Wednesday 21 June 2023

The consolations of philosophy of psychiatry: a sort of autoethnography

The aim of this paper is twofold. First, it is to offer a kind of autoethnography of a previously disinterested philosopher of psychiatry experiencing a common mental illness – Generalised Anxiety Disorder - and thus turning to philosophy for some sort of self-understanding. Second to assess how well Richard Moran’s account of self-knowledge in Authority and Estrangement illustrates my experience of anxiety (Moran 2007). The conclusion is that if offers a helpful third person account of the mismatch between avowal and reported belief that was the main focus of my symptoms but much less by way of first person understanding.

My experience

My background is as an academic philosopher who began to take an interest in the philosophy of psychiatry in 1994. My main academic interest, stemming from a PhD on Wittgenstein, was in the irreducibility of meaning to the ‘realm of [natural scientific] law’, in Sellars’ phrase (Sellars 1997). It seemed plausible to me that the irreducibility of the space of reasons to the realm of law might have interesting consequences for psychiatry. But mine was a purely disinterested academic interest. This is perhaps the usual approach to what is in part a professionalised academic subject with its formal rules for publication and dissemination of research. Furthermore, since 1994, the philosophy of psychiatry has become an increasingly accepted, if still very small, academic subdiscipline of philosophy. It has entered a period of Kuhnian ‘normal science’ with an increasingly agreed syllabus of disciplinary problems with a number broad familiar approaches (Kuhn 1962/96**). For example, delusions are a central focus and there are competing approaches which, nevertheless agree on many basic ground-rules for the debate. As in other philosophical subdisciplines, there is no academic expectation that experts in the field have any more direct experiential connection to the phenomena of which it is the philosophical study.

It has only been in the last half decade that I have experienced things in a more personal way, following what I would term, though psychiatry would not, a ‘nervous breakdown’, leading to a common diagnosis of Generalised Anxiety Disorder. Despite that name, my own anxiety focused narrowly on my employment, my to-do list and my email inbox. The main symptoms comprised sudden acute anxiety following a prompting thought about the day’s work schedule leading to distress, and initially retching and later vomiting. Simultaneously undergoing weekly psychotherapy, I was able over several months to notice and reflect on my thoughts while in extremis.

Centrally, as I experienced somatised anxiety, I was also able to acknowledge that there were no rational grounds for such severe anxiety. I had received assurance that my academic post was safe, that I was respected by colleagues, that no failure to write a committee report or author a new departmental policy would be treated severely. There was, in other words, nothing to fear. And yet, even as I reported that thought, my distress remained. In fact, the more I avowed that I really knew that there was nothing to fear, the more extreme my somatisation became, retching becoming sudden violent vomiting.

In reporting this back to my therapist, my apparently sincere assertion that there was nothing to fear began to seem less secure. Surely, I could not really believe that there was nothing to fear, given my behavioural responses? These responses were not merely expressed in involuntary bodily responses but also in motivated avoidance behaviours (of my computer, of trips to my university etc.). In short, it seemed both

That there was obviously nothing to fear. Thus, that I believed – that I knew - that there was nothing to fear. But also:

It seemed that I did not really believe that there was nothing to fear and my fear was dramatically behaviourally expressed.

Given my 25 years work in the philosophy of psychiatry, it assumed that there might be some practical consolation from the discipline for my own experience. Such consolation might, as a minimum, might be:

The consolation of philosophy: the provision of first person understanding of mental illness through philosophical analysis.

This is a merely a hypothesis. The rest of this paper will explore how well it fares in my experience and quotidian experiences like mine. What insight can philosophy offer to the conflicting self ascriptions both that ‘I believe that there is nothing to fear’ and ‘I do not believe that there is nothing to fear’ both as an expression of an anxiety disorder?

Avowal vs. report

In seeking self-understanding, I turned to Richard Moran’s Authority and Estrangement which I had antecedently thought a fine book. It sets out an influential recent approach to self-knowledge which replaces the idea of privileged inner and quasi-observational standing with the claim that self-knowledge paradigmatically stems from practical reasoning.

