological or psychological processes within the person to characterize mental disorders. He suggests that this needs to be complemented by an externalizing approach that gives due weight to social processes. The dominant approaches leave the social world underspecified and he notes psychiatry lacks an “ontology of the social.”To some extent, this recent critique—not by Ongaro but by some of the authors he cites—reveals a lack of familiarity or engagement with a rich literature in social epidemiology, psychosomatics and sociosomatics that has long demonstrated the close links between social and physiological processes (Krieger, 2021). This research has produced multiple examples of these relationships detailing their mechanisms and dynamics in ways that do not privilege internal processes. There is no problem identifying many specific instances of these links; for example, research has examined how exposure to racism and discrimination results in increased risk for psychiatric disorders (Kirkbride et al., 2024). We have listed many other such mechanisms related to depression in a recent paper (Gómez-Carrillo & Kirmayer, 2023). This work does not yield a single overarching model or explanation but reveals diverse kinds of mechanisms that interact in a multilevel system that includes both dynamic and linguistic modes (Gómez-Carrillo et al., 2023). Integration occurs in the functioning of this system and cannot be captured in any monolithic theory. This is not a limitation of the BPS, simply a reflection of the complexity of human beings.Can we have a general theory of the links between dimensions or domains in the BPS or will it always remain a piecemeal account that depends on the details of specific systems? Given the many different kinds of processes involved, it seems unrealistic to expect a totalizing theory. If so, both research and clinical work need practical ways to assess the myriad pathways and processes involved in psychiatric disorders in order to formulate cases efficiently, identify a manageable subset of factors to consider in a... (shrink)

Any progress in shaping up an externalist psychiatry, so previous discussion suggested, must begin from questions about the ontology of social causation. So far, research and theory have adhered to a naturalistic approach to the social causes of illness, concentrating mostly on the ‘social determinants of mental health’ (inequality, discrimination, housing insecurity, etc.). The paper starts with an assessment of ‘social determinants’ through the lens of epidemiology and critical psychiatry. It illustrates existing practical and political approaches that fight these constraints (...) and it highlights their therapeutic value. It argues, though, that a focus on social determinants is not sufficient for fully realizing externalism because a great portion of sociogenic illness remains causally indeterminate. Alongside political action, externalism requires a social etiology that is established by virtue of the meaning that it holds for patients, rather than by virtue of its capacity to identify objective social causes of illness. This entails abandoning naturalism about social causation and embracing constructivism. The paper shows that this methodological shift is less contradictory and more effective than it is commonly imagined. Drawing from further anthropological evidence, it concludes that only by lending support to projects that balance a focus on constraints with social construction will psychiatry be truly externalist. At stake is a prospect of effective treatment for sociogenic illness for the countless in struggle. (shrink)

The biopsychosocial (BPS) model in psychiatry has come under fire for being too vague to be of any practical use in the clinic. For many, its central flaw consists in lack of scientific validity and philosophical coherence: the model never specified how biological, psychological and social factors causally integrate with one another. Recently, advances in the cognitive sciences have made great strides towards meeting this very ‘integration challenge.’ The paper begins by illustrating how enactivist and predictive processing frameworks propose converging (...) accounts of biopsychosocial integration that are far superior to those of previous theories. It argues, however, that the main problem of implementing the BPS model has less to do with integration than with the lack of a social etiology. Psychiatric practice leans heavily towards ‘bio’ and ‘psycho’ approaches, without an equally developed set of explanatory and therapeutic resources for dealing with the ‘social’ dimension of illness. This leaves psychiatry essentially internalist in orientation. As illustrated most poignantly by conditions such as functional neurological disorders, internalism comes with the risks of stigma and the curtailment of therapeutic possibilities. The paper argues that the answer to the failings of the BPS model lies in combining the integration challenge with the development of an ‘externalist psychiatry,’ which casts both causes and treatment of psychiatric illness onto the social environment. The following two papers explore the conditions that might make this idea a reality. (shrink)

Philosophical speculation about how psychiatric externalism might function in practice has yet to fully consider the multitude of externalist psychiatric systems that exist beyond the bounds of modern psychiatry. Believing that anthropology can inform philosophical debate on the matter, the paper illustrates one such case. The discussion is based on 19 months of first-hand ethnographic fieldwork among Akha, a group of swidden farmers living in highland Laos and neighboring borderlands. First, the paper describes the Akha set of medicinal, ritual, and (...) shamanic practices, analyzing issues of stigma and medical pluralism within it. Second, it makes the case that the Akha realize a functioning biopsychosocial system which comes with a well-developed set of resources for treating the social dimension of illness. Externalism among the Akha re-frames psychiatric illness as a ‘problem in living,’ which becomes manageable as such. The paper claims that, in so doing, the Akha system succeeds in many of the areas where modern internalist psychiatry falls short, and that it does so because Akha society is structured in such a way so that its practitioners can shift the social environment around the patient. As a takeaway for philosophers, it suggests that the development of an externalist psychiatry must begin from questioning the accepted ontology of the social causes of psychiatric illness. