Abstract

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...