In seeking to explain and vindicate avowal as a privileged form of knowledge of oneself, I… relat[e] the capacity for “immediate” or “introspective” awareness of one’s attitudes with the capacity of the person to make up his mind. (Moran 2001 134)

Moran cites, among others, Gareth Evans:

[I]n making a self-ascription of belief, one’s eyes are, so to speak, or occasionally literally, directed outward — upon the world. If someone asks me “Do you think there is going to be a third world war?,” I must attend, in answering him, to precisely the same outward phenomena as I would attend to if I were answering the question “Will there be a third world war?” (Evans 1982: 225)

This expresses the view that self-knowledge of what one believes is based, centrally and usually, not on an inward turn but rather on looking ‘outwards’ (metaphorically or literally) to determine what one ought to believe. Moran refers to this as ‘transparency’, a notion he borrows from Roy Edgley:

[M]y own present thinking, in contrast to the thinking of others, is transparent in the sense that I cannot distinguish the question “Do I think that P?” from a question in which there is no essential reference to myself or my belief, namely “Is it the case that P?” This does not of course mean that the correct answers to these two questions must be the same; only I cannot distinguish them, for in giving my answer to the question “Do I think that P?” I also give my answer, more or less tentative, to the question “Is it the case that P?” (Edgley 1969: 90)

Moran stresses that by ‘transparency’ he does not mean that states of belief reduce to states of the world nor that agents are unaware of the difference between something being the case and them thinking it to be so. But rather:

[A] first-person present-tense question about one’s belief is answered by reference to (or consideration of) the same reasons that would justify an answer to the corresponding question about the world. (Moran 2001: 61)

Transparency is manifested in the role of avowal.

An avowal of one’s belief… is not made on any psychologically explanatory basis, and is rather the expression of one’s own present commitment to the truth of the proposition in question. (ibid: 89)

Avowal expresses a normative judgement of what one ought to think. It is an expression of practical knowledge sharing commonalities with Elizabeth Anscombe’s account of self-knowledge of actions of which she says: “I do what happens” (Anscombe 2000: 52). For actions, what one does is a worldly happening. And so there is the promise, at least, of an account of the kind of authority an agent has over her actions. She knows, in virtue of being its agent, what it is that actually transpires. (There is debate about how successfully she can accommodate cases where something breaks down in the world, such as signing a name with a pen with no ink.) And that is not a mere internal feature of her psychology but rather a feature of being a practical outward-looking agent. Moran argues, similarly, that self knowledge of beliefs is based on avowal of what one has determined one should think.

This is not the only form of self-knowledge Moran acknowledges. There is also the kind of insight one gains, not by determining what is to be thought on some independent matter, but what may emerge in, for example psychotherapy. This he calls a ‘report’.

[A] report on an attitude of mine has an explanatory basis, grounded in evidence, and need not imply a commitment to the attitude’s truth or justification, any more than its third-person equivalent would. Instead, the attribution is made in order to identify the states, forces, or whatever else that is driving the actual psychological machinery. (ibid: 89)

He gives the following example, which shows the different ‘logic’ of avowal and report:

The person who feels anger at the dead parent for having abandoned her, or who feels betrayed or deprived of something by another child, may only know of this attitude through the eliciting and interpreting of evidence of various kinds. She might become thoroughly convinced, both from the constructions of the analyst, as well as from her own appreciation of the evidence, that this attitude must indeed be attributed to her. And yet, at the same time, when she reflects on the world directed question itself, whether she has indeed been betrayed by this person, she may find that the answer is no or can’t be settled one way or the other. So, transparency fails because she cannot learn of this attitude of hers by reflection on the object of that attitude. She can only learn of it in a fully theoretical manner, taking an empirical stance toward herself as a particular psychological subject. (ibid: 85)

Moran offers as part of the characterisation of a report the fact that transparency does not hold for it. To determine what one believes qua a report is not a matter of determining, normatively, what one ought to think. In its case, the look is ‘inwards’, or perhaps to one’s behaviour. Equally, there is no normative connection from a report to its endorsement in an avowal. Just because one finds one believes something, that is no reason to think it the think one ought to think, that it is the thing to think on that matter. But the converse pressure does hold. If a report runs counter to what one avows, that ought to be a reason not to hold it. And indeed this is the structure of much psychotherapy: identifying beliefs one has insufficient reason to endorse and thus learning to discard them.

