By its
very nature, mental healthcare raises a number of key conceptual questions
calling for philosophical, rather than empirical, inquiry. This chapter
outlines some of the answers that have been proposed to, perhaps, the most
central question: what is a mental illness? We then discuss links between
answers to this question and concerns about the justification of coercion in
mental healthcare, shared decisions about recovery, and the objectivity, or
otherwise, of psychiatric taxonomy.
Introduction
Mental
illness and mental healthcare raise a number of difficult and deep questions.
Here are just a few.
·
What
is the difference between just being different and having a mental illness?
·
What,
if anything, is the justification for detaining people merely because they have
a particular kind of illness?
·
Should
someone with a mental illness have less say over the nature of their recovery than
someone with a physical illness?
·
Can
a classification or taxonomy of mental illness, such as the recently published
DSM-5, aspire to be as objective as the Periodic Table in chemistry. Or is it
more like the Top 40?
Questions
such as these seem to arise not just from quirky or accidental features of
healthcare in this particular country at this particular time but from
something deeper and more general: the very idea of mental health and illness.
If that is so, they cannot be answered by empirical means - experiments,
questionnaires etc - because such means presuppose that we already know what we
mean by ‘mental health’ and ‘mental illness’. Thus trying to answer questions
like these calls for a method based on examining our concepts. That method is
philosophy. So in thinking about questions such as these, we are researching the
philosophy of mental healthcare.
In this
chapter, we will examine some recent attempts to answer the first question,
starting with Thomas Szasz' suggestion that the answer is ‘nothing’ because
there is no such thing as mental illness. We will then trace some connections between
accounts of mental illness and answers to the other questions set out above.
Szasz and the myth of mental illness
Thomas Szasz’ attack on the very idea of mental illness is often
thought of as belonging to a wider movement, called ‘Anti-Psychiatry’, which
began in the 1960s, questioning the legitimacy of psychiatry. Other thinkers
grouped under the same label include the French philosophical historian Michel
Foucault, who argued that mental healthcare was a form of social control
developed to support capitalism, and the radical British psychiatrist RD Laing.
In fact, Szasz rejected the label ‘anti-psychiatry’ as firmly as he rejected
the idea of mental illness.
The centrepiece of Szasz’ critique is an article and then a book
called ‘The Myth of Mental Illness’. A key argument is expressed in this
passage:
The concept of illness, whether
bodily or mental, implies deviation from some clearly defined norm. In the case
of physical illness, the norm is the structural and functional integrity of the
human body. Thus, although the desirability of physical health, as such, is an
ethical value, what health is can be stated in anatomical and physiological
terms. What is the norm, deviation from which is regarded as mental illness?
This question cannot be easily answered. But whatever this norm may be, we can
be certain of only one thing: namely, that it must be stated in terms of
psychological, ethical, and legal concepts…
[W]hen one speaks of mental illness, the norm from which deviation is measured is a psychosocial and ethical standard. Yet the remedy is sought in terms of medical measures that – it is hoped and assumed – are free from wide differences of ethical value. The definition of the disorder and the terms in which its remedy are sought are therefore at serious odds with one another… [Szasz 1972: 15]
[W]hen one speaks of mental illness, the norm from which deviation is measured is a psychosocial and ethical standard. Yet the remedy is sought in terms of medical measures that – it is hoped and assumed – are free from wide differences of ethical value. The definition of the disorder and the terms in which its remedy are sought are therefore at serious odds with one another… [Szasz 1972: 15]
The argument here starts from the assumption that mental and
physical illness involve deviations from different norms. Medical intervention,
however, is capable of addressing only one sort of deviation – that of physical
illness – and thus it cannot address the kind of deviation from a norm implicit
in mental illness. Since the conception of mental illness involves the idea
that it can be so treated, there is something incoherent about the very idea.
Since medical interventions are
designed to remedy only medical problems, it is logically absurd to expect that
they will help solve problems whose very existence have been defined and
established on non-medical grounds. [ibid: 17]
Szasz also develops a shorter argument.
If mental illness is a deviation from a psychosocial norm then this leads by
itself to an objection of circularity:
Clearly, this is faulty
reasoning, for it makes the abstraction ‘mental illness’ into a cause of, even
though this abstraction was originally created to serve only as a shorthand
expression for, certain types of human behaviour. [ibid: 15]
Critical thinking stop point: think about both these arguments.