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Models of Psychopathology and ReligionSuffering, Psychosis, and NeurodiversityKate Finley, PhD (bio)To draw out some implications of Scrutton’s paper, I will address a few points of clarification and objection as well as connections to empirical literature and topics for further research. Scrutton frames her discussion as an exploration of ‘both–and’ (BA) accounts, according to which “someone might experience both a religious experience and psychopathology” in contrast to an ‘either/or’ account, (...) which “presupposes that a person’s experience can be either psychopathological, or else a genuine religious experience” and focuses on instances of ‘voice hearing’ which may be a religious experience (i.e., God talking to you) and/or an instance of psychopathology (i.e., an auditory hallucination). She then defines religious experience as one which “comes from God... [specifically as] an instance of special divine action” and mental illness as dys-functional emotional, cognitive, and/or perceptual processes resulting in suffering that is in need of healing and/or treatment.1One potentially ambiguous point concerns the potential causes of psychopathology—while in some places, Scrutton seems to assume that psychopathology can only be caused by natural (biopsychosocial) causes, in others, she highlights “conjunctive causal explanations” on which divine action can occur within and through ‘natural’ (e.g., psychological, neurological) phenomena and processes. It is important to note that this latter approach is needed in order to truly entertain BA accounts which posit both natural and supernatural causes for the psychopathological experience in question. Relatedly, although Scrutton cites an intuitive view that a hallucination is a “distorted perception of reality,” instead an account of hallucination which allows for veridical as well as non-veridical hallucinations is needed.2 Without these assumptions, the categories of religious experience and psychopathology may seem to be mutually exclusive and thus an either/or account trivially true. For example, one might think that an instance of ‘hearing voices,’ if it is an auditory hallucination (and thus results from solely natural causes and is non-veridical), then cannot also be a religious experience (brought about by divine [End Page 261] action and veridical). These are friendly clarifications of Scrutton’s setup which also highlight the need for further explanation of the relationship between human and divine causation in such cases.There is also some ambiguity about what counts as a singular experience for Scrutton’s purposes—for example, ‘hearing voices over the course of a few minutes or hours’ or ‘hearing voices off and on over a period of a few months and reflecting on these occurrences.’ Scrutton seems to favor the latter, using ‘experience’ in a “diachronic and holistic sense,” and sees the former as too narrowly focused on only part of an experience. On Scrutton’s understanding, much more, perhaps even all of what is recounted about Abeo would count as parts of her experience—thus, a BA account of this experience being correct would mean that all of the individual instances of voice hearing would be both psychopathological and genuine religious experiences (in some sense). In contrast, on the former more circumscribed understanding, each instance in which Abeo “seem[ed] to hear God talk to her” would count as a distinct experience—and thus, a BA account might be correctly applied to only some of these instances. While Scrutton’s approach can sidestep skeptical worries stemming from this view—what to make of the fact that Abeo may genuinely hear God speak to her on one day, but only seem to hear God speaking to her on another—I believe the former understanding of ‘experience’ allows for important nuance and specificity when addressing these issues. As a friendly clarification, this point mainly draws attention to the different implications of understanding Scrutton’s models as employing either the first or the second understanding of ‘experience.’In objecting to the Mysterium Tremendum Model 1, she claims that because Christians (qua Christians) “do not undergo suffering pointlessly [(i.e., in a way that does not further their spiritual life)],” genuine (salutary) religious experience would not lead to psychopathology (presumably pointless suffering). Notably, the claim that psychopathology results in pointless suffering is seemingly challenged both by Scrutton’s preferred Model 4... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Deepening and Expanding Both–And ApproachesTasia Scrutton, PhDExcitingly for the topic of religion and mental health, both Gipps’ and Finley’s commentaries point to the emergence of a both-and consensus. Finley does this in a number of ways, for example by pointing to the ways in which her own brilliant research has provided further and more specific support for a “honeysuckle on a broken fence” model, and also inviting a renewed (...) examination of Model 3 in response to studies on absorption, psychosis and religious experience. Gipps does this by putting forward an additional both-and model, according to which a potential or early-stage instance of mental illness, responded to by a grace-ful engagement with psychotherapy, becomes instead an instance of metanoia through which the person’s drives and emotions are integrated into a more rounded adult psyche.As well as pointing to the emergence of a both-and consensus, Finley and Gipps’ commentaries importantly reflect the fact that both-and accounts are likely to be diverse, complex and multi-faceted. As Gipps notes, my account focuses on spiritual guidance and medication, especially psychiatric medication; the therapeutically informed psychological perspective that Gipps provides is a very welcome addition to the discussion. In addition to both-and accounts being diverse, different psychiatric conditions and symptoms may invite different models, and multiple models may be in play in one person’s life at the same time. Finley gives an example of this possibility when she posits that a version of model 3 might fruitfully by understood as part of, or perhaps combined with, Model 4.Hopefully this paper and the two commentaries on it open the door to a deeper account of the “honeysuckle on a broken fence” model and potentially to other both-and models too. I want to see that door open—but perhaps not too open, and I think less open certainly than Finley and perhaps also Gipps would like. This is because of my view of the relationship between suffering and