Might this structure shed light on the experience of anxiety (at least as I experience it) thus offering philosophical consolation?

Avowal, report and anxiety

Mapped onto Moran’s distinction, the avowal in the earlier anxiety vignette is:

There is nothing to fear. Thus I believe that there is nothing to fear.

The report seems to be:

From my experience and behaviour, it seems that I do not believe that there is nothing to fear.

From a third person perspective, the combination of these two conflicting, contradictory beliefs is clearly irrational and yet familiar. It is a familiar trope of psychotherapy to uncover implicit and hidden beliefs using the evidence of behaviour and feelings, often when the analysand is prompted to think about particular life events or relationships. Such contradictions might also be ascribed from a purely third personal perspective by others, taking account of everything an agent says and does. Considering a psychotherapeutic context helpfully reinforces the idea in Moran’s account that a report can still be a form of self-knowledge, even if arrived at via a different attitude to avowal. And in Freudian influenced therapy, the analysand’s acceptance of a belief plays a central evidential role. If a possibility suggested by a therapist is repeatedly rejected after serious consideration then this is fallible evidence that the subject does not have the proposed belief while their accepting it is strong evidence that they do.

But from a first person perspective, things remain puzzling in the case of (my) anxiety disorder because the report required no subtle investigation – it was / is manifest in the explicit symptomology and aversive behaviour – and its clear conflict with the avowal (that the thing to be thought is that there is nothing to fear) had /has no tendency to remove the reported belief. That there is an obvious conflict but which shows no sign being resolved either way – either by changing the avowal or removing the report – seems to be a central feature of what (my) dysfunctional pathological anxiety is.

In my case, I noticed increasing self-doubt about the sincerity of my claim – made to my partner and to my therapist – that I knew that I had nothing to fear, that I really believed that, that my feelings and behaviour were merely misfiring symptoms of an illness. Although my outwardly directed assessment of genuine risks remained the same, the strength of the reported belief made me doubt the transparent inference from ‘there is nothing to fear’ to ‘I believe there is nothing to fear’. Given that I was self-aware of all this fact too seemed baffling. Why didn’t the avowal that there was really nothing to fear not help?

Thus while Moran’s framework and the contrast between avowal and report seems to permit a description of my state for others – as a conflict between rational outward avowal and suborn reported belief and consequent emotion – it left me puzzled as to the experience of the intractability of the reported belief and its associated emotional and bodily expression. On Moran’s account, the authority of avowal is a central aspect of rational agency and so not being able to take up this stance, despite self-conscious awareness both of my own phenomenology but also Moran’s philosophical account of it, seemed bizarre. The framework provided no first person philosophical consolation.

Two irrational, phobic comparisons

My experience of anxiety contrasts with two other irrationalites. Fear of spiders and fear of flying. While puzzling in the way of all irrationality, these seem to behave differently both from each other. Might they provide a way to shed first person insight on anxiety? I will describe my own experience of both in the same spirit of autoethnography. I claim no generality for my particular experiences.

Fear of spiders: In the context of a petting zoo, I am offered the opportunity to let a large, harmless spider walk along my arm. I recoil in horror. Rationally, I know that, in this context, any such spider is harmless. There is nothing to fear from the spider. Knowing that the thing to think, I avow that fact: “I know there is nothing to fear”. I completely believe that there is nothing to fear. I have no lingering doubts about safety protocols or the zoo’s knowledge of biology. I have no doubts on that score. And yet I feel bodily fear, expressed in my recoil and aversion.