Are they successful in implying that mental illness could not exist? It might
help to summarise them on the back of an envelope. How might one challenge
them?
Neither of Szasz’ arguments is
compelling. Consider the argument of circularity. We can set it out in logical
steps as follows:
1. Mental
illness is an abstraction from a description of deviant behaviour. It is defined in terms of behaviour.
2. Mental
illness is supposed to be a cause
of deviant behaviour.
3. Nothing
can cause itself.
4. So
there is no such thing as mental illness.
The argument is driven by a
tension between the claims in the first two premises. But on reflection, there
is a natural view of mental illness that captures what seems right about the
first premiss without leading to the tension with the second. We can concede
that mental illnesses are identified via someone’s behaviour (for example, what
they say and do) without thinking that the illness is the behaviour. It may be that the illness is the cause of the deviation such that, even
though it is picked out by its characteristic effects, it is not identical to
them.
Here is an example of this sort
of reasoning from a different and clearer context. Lee Harvey Oswald’s action
of pulling the trigger on 22nd November 1963 may be described as his
mudering president John F Kennedy,
the action of the moment described by its slightly later effect. The action of
pulling the trigger thus both caused the death of the president but is also
labelled using that later event. But no defence lawyer could have argued that,
because nothing can cause itself, there could be no such act. If the analogy
holds then Szasz’ argument fails. To succeed he would need some independent
reason to rule out the idea that the idea of a mental illness is the idea of
something that causes characteristic
behaviour.
The same objection applies, also,
to the argument from different norms. Just because mental illness is identified
via divergence from psychological, ethical, and legal norms does not rule out
the idea that it comprises some underlying biological cause of such divergence
and hence might be subject to medical treatment thus undermining Szasz’
argument.
Despite these objections,
however, it may seem that such a defence of mental illness concedes too much in
conceding that it is a defined in essentially value-laden terms. After all,
that alone suggests that mental illness status cannot be objective. Hence it is
worth briefly examining two responses from Christopher Boorse and Robert
Kendell which challenged just this point.
Kendell, Boorse and value-free accounts of mental illness
Like Thomas Szasz, RE Kendell was
a Professor of Psychiatry but unlike Szasz, he was an establishment figure
becoming Chief Medical Officer for Scotland and President of the Royal College
of Psychiatrists in the UK. In ‘The concept of disease and its implications for
psychiatry’ he argues in defence of mental illness or disease by suggesting a
method for assessing the status of mental illness:
before we can begin to decide
whether mental illnesses are legitimately so called we have first to agree on
an adequate definition of illness; to decide if you like what is the defining
characteristic or the hallmark of disease. [Kendell 1975a: 306]
Reviewing the history of the
debate he comments:
By 1960 the ‘lesion’ concept of
disease, and its associated assumptions of a single cause and a qualitative
difference between sickness and health had been discredited beyond redemption,
but nothing had yet been put in its place. It was clear, though, that its
successor would have to be based on a statistical model. [ibid: 309]
But, as Kendell goes on to say,
whilst a statistical model may address some of the weaknesses of a single
lesion model, statistical abnormality by itself cannot distinguish between
‘deviations from the norm which are harmful, like hypertension, those which are
neutral, like great height, and those which are positively beneficial, like
superior intelligence’ [ibid: 309]. It cannot distinguish disease from mere
difference. Some further criterion is needed to address the fact that illness
is a specific kind of deviation from
the norm.
Kendell’s preferred solution is
based on the work of the British chest physician, JG Scadding.
Scadding was the first to
recognise the need for a criterion distinguishing between disease and other
deviations from the norm that were not matters for medical concern, and
suggested that the crucial issue was whether or not the abnormality placed the
individual at a ‘biological disadvantage’... He defines illness not by its
antecedents – the aetiological agent or the lesion producing the overt
manifestations – but by its consequences. [ibid: 309]
Kendell goes on to argue that ‘biological
disadvantage’ must involve increased mortality and reduced fertility, ‘whether
it should embrace other impairments as well is less obvious’ [ibid: 310]. Thus
he uses this criterion to test the idea of mental illness. Do they produce
biological disadvantage by reducing fertility or life expectancy? After some
investigation – which turns on empirical facts about the effects of these
putative illnesses – he is able to come to a modest, positive conclusion.
Schizophrenia, manic depressive
illness, and also some sexual disorders and some forms of drug dependence,
carry with them an intrinsic biological disadvantage, and on these grounds are
justifiably regarded as illness; but it is not clear whether the same is true
of neurotic illness and the ill-defined territory of personality disorder.