psychopathology, and suffering and evil (or badness), which I want to discuss in more detail below.Suffering, Badness, and PathologyThe first thing I want to say is that I think that suffering is bad, by which I mean that it is undesirable. This is true to the way we talk about suffering (if someone tells us that they are suffering, we express regret, not joy), and it is important [End Page 265] morally to remember that suffering is an evil if we are to work to prevent and overcome it (including in ways relevant to mental illness, such as through social justice, peace-building and medical care). It can be tempting to romanticize suffering and to try to justify its romanticization on the basis that sometimes good things come out of situations of suffering. However, to do this is to conflate what something is with other things it may become intertwined with. It is also to encourage masochistic and socially and politically conservative forms of spirituality that are antithetical to the Christian Gospel, since it baptizes suffering rather than seeing suffering as something people are called to be liberated from.The second thing I want to say is that I think that pathology, including psychopathology, involves suffering, and that if it does not involve suffering (either in a specific moment or over time) then it is not pathology. The centrality of suffering to pathology is indicated by the fact that the term ‘distress,’ which denotes suffering, appears in the DSM-5 618 times. The presence of either distress or impairment in social, occupational or important other areas of functioning (which, over time, is likely to lead to suffering) is a prerequisite of many psychiatric conditions, according to DSM-5. Homosexuality was rightly removed from the DSM and other psychiatric manuals when it became clear that same-sex attraction does not inherently involve distress (and so suffering). Significant for the shift towards demythologizing homosexuality was Evelyn Hooker’s 1957 study, which showed no similarities in the well-being and happiness of 30 homosexual and 30 heterosexual men (Ebacioni, 2014, p. 4). To take another example, hearing voices (with no... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:MetanoiaRichard G. T. Gipps, ClinPsyD, PhD (bio)A “honeysuckle on a broken fence”: Scrutton’s (2024) theologically potent image offers us a dignified vision of how a living faith and the experience of mental illness might intersect. Mental and physical illness, deprivation and bereavement sometimes provide a propitious structure on which faith’s bright strands may grow. Scrutton posits no simply causal relationship between faith and mental illness, and steers us helpfully (...) away from the narcissistic overvaluation of inner experience too often met with in (1) mysterium tremendum (meeting-God-blew-my-mind), and (3) mental openness (divine-light-pours-through-the-cracks), formulations. She helps us to avoid settling, too, for the clever-sounding but ultimately too-easy idea of (2) ‘mental illness’ and ‘religious experience’ as different descriptions under which identical experiences may sometimes be brought. For one thing, and to animadvert now in my own vein: can we really—as William James aspires to, say, when he takes it for granted that the “more personal branch [of] feelings, acts, and experiences of individual men in their solitude, so far as they apprehend themselves to stand in relation to... the divine” can be neatly hived off from the “institutional branch of religion... worship... theology... ceremony... ” and so on—even individuate the relevant experiential phenomena independently of their meaning-conferring contexts? For another, it seems to me that too often in the literature of (1) (2) and (3) do we meet with a fatal confusion that can be expressed in terms of a conflation of two meanings of “ego,” as when a) the dropping of the kinds of boundaries which it makes sense to talk of putting up (i.e., our ego’s defensive, prideful, shame-driven shirking of intimacy) is muddled together with b) the crumbling of such individuating ego boundaries as constitute us. Such a confusion gets readily promulgated by vague and tacitly polysemic talk not only of ‘ego’ but also of ‘non-duality,’ ’transpersonal,’ and ‘higher’ and ‘lower’ ‘levels’ of ‘self’ and ‘consciousness’ (e.g., see Kasprow & Scotton 1999). Sometimes driving this, one can’t help suspect, is the narcissistic gain of conflating the dismal dissolution of ego boundaries in illness (Conrad, 1958) with the epiphanic transcendence of a grasping and fearful ego. Spiritual pride and spiritual bypass (i.e. fleeing the relational tasks of adult development into a self-preoccupied ‘spiritualised’ inner journey) (Welwood, 2000) then abound, not only for the sufferer but also for the lowly therapist who now receives their shamanic guide/hierophant upgrade. By contrast with all of this, Scrutton’s (4) honeysuckle on a broken fence model stands out in its theological dignity and psychological sobriety.Even so I found myself, on reading Scrutton’s piece, wondering whether a more romantic conception of a growing faith’s possible relation [End Page 257] to psychological disturbance might yet be available and sometimes even find application. What particularly came to my mind was that notion of metanoia as offered us by the existential tradition in both theology and psychopathology.Mark’s gospel begins with John the Baptist heralding Christ’s arrival and preaching the “baptism of repentance [metanoia; μετανοίας] for the remission of sins” (Mark 1:4). Jesus’s first public words then proclaim the same message: “the kingdom of God is at hand: repent ye [μετανοεῖτε], and believe the gospel” (Mark 1:15). ‘Repentance’ is today often understood as a sorrowful acknowledgement of one’s wrongdoings, but it has long been acknowledged that, if that be the meaning we give the term, it is an inapt translation of ‘metanoia’ (Walden, 1896). For what the gospel instead calls for is rather a wholesale turning about, or conversion, from ‘ego-dominance to surrender’ (Barron, 2021), i.e. from (a) defensive and illusory attempts to handle our vulnerability and dependency through self-reliance and self-affirmation to (b) an aliveness to grace (i.e. seeing our lives and their bounties under the aspect of the freely given gift) and a trusting surrender to the dominion of that God of love in which we anyway inexorably ‘live and move and have our being’ (Acts 17:28). The ‘I’ in Paul’s “It is no longer I who... (shrink)