Fear of flying: Before booking a flight, I remind myself of the safety records of the aviation industry and compare the risks of dying driving to the airport with that of taking the flight, finding the latter far smaller. I rehearse some of what I know about how accident inquiries have led to a robust culture of risk management from which the health sector now borrows. Objectively the risks of death by flying are far lower than risks I accept perfectly happily in other areas of life. I freely book my flight. On the day, however, I am anxious about boarding the plane, perspire and have a raised heartbeat. Physiologically, I am afraid. But, unlike the spider case, in this case I do begin to doubt the relevance of the general statistics to this particular case. I focus on the apparent fragility of the wings, and any unhappy mechanical noises despite my crass ignorance of what they might actually mean. With some embarrassment I admit that while I perhaps ought not to judge there to be significant risk, I cannot help believing myself to be at risk. My physiological responses are consistent with my first order beliefs even though I am aware of my own lack of expertise in this judgement.

Although there are overlaps, these two cases of irrational phobias have significant differences from each other. Proximity to the spider does not have any effect on my beliefs about its danger. My fear is encapsulated in the bodily recoil. It stands to the rest of my mental economy much as someone else’s fear might: a reaction – of theirs – to be expected, anticipated and managed where necessary. Just as someone else’s fear may be no reason to change one’s view of the situation – of the thing to think – so neither does my own, in this case.

By contrast, although, when booking my flight, an appraisal of airline safety is rationally persuasive, on the day of the flight other local factors intervene to undermine this belief. Given my fixation on the potential dangers attaching to just this plane in virtue of the flexing of just those wings and those unnerving mechanical noises, my bodily expressions of fear form a coherent whole with my current doubts. I am no longer convinced, in the moment, that there is nothing to fear. In fact, my fear may have quite specific, if objectively unjustified, foci. Fear makes features of the environment particularly salient. It is not that irrational feelings of fear are reasons for me to change my appraisal of general safety and hence of the safety of this particular plane – as instancing a generality - but fear may play a causal role in sensitising me to specific environmental cues. Even knowledge of this general feature of human psychology may not be enough to undermine a change in judgement or relative risk. Like my assessment of aviation safety, in the moment local factors may trump all general reasons.

Do either of these more familiar cases of irrationality shed light on my experience of anxiety and hence promise consolation?

I do not think they do. Even if it has a specific set of work-related objects, my fear in anxiety is not narrowly encapsulated as is my fear of spiders. Instead, it has a broader effect on the surrounding mental economy. I think about work irrationally and inappropriately often. I fret about tasks when trying to sleep. I am drawn back to check my work emails in the evening and at weekends. While the fear of spiders suggests a kind of mental compartmentalising, the fear in anxiety seems, as a matter of fact though not a matter of ‘ought’, to serve as a reason to doubt the sincerity of the avowal that I believe that there is nothing to fear. It has no such effect in the fear of spiders.

But unlike the fear of flying, fear in anxiety does not simply temporarily trump the world-directed considerations that motivate the avowal (that there is nothing to fear). In the case of flying, a more general belief about aviation safety is temporarily suspended for the duration of the flight during which the avowal is also replaced. But in anxiety, even while lying awake and worrying, I can still judge that this is not an accurate assessment of my objective situation.

In the spider phobia case, an encapsulated fear has no effect on my general avowal that there is nothing to fear. In the flight case, that avowal is suspended for the flight. But in anxiety, both the general avowal and the report co-exist in disharmony introducing an opacity between the normally transparent relation of external assessment – that there is nothing to fear – and what I believe. There is nothing to fear, but I do not believe it.

Moore’s paradox

‘There is nothing to fear, but I do not believe it’ is a variant of Moore’s Paradox, identified by G.E. Moore and subsequently discussed by Wittgenstein and others. The paradox stems from the fact that the two conjuncts express possibilities that can be, and often are, both true. And yet there seems something absurd in its first person expression though as a third person description it is perfectly ordinary.

Moran rejects accounts based on the pragmatics of assertion as the paradox remains if the contents are merely thought or judged. He also rejects expressivist accounts that deny that ‘I believe X’ ascribes any psychological state and merely presents the putative worldly fact of X. Such an analysis removes any hint of paradox by interpreting the Moore possibilities as simple contradictions. Instead, Moran suggests that the transparency of avowal suggests that our concept belief contains two distinct commitments.