[ibid: 315]
Two things are worth noting about
Kendell’s approach.
- His
criterion of illness is general. It applies to physical and mental
illness. Any condition is an illness if it leads to biological
disadvantage of the right sort. That said, it is originally derived from
considerations of paradigmatic physical illnesses.
- The
criterion is purely factual and value-free. It is a matter simply of
empirical fact whether a condition increases mortality and reduces
fertility. If it does, then it is an illness. If not, then not.
Kendell’s approach faces a
dilemma, however. On the one hand, there is ambiguity about what ‘biological
disadvantage’ means. Without some further specification, it will not shed light
on the nature of mental illness. But on the other, attempting to solve that
problem by appeal to the idea of increased mortality and reduced fertility
produces a theory of illness or disease which is vulnerable to the objection
that it does not articulate what is essential to the idea of all illnesses.
Roughly speaking, it seems plausible that one might be genuinely ill without
this leading to increased mortality and reduced fertility. Whilst those
measures might well address illnesses which, specifically, are life-threatening
and undermine reproductive ability, neither risk seems to be an essential
feature of everything that we might call ‘illness’ or ‘disease’.
At the same time, the US
philosopher Christopher Boorse also attempted to articulate a value-free,
purely descriptive account of disease – which he contrasts with illness,
although we will ignore that distinction here – but using a conceptually richer
notion: biological function. In ‘On the Distinction between Disease and
Illness’ Boorse claims that:
The state of an organism is theoretically
healthy, i.e. free of disease, insofar as its mode of functioning conforms to
the natural design of that kind of organism… the single unifying property of
all recognized diseases of plants and animals appears to be this: that they
interfere with one or more functions typically performed within members of the
species. [Boorse 1975: 57]
More precisely the theory runs:
An organism is healthy at any
moment in proportion as it is not diseased; and a disease is a type of internal
state of the organism which:
i) interferes with the performance of some natural function—ie some species-typical contribution to survival and reproduction—characteristic of the organism’s age
ii) is not simply in the nature of the species, ie is either atypical of the species, or, if typical, mainly due to environmental causes. [Boorse 1998: 108]
i) interferes with the performance of some natural function—ie some species-typical contribution to survival and reproduction—characteristic of the organism’s age
ii) is not simply in the nature of the species, ie is either atypical of the species, or, if typical, mainly due to environmental causes. [Boorse 1998: 108]
Like Kendell,
Boorse suggests that there is more to being diseased than being different. His
is not a merely statistical approach. Instead, the sense that there is
something wrong about having a disease is captured by the idea that it
threatens natural biological functions. But whilst there is a connection
between such functions and the contribution they make to an organism’s overall
fitness, not every such failure of function need be directly correlated with
actual increased mortality and reduced fertility. Biological function is
thus a more fine grained approach to the concept disease or illness that Kendell’s
appeal to biological disadvantage.
Critical thinking stop point: think about the
idea that illness or disease is a failure of biological function. Is this a
good definition? Are there any illness that are not such failures and are there
any failures that are not illnesses? How well does the idea apply to mental
illness?
There are two
main difficulties with Boorse’s approach. The first is that failure of
biological function seems more widespread than disease. In other words, not
every failure of function deserves to be called a disease. For example, the
function of sperm is surely to fertilise an egg. That function explains why
sperm production continues in populations. But very little sperm actually does
this. The benefit is so great that widespread failure can be accommodated
without any implication of disease. To cope with this problem, Jerome Wakefield
has proposed more recently that disease be restricted to the harmful failures
of function. His approach combines biological function and dysfunction with the
value: harm [Wakefield 1999]. Although his is perhaps the most famous
contemporary account, it faces the second of the objections to Boorse.
The second
problem concerns the application of the idea of function and dysfunctions to
mental phenomena: to thoughts and experiences. It seems relatively
straightforward to describe the function of the eye, for example, but rather
less clear what the function is of the profound sadness of bereavement or even
whether it is functional – since it is widespread – or the dysfunctional
consequence of emotional bonds that are elsewhere functional (see the critical
thinking box at the end). In such cases it may be that our assumptions about
what is and is not mental illness drives our assumptions about mental functions
rather than the other way round. If so, the account does not shed light on what
we mean by ‘illness’ or disease’.