Psychiatric literature about when instances of voice hearing should be regarded as religiously inflected psychopathology and when they should be regarded as religious experiences sometimes presupposes that a person’s experience can only be _either_ psychopathological, _or else_ a genuine religious experience. In this paper I will consider an alternative: the possibility of a both–and account. A both–and account might involve the idea that a religious experience causes psychopathology, or is psychopathology, or that people open to religious experiences may also be (...) susceptible to psychopathology. After arguing that these are either problematic or under-evidenced, I will argue for another version of a both–and account: that genuine religious experience can arise out of situations involving psychopathology. I will also point to some of the clinical and pastoral implications of my view. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Hermeneutical Injustice and Best PracticeAlasdair Coles, PhD, MRCP (bio)To a doctor who routinely sees people with psychosis and neurological conditions causing strange experiences, José Porcher’s paper is challenging and troubling.Challenging, because the accusation of hermeneutical injustice is accurate. In the hurly burly of the emergency department or a government outpatient clinic, doctors resort to reductionism, for the sake of urgent efficiency. A person becomes a “case of psychosis” and (...) the immediate questions are: “Should they be admitted? Are they fit to make their own decisions? What medication should we prescribe?” In that context, spending time on analyzing the contents of the delusions, and acknowledging their meaning to the individual, is a luxury. Most doctors, burnt out by COVID and struggling to get people basic healthcare, will probably be unconcerned about hermeneutical injustice. But, disdain for the experience of psychosis leads to loss of trust between patient and doctor, as nicely illustrated by Heriot-Maitland, Knight, and Peters’ first patient. One consequence is that patients withhold information they imagine will not be well received by the medical profession. In my experience, of studying the rare entity of people with epilepsy that causes pleasurable or even religious experience, the patients have usually not discussed this with their doctor (Coles & Collicut, 2019) A tangible medical consequence is that their doctors are not aware of the risk of non-compliance with anticonvulsant drugs, so that they are at risk of serial seizures or even sudden death.Porcher’s uncritical appreciation of the Avraham case worries me. Although one of the two therapists is described as “particularly well-versed in Jewish custom and lore” (Bilu et al., 1990), they are not believers. Yet, they take on priestly roles. For instance, after identifying Avraham’s “the Black” as a demon (“which the patient did not belie” [Bilu et al., p. 110]), they prescribe incantations based on Jewish exorcism rites. And, once Avraham was better, he and his wife attributed his “miraculous cure” to the therapists who they regarded as “pious and pure hearted” (Bilu et al., p. 116). Not only are Avraham’s secular therapists being disingenuous, it is dangerous for seculars to appropriate religious language, concepts, and customs. In particular, clumsy use of exorcism rituals can lead to long-term spiritual distress. Those ministers of religion who practice deliverance [exorcism] are highly trained, not least to respect the importance of asking for psychiatric [End Page 239] help. It is unwise not to return the professional favor. Avraham’s therapists should have called in a Jewish minister, trained in clinical pastoral care, to assist them.Key issues are raised by Porcher’s analysis of the Femi case. Femi presented with a psychosis that included religious content. This is common (Sofou et al., 2021): religious imagery is present in 5% to 50% of cases of psychosis, assessed by repeated studies across multiple cultures. The medical team concluded Femi had a psychosis, because his symptoms caused him harm (social isolation, absence from work). Porcher rightly condemns Femi’s therapists because they undermined his dignity, by invalidating his experience of God. And Porcher goes on to state the “both–and” view, that something can be psychopathology and a religious experience. So far so good. But what Porcher does not allow is that some people experience psychoses with very harmful and dark religious imagery, invalidation of which is therapeutic. So, when Porcher asks “what could ever justify someone in the judgment that someone’s religious experiences are illegitimate?” the answer is: compassion. Schizophrenia is not fun. And the disease causes hallucinations that have no relation to reality; to the person I saw recently who believed her clothes were eating her, how helpful would it be to validate the nonsense of clothes with teeth? It follows that some religious delusions may be just that. And people are helped by knowing that. That is the reality of care of the deluded patient. For those therapists who just assume all religious content is inauthentic, Porcher’s article stands as a useful corrective. But assuming the opposite may be as harmful or more. There has to be judgement somewhere along the line. Best practice is that this is done... (shrink)

A particularly deep form of hermeneutical injustice arises when clinicians undermine a patient’s meaningful interpretation of their alleged psychotic symptoms within a religious framework. Cases like Femi’s (Rashed, 2010) illustrate how diagnosing and treating psychotic symptoms with religious content can perpetuate this injustice. Femi’s symptoms, which were very real, were interpreted solely as indicative of a psychotic episode, without considering the possibility of a religious experience. Although hermeneutical injustice is often caused by negative stereotypes, lack of conceptual resources, implicit biases, (...) practices of epistemic privileging, patronizing attitudes, and wrongful pathologization, I propose that interpretive exclusivism about religious psychopathology plays a pivotal role in causing hermeneutical injustice when attributing psychotic symptoms with religious content—that is, the view that an experience is either psychopathological or religious (Scrutton, 2023). Routinely, on attributing psychosis, the potential for the patient to have a genuine religious experience is disregarded and excluded from the therapeutic process and from the very realm of possibility. Why? -/- . (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Religion, Psychiatry, and “Radical” Epistemic InjusticesRosa Ritunnano, MD (bio) and Ian James Kidd, PhD (bio)Hermeneutical injustice as