There are in this way two quite different types of commitment involved in my avowing a belief of mine. On the one hand, in saying “I believe it’s raining out” I commit myself to the state of the weather being a certain way. My avowal of this belief expresses the fact that it is not an open question for me whether it is raining or not. At the same time, however, I must acknowledge myself as a finite empirical being, one fallible person in the world among others, and hence acknowledge that my believing something is hardly equivalent to its being true. (ibid: 74)

The commitment to a judgement as to some external state of affairs is feature of rational agency, of being a subject capable of taking a view on the world. At the same time, one acknowledges that this is merely one’s particular and fallible stance on a the world. Thus while Moore’s paradox expresses an empirical possibility it clashes with one’s self-conception as an agent forming a commitment that things are thus and so in the world.

[A]s I conceive of myself as a rational agent, my awareness of my belief is awareness of my commitment to its truth, a commitment to something that transcends any description of my psychological state. (ibid: 84)

“Taking my beliefs to be true” is not an empirical assumption of the sort that I might make with respect to another person. Rather, it is the categorical idea that whatever is believed is believed as true. (ibid: 77)

Moran’s account of Moore’s Paradox is offered as further support of his account of self-knowledge as an expression of framing a commitment and thus self-ascribing a mental state as a feature of rational, practical agency. We would expect statements of Moore’s sort to be paradoxical if Moran is right. But I introduced the paradox as an expression of the nature of my anxiety disorder and hence its paradoxical nature is no help in arriving at a kind of philosophical informed but first person understanding of my own experience.

In his discussion, Wittgenstein makes the following suggestion of how one might attempt to understand such a statement.

§105. “Judging from my words, this is what I believe.” Now, it would be possible to think up circumstances in which this made sense. And then it would also be possible for someone to say “It is raining and I don’t believe it”, or “It seems to me that my ego believes this, but it isn’t true”. One would have to imagine a kind of behaviour suggesting that two beings were speaking through my mouth. (Wittgenstein 2009: 201)

I think that we may actually want to say something akin to this in the case of phobic reactions to spiders and similarly non-rational and encapsulated experiences. One might say: “I know that there is nothing to fear but my body – or my reptilian brain – does not!” In a case where the fear-reaction is bound up merely within a specific situation and has a narrow range of behavioural consequences and no inferential power over other beliefs, it is tempting to talk as though one comprises two agents, one more limited and brute and the other closer to the rational agent as a whole. But such a picture is harder to apply without puzzlement if the emotion is less circumscribed and has more general and widespread consequences for how one feels and thinks.

Puzzling shades of behaviour

One of the central themes in the varied discussions of mental states and experiences (including doubts about the innocence of the very label ‘mental state’) in Wittgenstein’s Philosophical Investigations is that:

§580. An ‘inner process’ stands in need of outward criteria. (Ibid: 161))

The outward criteria discussed are often abilities. For example, the discussion of rule following starts with the example of grasping the meaning of a word.

§139. When someone says the word “cube” to me, for example, I know what it means. But can the whole use of the word come before my mind when I understand it in this way? Yes; but on the other hand, isn’t the meaning of the word also determined by this use? And can these ways of determining meaning conflict? Can what we grasp at a stroke agree with a use, fit or fail to fit it? And how can what is present to us in an instant, what comes before our mind in an instant, fit a use? (ibid: 59)

Here it seems that correctly being able to use the word ‘cube’ is the criterion of being able to understand its meaning and the puzzle this raises is how one can self-ascribe such knowledge in a flash since it seems impossible that a potentially infinitely extended usage could come to mind. Rejecting philosophical explanations of which somehow encode the usage into something like a picture or diagram, Wittgenstein suggests that first person avowals are often fallible glad starts:

§323. “Now I know how to go on!” is an exclamation; it corresponds to an instinctive sound, a glad start. Of course, it does not follow from my feeling that I won’t find I’m stuck when I do try to go on. (ibid: 112)

When all goes well, a rational agent can successfully self-ascribe the ability to meet the outward criteria of the state in question. But this does not assume that the criteria are simple behaviours and hence that what is self-ascribed is simply behavioural. Wittgenstein invokes the idea of ‘fine shades of behaviour’.