Fulford and value-laden accounts of mental illness
So far we have contrasted Szasz’
claim that mental illness is value-laden and Kendell’s and Boorse’s claims that
it is value-free. How can we referee their dispute? A useful perspective is
provided by the psychiatrist and philosopher Bill Fulford. The significant
feature of the debate, he argues, is not so much on what they explicitly disagree but on what they implicitly agree and disagree. Once this
is highlighted, a different conclusion can be drawn. Taking Szasz and Kendell
to represent the poles of the debate, Fulford argues that:
Both authors assume that mental
illness is the target problem: Szasz wants to ‘raise the question, is there
such a thing as mental illness’? Kendell, similarly, seeks to ‘decide whether
mental illnesses are legitimately so-called’. Both then turn to the concept of
physical illness, acknowledging certain difficulties of definition, but
suggesting criteria which they take to be self-evidently essential to its
meaning: Szasz’ criterion is ‘deviation from the clearly defined norms of the
structural and functional integrity of the body’. Kendell’s is ‘biological
disadvantage, which must embrace both increased mortality and reduced
fertility’. Finally, both return to mental illness. Szasz points out that for
mental illness, the relevant norms of bodily structure and functioning are not
available: on the contrary, he argues, the norms of mental illness are
‘ethical, legal and social’. Kendell, on the other hand, draws on
epidemiological and statistical data to show that many mental illnesses are
biologically disadvantageous in his sense, being associated with reduced life
and / or reproductive expectations. Hence by Szasz’ criteria of physical
illness, mental illness is a myth, whereas by Kendell’s it is not. [Fulford
1999a: 169]
According to Fulford, Szasz and Kendell both agree that mental
illness is conceptually difficult and, by contrast, physical illness is straight-forward
in part because the latter is value-free. From this they deduce value-free
criteria for illness and apply them to mental illness with different results. As
described above, Szasz argues that supposed mental illnesses are deviations
from value-laden norms and thus do not meet the value-free criteria for
illness. Kendell argues that they do fit his preferred criteria of increased
mortality and decreased fertility.
Fulford argues, however, that the assumption that Szasz and
Kendell, and Boorse for that matter, share is wrong. Physical illness is not value-free.
It merely seems that way because we tend to agree on the values that underpin
physical health and illness whilst there is much more variation in the values
governing mental health and illness. Further, it is a general feature of value
judgements that when we agree on underlying values they can become disguised by
value-free criteria.
What’s the evidence? RM Hare on value terms
Fulford’s account of value
terms draws on the work of philosophers such as RM Hare (1919-2002) and JL
Austin (1911-1960), writing particularly in the middle decades of the 20th
century, in the ‘Oxford school’ of linguistic analytic philosophy. In his Language
of Morals, Hare discusses the logical properties of value terms [Hare
1952].
The value judgments expressed
by (or implicit in) value terms are made on the basis of criteria that,
in themselves, are descriptive (or factual) in nature. The value
judgment expressed by ‘this is a good strawberry’, in one of Hare’s examples,
is made on the basis that the strawberry in question is, as a matter of fact, ‘sweet,
grub-free’. Hare points out that where the descriptive criteria for a given
value judgment are widely agreed, the descriptive criteria that may come
to dominate the use of the value term as a consequence of repeated association.
In the case of strawberries, most people in most contexts prefer or value
strawberries that are sweet and grub-free. Hence the use of ‘good strawberry’
comes to be associated with descriptions such as ‘sweet, grub-free, etc’. This
contrasts with, say, pictures where there are no settled descriptive criteria
for a good picture because there is no general agreement about pictorial
aesthetics.
Hare’s general conclusion
is this: value terms by which shared values are expressed may come, by a
process of simple association, to look like descriptive (or factual)
terms, whereas value terms expressing values over which there is disagreement,
remain overtly value-laden in use.
Fulford argues that the same contrast applies to mental and
physical illness. It is because mental healthcare is concerned with areas of human
experience and behaviour, such as emotion, desire, volition, and belief, where
people’s values are particularly
highly diverse that it seems more value-laden than physical illness.
Fulford’s
positive account of the nature of illness draws on the idea of ordinary
doing as the kind of action that one ‘gets on and does’ without having to try,
without having intentions explicitly in mind [Austin 1957]. A failure to be
able to do this kind of thing, in the absence of external constraint, captures,
Fulford argues, the character of experiences of illness. As a hypothesis,
moreover, it helps to explain a number of the key features of medicine. In
particular, the idea that illness comprises an internally generated failure of ordinary doing explains
its values-ladenness because the ineliminable concept of failure of
ordinary doing itself suggests an ineliminable negative value judgement.