a concept has evolved since its original formulation by Miranda Fricker (2007). The concept has been taken up in psychiatry, with its moral, epistemic and clinical premium on the interpretation of extremely complex and difficult experiences (Kidd et al., 2022). There are many varieties of hermeneutical injustice with different forms, sources, degrees, (...) effects, and interpersonal and socio-structural aspects (Medina, 2017). José Eduardo Porcher has proposed the addition of a new form of ‘radical’ hermeneutical injustice, with a case study of psychotic symptoms involving religious content.He offers different characterizations of this injustice:a particularly radical form of injustice, namely, having their own interpretation of their experiences unjustifiably undermined.a form of hermeneutical injustice that occurs when a patient diagnosed with psychosis is denied the opportunity of interpreting their own experiences within their own religious framework.These are different things. Denying someone the opportunity to interpret their experiences in their own, preferred framework is one way of undermining their interpretations. Another is forcing someone to use your own preferred framework and then belittling their own, which seems doubly wrong. Misusing some preferred interpretive framework can be as unjust as not using it. The two definitions could be combined, but then much will depend on what it means to undermine someone’s interpretation of an experience. We think there is a form of radical hermeneutical injustice—different to the one described by Porcher. Some interpretations of kinds of experience with religious content can be undermined if one is committed to a metaphysical naturalism. In these cases, one person cannot regard someone’s interpretive framework as coherent or intelligible (one that involves supernatural entities, for instance).Most discussions of hermeneutical injustice focus on social structures. Fricker notes structural dimensions to hermeneutical injustice. In a standard case, a group has unequal participation in collective practices for making and using interpretive resources (Ritunnano, 2022). In a rich analysis, José Medina describes four ‘axes’ or dimensions for distinguishing forms of hermeneutical injustice [End Page 235] (Medina, 2017). The source of these injustices can be semantic or performative. The dynamics may be structural or interpersonal, or both. Moreover, there are different degrees of breadth and depth, defined here in terms of the ‘reach’ of the injustice across one’s life, and the depth of damage to one’s hermeneutic agency, respectively (Medina, 2017, p. 45). On this model, what might count as ‘radical’ hermeneutical injustices? Deep and broad hermeneutical injustices can be radical when they are very broad in scope and very deeply damaging. This might be what Porcher has in mind. But we think there is a further option, relevant to his case study.Porcher focuses on a case where individuals experience unusual beliefs and perceptions with religious content receive a ‘psychosis’ diagnosis. The alleged injustice is that the possibility of a genuine religious experience is not recognized and validated. The example is Femi, a young man with Christian background, who enters the mental health system following the onset of psychotic ‘symptoms’. After being found “disoriented and depleted in public” – tired and undernourished—Femi is compulsorily admitted to hospital, explaining he undertook fasting and isolation in response to orders from God. During this time, Femi devoted himself to Bible reading and stopped going to work. In hospital, where the authenticity of God’s voice is challenged by clinicians, Femi is treated for acute psychosis with pharmacotherapy. While remission of symptoms follow, there is no functional recovery, and Femi is described as “unmotivated and apathetic”.Femi interpreted his experiences in religious terms, but this interpretation is not accepted or pursued by the clinicians. Is this a hermeneutical injustice? If so, is it a ‘radical’ one? Granted, Femi’s religious interpretation may be psychologically adaptive—enhancing his sense of life as meaningful (Ritunnano & Bortolotti, 2022). But this is consistent with it being a hermeneutical injustice. Plus, a religious framing may be conducive to his functional recovery after being discharged, especially in conjunction with a supportive religious community, able to help him articulate, understand, and respond to those religious experiences (see Cottingham, 2005; Wynn, 2005). However, none of... (shrink)

In this paper, I argue that a special kind of hermeneutical injustice occurs when someone is not permitted to interpret their experiences in a meaning-making way. I suggest that this occurs in certain cases where the possibility that the patient has a genuine religious experience is excluded by a medical diagnosis. In such cases, it is not that an experience is incomprehensible because of the absence of a valid interpretation. Instead, one perspective is not only dominant but exclusive, so the (...) ensuing power imbalance is absolute. I begin by introducing the notion of hermeneutical injustice and subsequent refinements that have been instrumental in applying it to psychiatry. Then I show how even though voice-hearers are liable to be victims of such injustices, the literature has neglected the specific harm done to someone whose interpretation of their own experience is obliterated because of the dominance of exclusive medical views. To illustrate this, I point to a case that evinces the harms perpetrated toward patients diagnosed with psychotic symptoms with religious content and argue that depriving persons of meaning-making interpretations of their own experiences constitutes a profound and willful form of hermeneutical injustice. I then gesture toward studies on the religious reframing of anomalous experiences through contact with a normalizing framework. Finally, I pry from a successful case a general directive toward the virtue of hermeneutical justice through the attitudes of respect to first-person authority and the hermeneutical flexibility it embodies. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:What Can (and Cannot) Be Said About the Distinction Between Religious Experience and PsychopathologyMohammed Abouelleil Rashed, MD, PhDThe distinction between religious experience and psychopathology as a puzzle to be pondered, debated, clarified, and analyzed is an example of a thoroughly modern problem. It is modern in that the distinction can only make sense if our starting assumption is the existence of unique and separate types of experience that might (...) overlap phenomenologically but are ultimately different entities that should be distinguished from each other. And it can only have this sort of sense in a secular worldview where the possibility of a fully areligious type of psychological suffering is on the table and widely accepted. By framing the matter in this way, the debate presupposes, rather than argues for, the existence of unique and separate types of experience. This is a major presupposition, and its coherence cannot be assumed, nor can we ignore the impact of our standpoint in the debate on whether or not we can actually make that distinction let alone resolve it. In the original paper (Rashed, 2024), I deconstruct the distinction by examining what can, and cannot, be said about it given the standpoint that we adopt. In what follows, I respond to Awais Aftab’s and Warren Kinghorn’s thoughtful commentaries on my paper and in the process clarify my thesis further.What We Believe and the limits of What We Can ArgueAwais Aftab (2024) perceptively points out that the way I define the terms renders the distinction between religious experience and psychopathology an instance of the broader distinction between the religious worldview and the scientific worldview. Accordingly, my approach deviates from the usual [End Page 219] approach in these debates, which tend to focus on specific areas of phenomenology (delusion, hallucinations, low mood, etc.). This focus then directs the debate toward distinguishing these states from each other, and not toward asking if there is a distinction that needs to made at all, and, if there is, what the distinction is really about. In order to overcome this potential blind spot, we need to step back and examine our assumptions about the possibility and the nature of the allegedly competing conceptions of religious experience and psychopathology. And to do so, we need to apprehend the distinction in the broadest possible sense, as it is there that we can identify our assumptions about those ‘things’ we are trying to distinguish from each other.The first step in deconstructing this debate is to identify our stance towards the categories of religious experience and mental disorder, and what this stance enables us to say and prohibits us from saying. On an ontological stance, we would be dealing with two distinct categories of experience out there in the world for us to identify, study, and differentiate; there is a truth of the matter as to the origin of the experience, a truth that we can get hold of if we can get to the essence of the respective phenomena. On a constructivist stance, there is no sense to this claim, and what we have are two possible interpretations of experience that cannot be differentiated from each other from a natural or a supernatural standpoint; they do not reflect distinct types of experience, merely the attribution of meaning, which can always go the other way depending on the social situation and the cultural context. And so, our initial stance as to an ontological or constructivist understanding will constrain from the outset what can and cannot be said about the distinction between religious experience and psychopathology. The issue is further complicated by the fact that we can hold a range of positions: we can, at the same time, adopt an ontological view of religious experience and a constructivist view of mental disorder, or vice versa, and in each case we might end up in a different place.For philosophers, theologians, and others writing from a religious standpoint, we can assume that they are adopting an ontological reading of religious experience. In other words, they take it to be true that some experiences have a divine origin, connect the person to non... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Two Different “Religious Experience vs Psychopathology” DistinctionsAwais Aftab, MD (bio)Mohammed Rashed’s analysis of the distinction between “religious experience” and “psychopathology” challenges the assumptions that underlie traditional efforts to make such a distinction and he arrives at a provocative and memorable conclusion: “The distinction between religious experience and mental disorder can only be invoked from a secular standpoint but can only be clarified from a religious standpoint. In other words: (...) if you have the grounds to invoke it, you cannot have the tools to clarify it; and if you have the tools to clarify it, you do not have the grounds to invoke it” (Rashed, 2024). (For another recent discussion that challenges underlying assumptions of this dichotomy, see Gipps and Clark (2024) on the distinction between religious delusion and religious belief.)There is great merit in Rashed’s analysis, and I am in agreement with many aspects of the discussion. In particular, I admire Rashed’s ability here, as well as elsewhere (Rashed, 2021), to break the impasse of definitional debates by deconstructing and destabilizing the distinctions involved. In this commentary I’d like to note some points of disagreement and qualification that I hope can move Rashed’s analysis forward in a constructive way.The first thing I want to bring up is that Rashed defines religious experience very broadly: “Psychological distress or anomalous experience that has a religious origin, content, or end (purpose).” This effectively turns the distinction between religious experience and psychopathology into an instance of the general distinction between the religious worldview and the secular worldview. “Mental disorder” is understood by Rashed to be an exclusively secular concept. I am not sure this way of framing the dichotomy is entirely correct. If our notion of “religious experience” include any anomalous experiences believed to serve a religious purpose, then Rashed is correct that for the religious no anomalous experience would be excluded. And if “mental disorder” requires giving up on the idea of a divine purpose for our [End Page 211] suffering, then indeed the religious do not have the grounds to invoke it.I’d suggest that a better approach may be to think of two different “religious experience vs psychopathology” distinctions, one within the context of the religious worldview and one within the context of the secular worldview. Both are fuzzy and present demarcation problems of their own; both can be and ought to be destabilized.Rashed recognizes that the religious worldview does make space for illness and disease; it’s just that he says even these concepts are understood within a broader religious view of suffering:the proposal is not that religious traditions have no category of distress that is somatic in nature—of course they do—but that even with those categories, religion is never far off the horizon and will make an appearance at some point, if not in the origin or content of distress, then in terms of its broader purpose and so the recommended interventions.