§210. ‘Fine shades of behaviour.’ — When my understanding of a theme is expressed by my whistling it with the correct expression, this is an example of such fine shades. (ibid: 217)

§192. When should I call it just knowing, not seeing? – Perhaps when someone treats the picture as a working drawing, reads it like a blueprint. (Fine shades of behaviour. – Why are they important? They have important consequences.) (ibid: 215)

The idea that ‘fine shades’ of linguistic behaviour may be criterial for some mental states and experiences suggests a subtly different response to the linguistic phenomenology. The key tension in my anxiety phenomenology concerns whether I really believe that there is nothing to fear. Moran aims to reconcile the claim that ‘belief’ and ‘believe’ is univocal with it having different aspects or uses. It can be justificatory, in first person avowal, and it can be explanatory of behaviour and other beliefs either from the third person or in a first person theoretical report. He also suggests that his aim is to capture the central case where all goes well from which ideal deviations can be noted (akin to the spirit of perceptual or epistemic disjunctivism) (Moran 2007: 131). This suggests a limit to the kind of understanding his model can provide for pathological cases where transparency is, at least, threatened. It suggests the need to approach the phenomenology taking what seem to be baffling temptations at face value. Anxiety simply can be a state or experience in which an outwardly directed rational judgement that there is nothing to fear can fail to lead to a whole-hearted self-ascription that I believe that there is nothing to fear because of the very clear and manifest experience of fear. That fear motivates at least the suspicion that one does not fully believe the first avowal. And yet, the self-reported belief that there is something to fear has no tendency to pass ‘outwards’ to the judgement that there objectively is. The structure of belief itself seems to be transformed in anxiety despite possession of the philosophical tools to approach it. The rational balance of the two commitments Moran ascribes to the concept of belief breaks down with no tendency for the self-correction of an unavowed report – either undermining the avowal or the reported belief - as often happens in psychotherapy. And hence self-understanding, and hence consolation, in anxiety remains merely partial.

A coda on expertise by experience

One of the standard assumptions about experts is that their testimony is trustworthy, that knowledge can be inherited from their sincere assertions. In healthcare, expert status is increasingly accorded not just to trained professionals but to those who, in virtue of their experiences, have something to say about the nature of illness. One motivation for this might be a graded form of empiricism: that relevant experience is necessary for knowledge and experts by experience have important experience, which is not shared by clinicians in virtue merely of their training. But is such experience also sufficient for a form of expertise?

My own experience suggests that this is not a simple question. While experts might be expected simply to put their knowledge of a subject into words, and hence to transmit some of it to those with ears to hear, I have found my illness baffling to me. I have lacked a deeper understanding of what have remained baffling feelings and emotions, continuing to hold conflicting beliefs even while aware of that fact. Since expertise admits of degrees – else there would be no such thing as professional sport – I suspect that one level of sufficiency for a form of expertise is simply to convey some of what it is like to others who have not had those experiences, first hand. But my own illness suggests that those powerful and articulate first persona narratives – of which there is an increasing number - on essentially more confusing and less run-of-the-mill illnesses have achieved something of wonder.


Anscombe, E. (2000) Intention. Cambridge,Mass.: Harvard University Press

Baldwin, T. (2007) ‘The Normative Character of Belief,’ in Green and Williams Moore's Paradox Oxford: Clarendon Press

Edgley, R. (1969) Reason in Theory and Practice. London: Hutchinson

Kuhn, T.S. (1962/ 1996) The Structure of Scientific Revolutions. Chicago, IL: University of Chicago Press

Moran, R. (2001) Authority and estrangement. Princeton: Princeton University Press

Sellars, W. (1997) Empiricism and the Philosophy of Mind. Cambridge, MA: Harvard University Press

Wittgenstein, L. (2009) Philosophical Investigations, Oxford Blackwell