This is true of physical illness as well as of mental illness but
because there is much more agreement about the sorts of things we should be
able physically or bodily to be able to do, the underlying values can become
hidden behind factual criteria for working muscles, hearts and lungs etc. This
contrast between divergent values in mental healthcare and shared values in
physical medicine explains why there is an Anti-Psychiatry movement but not an
Anti-Cardiology one.
Having
now sketched some competing views of mental illness, and highlighted the
potential connection between illness and values, we can now see what
connections there are to the other questions raised at the start.
Applications to other questions?
First, is
there a connection between mental illness and a justification for compulsory
treatment? Fulford argues that his account sheds light on why psychotic illness
justifies coercion. On his account, illness is an internally caused failure of
ordinary doing. In the case of other illnesses, the failures concern
difficulties in the execution of actions. But psychosis involves a loss of
insight. It thus involves a defect in the reasons someone has for acting. And
because actions are identified as the actions they are on the basis of why
someone did them this leads to a constitutive failure to frame, rather than
merely to carry out, an action. However, in general, peoples’ actions can
excused when there is a breakdown in intention. If one does something which
might normally deserve blame merely by accident, mistake or impaired consciousness,
one can be excused because one is not responsible for the act. Illness can also
act as an excuse.
All non-psychotic illnesses… involve… instrumental failures of
‘ordinary’ doing, difficulties in doing what one intends to do. And
difficulties of this sort often mitigate and, if very severe, may even excuse.
But in the case of psychotic illness, the failure of ‘ordinary’ doing … is a
failure in the very specification of what is done. The psychotic, therefore…
lacks intent… [H]e is thus in the same position as others who lack intent in
that he is not responsible for what he does, and, hence, excused. [Fulford
1989: 242-3]
This idea that lack of intent excuses an action can be connected through
two links to the problem of justifying compulsory treatment. First, psychotic
illness, in which a subject lacks insight into his or her condition, undermines
the subject’s capacity to form reasons and thus connects to defective intent.
Secondly, a subject whose purported actions can be excused by defective intent,
which may undermine their status as actions, is also by that fact the
kind of subject whose autonomy can justifiably be overridden.
As Fulford spells out, there is
of course a sense in which people with psychotic loss of insight clearly do
form intentions, just as there is a sense in which they clearly do have reasons
for their actions. The point is rather that, to the extent that their actions
reflect psychotic loss of insight, their reasons are defective, in whatever (as
yet to be determined) way delusional reasoning is defective. Defective reasons
for action imply defective intentions, hence, excuse and hence also a rationale
for compulsion by others.
This general approach promises to shed light on the key justification
for compulsory treatment. There are, however, still some questions remaining.
Do all cases that merit compulsory treatment involve defective intent? Why
precisely does such a defect justify treatment? What exactly is the connection
between the possibility of excusing purported actions because of some failure
of intent and overriding the agent’s remaining autonomy? And what precisely
comprises a relevant defect of intent? Is it right to say that there is a lack
of intent, or a failure within the specification of intention, or an impaired intention
or what? Nevertheless, it suggests that psychiatry carries with it quite
specific medical ethical complexities which flow from the fact that it centres
on disorders of human agency.
This line
of reasoning suggests one factor in an answer to the next question raised at
the start, too: should someone with a mental illness have less say over the
nature of their recovery than someone with a physical illness? The extent to
which mental illness can undermine a capacity to frame decisions has to be
addressed in decisions about treatment and management. But there is another
factor which pulls in the opposite direction. Just as both Fulford and to a
lesser extent Wakefield argue the very idea of mental illness is value-laden,
so it seems that recovery in mental healthcare is value-laden. This is because
it is not merely a matter of getting batter, or returning to how one was before
its onset, or returning to a statistically normal set of mental capacities.
Rather it involves the section of a way of living which is right for the person
concerned.
The
Sainsbury Centre for Mental Health policy paper ‘Making recovery a reality’,
begins by summarising some key points of emphasis which, it is suggested,
characterise any broadly conceived recovery-based approach. These points
include:
Recovery is about building a meaningful and
satisfying life, as defined by the person themselves, whether or not there are
ongoing or recurring symptoms or problems.
Recovery represents a movement away from pathology, illness and symptoms to health, strengths and wellness.