(Rashed, 2024, pp. 201)A vital implication of this is that the distinction between religious experience and a secular view of somatic illness would pose the same problem as the distinction between religious experience and mental illness; the religious would not have grounds to invoke it, for no illness is devoid of religious significance. And yet, the religious do meaningfully talk of “illnesses” and “diseases,” and they do meaningfully talk of “madness” (if not mental illness), and many often do meaningfully differentiate between madness and mysticism. This shows that the religious worldview has its own notions of disease and psychopathology, which differ from their secular counterparts in the sense that suffering involved is imbued with a divine purpose. The religious scholars interested in differentiating between the anomalous nature of the mystical experience and the anomalous nature of madness are interested, in part, in marking out abnormalities of thought and behavior so severe that they come to resemble the effects of somatic illness. Madness is where the internal coherence of the mystical experience breaks down, and becomes an instance of suffering at par with somatic illness.The secular worldview recognizes the phenomenology of religious experience—there is religious or mystical content—but... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Mental Disorder and Religious ExperienceThe Need for a Humble, Pragmatic PluralismWarren Kinghorn, MD (bio)Mohammed Abouelleil Rashed follows Charles Taylor’s argument that in the “therapeutic turn” of modernity, “certain human struggles, questions, issues, difficulties, problems are moved from a moral/spiritual to a therapeutic register,... from a hermeneutic of sin, evil or spiritual misdirection, to one of sickness” (Taylor, 2007, pp. 619–620). While the project of construing mental disorder in naturalistic, (...) non-religious terms carries the risk of subsuming “the rest of life” into the realm of the medical, it is nonetheless needed in order “to protect a region of illness and incapacity from the reach and excesses of the hermeneutic disciplines with their tendency to over-interpretation, and from cultural traditions, including religious discourse, that can implicate the person in narratives of evil, sin, faithlessness, spiritual misdirection, and moral deviance.” Rashed notes, however, that this medical narrative is challenged not only by religious communities but also by various forms of identity-based activism including the Mad Pride and Neurodiversity movements. He argues that strict illness/purpose, deficit/value, mechanism/meaning dichotomies have become “unstable” and encourages scholars to focus their attention on resolving the apparently contradictory realities that people sometimes demand and require medical forms of care while investing significance in the sociocultural and existential context of their distress and refusing reductionistic constructions of their distress as illness.I agree wholeheartedly with Rashed’s conclusion that clinicians and scholars must move beyond a strict mechanism/meaning dichotomy with respect to unwanted and/or disvalued experience and behavior, and must remain open to the social and contextual interpretations that particular cultural communities—including religious communities—offer. But as a psychiatrist who is also [End Page 215] a Christian theological ethicist, I suggest that this sensible conclusion can be reached more straightforwardly by adopting a more flexible approach to “religious experience” and by abandoning the assumptions that mental disorder is “a fully areligious type of suffering” and that religious experience and mental disorder are “fundamentally separate apprehensions of our experience.”Although Rashed never defines religious experience, he posits a distinction between “psychological distress or anomalous experience that has a religious origin, content, or end (purpose)” and “psychological distress or anomalous experience that has no religious origin, content, or end (purpose).” He then helpfully describes how Islamic tradition narrates psychological suffering as deviation from fitrah and as God’s trial, arguing that in Islamic perspective “mental disorder cannot be disentangled from the person’s religious situation and from the religious origin, content, or end (purpose) of his distress.” I make no claim about Rashed’s interpretation of Islam, but would observe that many voices within Christian tradition resist both the equation of psychological suffering with wrongdoing and the assertion that God is the direct cause of psychological suffering (see, for example, John Paul II, 1984). Suffering may instead have to do with being sinned against (as in the case of war, assault, or oppression), or the experience of living in a fallen world that God will one day make right. When the psalmist cries, “Save me, O God, for the waters have come up to my neck” (Psalm 69:1, NRSVue), many Christians observe that it is the psalmist’s enemies, not God, who are the proximate cause of the psalmist’s distress. That is to say, Christian tradition allows for a broad range of interpretations about the cause of distress, including distress resulting from injury, physical illness, and oppression. Christians are encouraged to regard all of their lives as in some way related to God as the creator, sustainer, and orienting end of life—and so in that sense all experience is “religious” in nature. But at least for Christians this does not preclude more naturalistic or sociological interpretations of distress and suffering.Rashed is right that a “fully areligious type of suffering” with “no religious origin, content, or end (purpose)” can only be invoked from a secular standpoint—if “secularity” is taken in Charles Taylor’s first sense of “public spaces... [that] have been allegedly emptied of God, or of any reference to ultimate reality” (Taylor, 2007, p. 2). This is not because... (shrink)