Hope is central to recovery and can be enhanced by each person seeing how they can have more active control over their lives (‘agency’) and by seeing how others have found a way forward.
Self-management is encouraged and facilitated. The processes of self-management are similar, but what works may be very different for each individual. No ‘one size fits all’…
Recovery is about discovering – or re-discovering – a sense of personal identity, separate from illness or disability. [Shepherd Boardman and Slade 2008: 0]
Recovery represents a movement away from pathology, illness and symptoms to health, strengths and wellness.
Hope is central to recovery and can be enhanced by each person seeing how they can have more active control over their lives (‘agency’) and by seeing how others have found a way forward.
Self-management is encouraged and facilitated. The processes of self-management are similar, but what works may be very different for each individual. No ‘one size fits all’…
Recovery is about discovering – or re-discovering – a sense of personal identity, separate from illness or disability. [Shepherd Boardman and Slade 2008: 0]
The Scottish Recovery Network summarises its views
of recovery in similar terms:
Recovery is about living a
satisfying and fulfilling life.
Recovery is about more than the absence of the symptoms of illness. Some people describe themselves as being in recovery whilst still experiencing symptoms….
Some people consider recovery as being ‘back to the way things were’ or back to ‘normal’ but for others recovery is more about discovering a new life or a new way of being. [Scottish Recovery Network 2007: 3]
Recovery is about more than the absence of the symptoms of illness. Some people describe themselves as being in recovery whilst still experiencing symptoms….
Some people consider recovery as being ‘back to the way things were’ or back to ‘normal’ but for others recovery is more about discovering a new life or a new way of being. [Scottish Recovery Network 2007: 3]
On this
conception, recovery involves a value-rich personal choice. But given, as we
have already described, there is a wide divergence of views about the values
relevant to mental health and illness, especially to living a good life, this
places much greater need for those with mental illnesses to be centrally
involved in decisions about their care and there hopes for recovery.
The final
question is harder. Can a classification or taxonomy of mental illness, such as
the recently published DSM-5, aspire to be as objective as the Periodic Table
in chemistry. Or is it more like the Top 40? According to Kendell and Boorse,
mental illness (or more precisely disease in Boorse’s case) is a value-free,
purely factual notion. But vas we have seen, their accounts face objections.
According to Fulford and Wakefield, it is a value-laden notion. For Wakefield,
this is a single value: harm. For Fulford, there may be a plethora of values.
Indeed, the US psychiatrist John Sadler published a lengthy book on the wide
variety of values and even kinds of values in DSM-IV [Sadler **]. If this is
the case, what kind of classification or taxonomy can underpin mental
healthcare?
First,
any value-laden classification will be different from the value-free Periodic
Table in chemistry. Even if the criteria for including symptoms or experiences
into a particular category are factual and descriptive – like the criteria for
a good apple – they will reflect original value judgements which cannot be
measured by any instrument.
But
second, the issue of the objectivity of a value-laden classification depends on
the nature of the values involved. If they are mere expressions of subjective
preference, like the Top 40, then they do not answer to anything objective and
cannot aspire to being true. On the other hand, they might be thought to be
expressions of something independent of any individual’s judgement as moral
codes are often thought to be. If so, whilst distinct from the purely
descriptive objectivity of the Periodic Table, classifications of mental
illnesses would still have a more complex form of objectivity. This raises a
key question: what is it to get such judgements right?
Conclusions
By its
very nature, mental healthcare raises profound conceptual questions which call
for philosophical rather than empirical research aimed at arriving at a clearer
understanding of the underpinning ideas guiding healthcare. This chapter has
illustrated this by addressing a fundamental question of what, if anything,
mental illness is and briefly sketching some of the key ideas advanced over the
last fifty years. One question these rival views differ on is whether mental
illness, or disease, is a value-laden or value-free concept and, if the former,
what kind of values.
Addressing
that question, however, suggests connections to others, such as the
justification of coercion, the nature of recovery and decisions made about it,
and the objectivity of basic psychiatric taxonomy. A full and proper
understanding of the nature of mental illness – the very idea of it – connects
to other pressing areas. Philosophical understanding of mental healthcare is
thus not merely an optional extra but a key guide to and resource for good
practice.
Critical debate box: Grief,
depression and the bereavement exclusion criterion
[To be added: Brief summary of the debate about the
exclusion from DSM-5 of the bereavement exclusion criterion for depression.]
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