Debates on the distinction between religious experience and mental disorder tend to assume, rather than argue for, the existence of unique types of experience: the religious and the psychopathological. This paper interrogates this approach to the problem. It deconstructs the distinction by examining what the distinction is about beyond the terms in which it is presented and whether it matters who is trying to make it. A key idea is that one’s standpoint in the debate—that is, whether one adopts a (...) religious or a secular standpoint—determines what they can say about the distinction. This leads to the central argument of the first part of the paper: The distinction between religious experience and mental disorder can only be invoked from a secular standpoint but can only be clarified from a religious standpoint. In other words, if you have the grounds to invoke it, you cannot have the tools to clarify it; and if you have the tools to clarify it, you do not have the grounds to invoke it. In the second part, the paper follows through the implications, from a secular standpoint, of accepting this argument. It appeals to the politics of difference and to mental health activism to argue against the binary view whereby mental distress is either illness and incapacity or a path to purpose and identity. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Introduction to the Special Theme Religious Experience and PsychopathologyMohammed Abouelleil Rashed, MD, PhDIn the first verse of the seventeenth sura of the Qur’an, Al-Isra’,1 we learn about Prophet Mohammed’s night-time journey to Al-Quds (Jerusalem):Glory to Him who made His servant travel by night from the sacred place of worship [in Mecca] to the furthest place of worship [in Al-Quds], whose surroundings We have blessed, to show him some of (...) Our signs.The year was 621 AD. The Prophet was transported by a fabled creature known as Al-Buraq—a name that derives from the Arabic word for lightning—that was able to cover the distance of a month-long journey in a matter of hours. Accompanied by the Angel Jibreel, the second part of the journey, Al-Mi’raj,2 involved an ascension to the Heavens. Along the way, the Prophet met several past Messengers until, now all alone, he received communications from Allah and, according to some accounts, encountered the Divine manifestation.When he returned to Mecca the following morning and recounted his miraculous journey, he met with a familiar range of responses. Abu Bakr Al-Siddiq, who was to become the first Caliph following the Prophet’s death, immediately believed him and never doubted the veracity of his account. Members of the Quraish tribe, a polytheistic tribe then dominant in the Arabian Peninsula and hostile to the Prophet, denounced his account outright, mocking him for its apparent impossibility or accusing him of madness. Others agreed that the Prophet had undergone the experiences he described but reasoned that this was a spiritual journey and not a physical one of literal bodily transportation. Later Christian critics went further by reducing the experience to the manifestations of epilepsy and insanity, or by questioning its Divine origin and attributing it to spirits and satanic entities.It really did matter how the Prophet’s experiences were understood and received: the stakes could not be higher. Here was the Prophet in the 11th year of a mission that called for a renewal of the message of monotheism. If true, this journey to the three holy sites of Islam (Mecca, Medina, Al-Quds) and to the Heavens was further evidence of his Prophethood and one of his miracles. His [End Page 195] critics and his followers had their own answer to the question on everyone’s mind: did the Prophet really undergo these experiences, whether in a spiritual or physical sense, or was it an expression of a pathological disturbance?________The year is 1997 AD. Mike Jackson and Bill Fulford publish a paper entitled Spiritual Experience & Psychopathology. The paper engages the exact question that troubled the Prophet’s critics and allies 1,376 years earlier. The question is now framed as a distinction between spiritual and pathological varieties of psychotic phenomena. And even though the stakes do not rise to the level of Prophethood—we have banished Prophets a long time ago—they are high enough:Spiritual experiences, whether welcome or unwelcome, and whether or not they are psychotic in form, have nothing (directly) to do with medicine.... It would be quite wrong, then, to “treat” spiritual psychotic experiences with neuroleptic drugs, just as it is quite wrong to “treat” political dissidents as though they were ill.(Jackson & Fulford, 1997, p. 42)Jackson and Fulford were not the first to invoke the distinction as a problem to be examined. In modern times, this is usually traced to William James’ Varieties of Religious Experience (1902), where he drew attention to the overlap between religious experiences and psychosis. James, like Jackon and Fulford a century later, noted the phenomenological similarities among these two ‘types’ of experience: voices, visions, an ineffable sense of significance to otherwise mundane events, and the loss of agency to external forces and powers.The 1997 paper stimulated much debate, responses, and rebuttals. In the process, at least four approaches for drawing the distinction have emerged: by appealing to the outcome of the experience; by appealing to theological criteria; by examining the organization of the experience; and by paying attention to the process of meaning-making in its cultural context. On the... (shrink)

In the phenomenology of Henri Maldiney, subjectivity is ontologically constituted by passibility, which designates the affective capacity of enduring a critical event. This ontological constitution of subjectivity does not concern an intentional act of self-constitution, but rather an ontological event in which a subject can only emerge as the effect of an existential wound. Unlike animals, who are captive to their environment and who must respond to unforeseen circumstances with a variety of actions, human beings can transcend the formative cycle (...) between an external event and the necessity of a behavioral response. The human capacity to bear an event is a capacity to take an affective attitude to one’s suffering, which ranges from openness to closure. As such, passibility is a responsive capacity that shapes a variable degree of freedom: it makes possible a detachment from one’s ego and self-image, a projection into the future, and allows for making choices. In this chapter, we will examine what this distinct mode of affectivity entails, and how it is constitutive of subjectivity. How is it distinct from mere animal sensing and behavior? And if indeed human beings do not relate to their sufferings and their passions as egological subjects relate to the objects of their representations, then how should we conceive this distinct mode of subjectivity? (shrink)